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.
