Scoliosis

scoliosis Scoliosis is an abnormal curvature of the spine. If your child has scoliosis, the view from behind may reveal one or more abnormal curves.

Scoliosis runs in families, but doctors often don’t know the cause. More girls than boys have severe scoliosis. Adult scoliosis may be a worsening of a condition that began in childhood, but wasn’t diagnosed or treated. In other cases, scoliosis may result from a degenerative joint condition in the spine.

Fortunately, most cases of scoliosis don’t get worse, and periodic checkups may be all your child needs. Children with a more severe curve that continues to increase may require a brace, surgery or both.

The spine is an elegant structure — from the side it takes the form of an elongated S, the upper back bowing outward and the lower back curving slightly inward. Viewed from behind though, the spine should appear as a straight line from the base of the neck to the tailbone. Scoliosis is an abnormal curvature of the spine.

Signs and symptoms of scoliosis may include:

  • Uneven shoulders
  • One shoulder blade that appears more prominent than the other
  • Uneven waist
  • One hip higher than the other
  • Leaning to one side
  • Fatigue

If a scoliosis curve gets worse, the spine will also rotate or twist, in addition to curving side to side. This causes the ribs on one side of the body to stick out farther than on the other side. Severe scoliosis can cause back pain and difficulty breathing.

Doctors don’t know what causes the most common type of scoliosis. When a cause can’t be identified, scoliosis is called idiopathic.
Sometimes, an underlying disease that affects the neuromuscular system, a leg-length discrepancy or a birth defect may cause scoliosis. Scoliosis can also begin during fetal development. Congenital scoliosis is a type of birth defect that affects the development of the vertebrae and may occur with other congenital problems, such as heart or kidney abnormalities.
Scoliosis runs in families and may involve genetic (hereditary) factors that haven’t yet been identified. Doctors also recognize that spinal cord and brainstem abnormalities play a role in some cases of scoliosis.

Scoliosis isn’t caused by poor posture, diet, exercise, or the use of backpacks.

The cause of most scoliosis is unknown (idiopathic). Scoliosis is often first noticed around the time of adolescence, during a growth spurt. Growth is often the cause for worsening of an existing curve.

Other than growth, risk factors that make it more likely that a scoliosis curve will get worse include:

  • Sex. Curves in girls are more likely to worsen than are curves in boys.
  • Age. The younger the child when scoliosis appears, the greater the chance the curve will worsen.
  • Size of the curve. The greater the curve size, the higher the likelihood that it will worsen.
  • Location. Curves in the middle to lower spine are less likely to progress than are those in the upper spine.
  • Spinal problems at birth. Children who are born with scoliosis (congenital scoliosis) have a greater risk of worsening of the curve. Congenital scoliosis is thought of as a birth defect affecting the size and shape of the bones of the spine.

The development of scoliosis is usually gradual and almost always painless. A curve can develop without the parent or child knowing it. Early detection is important in order to start treatment that can prevent the curve from getting worse. For this reason, many schools provide screening for scoliosis.

Unfortunately, scoliosis usually becomes noticeable during the time that children become more self-conscious about their bodies (ages 10 to 15), so parents and others are even less likely to see the problem. Have your child examined if you notice any of the signs of scoliosis.

Although rare, scoliosis has the potential to lead to serious health problems, such as severe back pain, difficulty breathing, physical deformity, and even injury to the lungs and heart. Be sure to have your child see your doctor if you have a family history of scoliosis.
Your child’s doctor may check for scoliosis at routine well-child visits. Many schools also have screening programs for scoliosis. If your child has a positive screen for scoliosis at school, see your doctor to confirm the condition.
Your doctor will ask about your child’s personal and family medical history and may take these diagnostic steps:

  • Physical examination. Your doctor examines the spine as well as the shoulders, hips, legs and rib cage for signs of scoliosis.
  • X-rays. Your doctor may order an initial X-ray to confirm the diagnosis and determine the size of the spinal curvature. After that, periodic X-rays are done to monitor the curve and help make treatment decisions.

Doctors describe a child’s scoliosis based on the shape and size of the curve, the location of the curve and other factors:

  • Shape. Curves develop side to side as a C- or S-shaped curve. The rotation of the spine causes the ribs and muscles near the spine to move out of normal alignment.
  • Location. The curve may occur in the upper back area where the ribs are located (thoracic), the lower back area (lumbar) or in both areas (thoracolumbar).
  • Direction. Scoliosis can bend the spine to the left or to the right.
  • Angle. Doctors measure the angle of the curve on X-rays. A normal spine without scoliosis, viewed from the back, measures zero degrees — a straight line. A very large curve that bends the spine to a horizontal position, or parallel to the floor, is described as at 90 degrees. Scoliosis is defined as a spinal curvature of greater than 10 degrees. Most doctors can detect even mild curves during a physical exam but use X-rays to measure the size of the scoliosis. Your child’s doctor can compare these measurements over time to see if the curve is getting worse.
  • Cause. About 85 percent of scoliosis cases are idiopathic, meaning the cause is unknown.

While most people with scoliosis have a mild form of the disorder, scoliosis may sometimes cause complications, including:

  • Lung and heart damage. In severe scoliosis — a curve greater than 70 degrees — the rib cage may press against the lungs and heart, making it more difficult to breathe and harder for the heart to pump. In very severe scoliosis — a curve greater than 100 degrees — damage to the lungs and the heart can occur. Any time breathing is compromised, the risk of lung infections and pneumonia increases.
  • Back problems. Adults who had scoliosis as children are more likely to have chronic back pain than are people in the general population. Also, people with untreated scoliosis may develop arthritis of the spine.
  • Body image. Your child might feel isolated and develop a poor body image from the deformity created by scoliosis during childhood and teenage years. As a parent, try to keep your child involved in activities that build confidence. Encourage friendships and normalcy whenever possible.

 

Most children with scoliosis have mild curves — less than 20 degrees — and probably won’t need treatment with a brace or surgery. Periodic checkups and X-rays are needed, though, to be sure the curve doesn’t worsen (progress). Children who are still growing need checkups about every four to six months to see if there have been changes in the curvature of their spines.

The decision to treat scoliosis is based on many factors. While there are guidelines for mild, moderate and severe curves, the decision to begin treatment is always made on an individual basis. Treatment decisions depend on your child’s age, maturity, sex, family history, curve size on X-rays and how much he or she is likely to grow.

Braces
If your child has a curve of 25 to 40 degrees and is still growing, your doctor may recommend using a brace. Wearing a brace won’t cure scoliosis, or reverse the curve, but it usually prevents further progression of the curve. Most braces are worn all the time, during the day and night. Scoliosis braces can prevent progression and the need for surgical treatment up to 90 percent of the time. Like many treatments, scoliosis braces are only effective if they are worn as directed. Both the child and the child’s family need to understand the importance of wearing the brace.

Children who wear braces can usually participate in most activities and have few restrictions. Kids can take off the brace to participate in sports or other physical activities.

Once the skeleton is mature — about 15 to 16 years old for girls and 17 to 18 years old for boys — or if the curve is too large — more than 40 to 45 degrees — a brace won’t help.

Braces aren’t useful for the treatment of congenital scoliosis because the curve is caused by abnormally shaped bones in the spine.

Braces are of two main types:

  • Underarm or low-profile brace. This type of brace is made of modern plastic materials and is contoured to conform to the body. Also called a thoracolumbosacral orthosis (TLSO), this close-fitting brace is almost invisible under the clothes, as it fits under the arms and around the rib cage, lower back and hips. A custom brace is molded to place corrective forces on the curve. Other types of braces place pads in areas to stabilize the curve.
  • Milwaukee brace. This full-torso brace has a neck ring with rests for the chin and for the back of the head. The brace has a flat bar in the front and two flat bars in the back. A Milwaukee brace may be used for curves in the upper spine. However, this brace is not commonly used today.

Other types of braces are being evaluated — some are worn only at night, others are made of material that is more flexible or use different mechanisms of pressure. However, there is currently no conclusive evidence available to support their effectiveness.

A brace isn’t effective unless a child wears it as prescribed. A brace will feel uncomfortable and awkward at first. After an initial period of adjustment, however, wearing a brace begins to feel normal. Your child may need help building a positive attitude about wearing the brace and maintaining a healthy body image.

Surgery
If your child’s curve is greater than 40 to 50 degrees, your doctor will likely recommend surgery because scoliosis of this size tends to get worse throughout a child’s lifetime. Scoliosis surgery involves techniques to fuse or join the vertebrae along the curve. Surgery is most commonly done through an incision in the middle of the back. For very rigid or severe curves, additional surgery may be needed through the side of the body.

“Fusion” means joining two pieces together. In the treatment of scoliosis, fusion involves connecting two or more of the bones in your spine (vertebrae) with new bone. The process is similar to what occurs when a broken bone heals. Eventually, the vertebrae fuse together preventing further progression of the curve. Doctors attach metal rods, hooks, screws or wires (implants) to the spine to hold the vertebrae together during the months after surgery while the bones fuse or heal together. The implants are left in the body, even after the bones have fused, to avoid another surgery. These implants can’t be seen or felt. In addition to supporting the fused area, implants also apply force to the spine to help correct the deformity and help straighten the curve.

Scoliosis surgery is a complicated orthopedic surgical procedure. The operation takes several hours. Hospitalization can last five to seven days, and activities are restricted for several months. The results of surgery are usually very good, with dramatic improvement in the scoliosis curve size.

Complications may include bleeding, infection, pain, nerve damage or failure of the bone to heal. Rarely, another surgery is needed if the first one fails to correct the problem.

Other therapies
Other treatments that have been studied for treatment of scoliosis include:

  • Electrical stimulation of muscles
  • Chiropractic manipulation
  • Exercise

There’s no evidence that any of these methods prevent spinal curvature from progressing. Although exercise alone can’t stop scoliosis, exercise may have the benefit of improving overall health and well-being.