Understanding Idiopathic Scoliosis

The term scoliosis is used to describe a condition, which represents an abnormal curvature of the spine, but it is not a disease or a diagnosis. Scoliosis can be caused by congenital, developmental or degenerative problems, but most cases of scoliosis actually have no known cause, and this is known as idiopathic scoliosis.

Scoliosis usually develops in the thoracic spine (upper back) or the thoraco-lumbar area of the spine, which is between the thoracic spine and lumbar spine (lower back). It may also occur just in the lower back. The curvature of the spine from scoliosis may develop as a single curve (shaped like the letter C) or as two curves (shaped like the letter S).

While there are many forms of scoliosis, four of the most common ones include:

• Congenital scoliosis. This is a relatively rare form of congenital malformation of the spine. These patients will often develop scoliotic deformities in their infancy.
• Neuromuscular scoliosis. This may occur when the spine curves to the side due to weakness of the spinal muscles or neurologic problems.  This form of scoliosis is especially common for individuals who cannot walk due to their underlying neurolomuscular condition (such as muscular dystrophy or cerebral palsy).  This may also be called myopathic scoliosis.
• Degenerative scoliosis. Scoliosis can also develop later in life, as joints in the spine degenerate and create a bend in the back. This condition is sometimes called adult scoliosis.
• Idiopathic scoliosis. By far the most common form of scoliosis is idiopathic scoliosis, which most often develops in adolescents and typically progresses during the adolescent growth spurt.  Because it most often occurs during adolescence, this condition is sometimes called adolescent scoliosis.

Idiopathic scoliosis

This is by far the most prevalent form of scoliosis and occurs to some degree in approximately one half million adolescents in the US. There is no known cause of idiopathic scoliosis (“idiopathic” refers to a disease or condition or unknown origin) although it does tend to occur in families.
Idiopathic scoliosis is usually categorized into three age groups:

• From birth to 3 years old - called infantile scoliosis.
• From 3 to 9 years old - called juvenile scoliosis.
• From 10 to 18 years old – called adolescent scoliosis.

This last category, from 10 to 18 years old, comprises approximately 80 percent of all cases of idiopathic scoliosis.

The risk of curvature progression is increased during puberty, when the growth rate of the body is the fastest.  Scoliosis with significant curvature of the spine is much more prevalent in girls than in boys, and girls are eight times more likely to need treatment for scoliosis, because they tend to have curves that are much more likely to progress. Still, the majority of all cases of scoliosis do not require treatment.

It is important to note that idiopathic scoliosis results in spinal deformity, and is not typically a cause of back pain. Of course, people with scoliosis can develop back pain, just as most of the adult population can develop back pain. However, it has never been found that people with idiopathic scoliosis are any more likely to develop back pain than the rest of the population.

Symptoms and diagnosis of idiopathic scoliosis

People with a family history of spinal deformity are at greater risk for developing scoliosis. Early detection is essential.

There are several common physical symptoms that may indicate scoliosis. Any type of back pain is not usually considered a scoliosis symptom. Most typically, symptoms of scoliosis may include one or several of the following:

• One shoulder is higher than the other
• One shoulder blade sticks out more than the other
• One side of the rib cage appears higher than the other
• One hip appears higher or more prominent than the other
• The waist appears uneven

Frequently, a scoliosis curve in the spine is first diagnosed in school exams or in a regular check up with a pediatrician. Most students are given the Adam’s forward bend test routinely in school to determine whether or not they may have scoliosis. The test involves the student bending forward with arms stretched downward toward the floor and knees straight, while being observed by a healthcare professional. This angle most clearly shows any asymmetry in the spine and/or trunk of the adolescent’s body.

Because a scoliosis curvature is usually in the thoracic or thoracolumbar spine (upper back or mid back), if a rib hump or asymetry of the lumbar spine is found, or if the shoulders are different heights, it is possible that the patient has scoliosis. If this is the case, follow-up with a physician for a clinical evaluation and an x-ray is the next step.

• Physician’s exam. The clinical evaluation with the physician will usually include a physical exam, during which the physician will also test to make sure that there are no neurological deficits, which are uncommon but necessary to check for.
• X-ray. The x-ray is ordered to both confirm the diagnosis and check on the magnitude of the curvature. The x-ray will also give some indication as to the skeletal maturity of the patient.

In rare instances a physician may also request an MRI scan of the thoracic and/or cervical spine. If there are any neurological deficits that would indicate impingement of the spinal cord (e.g. hyperactive reflexes), if there is a left-sided thoracic curvature (they are almost always right sided), or if the child is very young (8 to 11 years old), an MRI scan is advisable to examine the possibility of an intracanal spinal lesion, which can cause scoliosis.

Depending on the results of the physician’s clinical evaluation and the diagnostic tests, a treatment plan will be recommended that may include observation, bracing, or possibly surgery.

Non-surgical treatment options for idiopathic scoliosis

Treatment decisions are primarily based on the skeletal maturity of the patient (or rather, how much more growth can be expected) as well as the degree of curvature. The cause of idiopathic scoliosis is unknown (idiopathic literally means "cause unknown"), but the way curves behave is fairly well understood. The younger the patient and the bigger the curve, the more likely the curve is to progress.

There are essentially three treatment options for adolescents with scoliosis: observation, bracing, and scoliosis surgery. There have been large trials of other forms of treatments, none of which have been shown to be effective. Electrical stimulation, physical therapy, chiropractic manipulation, osteopathic manipulation, or other manual treatments have not been shown to reduce the curvature or to prevent progression.

There is no reason to require a child to modify their activities, such as wearing their book bag on one shoulder or another, or to limit their activities, since activity does not affect the curve.

Because idiopathic scoliosis is considered a deformity, scoliosis treatment is largely centered on reducing or limiting the progression of the deformity and is not focused on treatment of pain.

Observation

The curvature is measured on x-rays by what is known as the Cobb method, and this form of measurement is accurate to within 3 to 5 degrees.

Curves that are less than 10 degrees are not considered to even represent scoliosis but rather spinal asymmetry. These types of curves are extremely unlikely to progress and generally do not need any treatment. If the child is very young and physically immature, then the progress of the curve can be followed during the child's regular check up with his or her pediatrician. If the curve is noticed to progress beyond 20 degrees, then the child should be referred to an orthopedic surgeon for continued treatment.

Curves that are between 20 to 30 degrees in a growing child can be observed at 4 to 6 month intervals. Any progression that is less than 5 degrees is not considered significant. If the curve progresses more than 5 degrees, then the curve will need treatment. Any curve over 30 degrees in a skeletally immature patient (child who is still growing) will need treatment.

Treatment for patients with progressing curves, or curves over 30 degrees in a skeletally immature patient, is usually centered on use of a back brace.

Back braces

Bracing is designed to stop the progression of the spinal curve, but it does not reduce the amount of angulation already present. The majority of curve progression happens during a child's growth phase, and once the growth has ended, there is little likelihood of progression of a curve. Therefore, bracing is continued until the child is skeletally mature and finished growing.

The only curves that tend to continue to progress after skeletal maturity are those that are greater than 50 degrees in angulation, so the treatment objective is to try to get the child into adulthood with less than a 50 degree curvature.

There are two types of commonly used scoliosis braces: a thoracolumbar sacral orthosis (TLSO) and a Charleston bending brace.

• The TLSO is a custom molded back brace that applies three-point pressure to the curvature to prevent its progression. It can be worn under loose fitting clothing, and is usually worn 23 hours a day. It can be taken off to swim or to play sports.
• A Charleston bending back brace applies more pressure and bends the child against the curve. It is worn only at night while the child is asleep.

Since bracing only works to stop the progression of the curvature in a growing child, it is not used for those children who are already skeletally mature or almost mature. It is only used for younger children (girls who are about 11 to 13 years old, and boys who are about 12 to 14 years). If an older child has a curve greater than 30 degrees and is almost mature, his or her curvature will be treated with observation only, as there is little growth left and bracing will be unlikely to do much good.

Unfortunately, even with appropriate bracing, some spinal curves will continue to progress. For these cases, especially if the child is very young, bracing may still be continued to allow the child to grow before fusing the spine. Many times it is very difficult to predict which curves will continue to progress and need surgery later, especially if the child is young and skeletally immature. When in doubt, many physicians will recommend treatment with a brace.