Scoliosis

Overview

Scoliosis is defined as a lateral curvature of the spine with rotation of the vertebrae about the vertical axis. Scoliosis can occur in either the upper back (thoracic), lower back (lumbar), or rarely, in the neck (cervical). Scoliosis is the most common spinal deformity affecting adolescents 10-16 years of age. Most cases (about 85%) of scoliosis occur during adolescence and are idiopathic (have no known cause). Scoliosis occurs in approximately 2-3% of children between the ages of 10 and 16. Although the cause of idiopathic scoliosis is not known, recent research has focused on genetic, hormonal, and environmental factors leading to the development of scoliosis.

Diagnosis

Most curves are initially detected on school scoliosis screening exams or by the child's pediatrician during routine well-child visits. Your child will most likely be referred to a pediatric orthopaedic surgeon who will perform a complete medical history and physical examination. Scoliosis is suspected by noting the presence of various asymmetries of the body in certain positions.

The shoulders may be of different heights, and the shoulder blade may be more prominent on one side when compared to the other. In addition, there may be an asymmetry in the waistline, and the head may not be centered directly above the pelvis. On the forward bend test, the physician will look for a thoracic or lumbar asymmetric prominence. Scoliosis is usually not noticeable until the curve is about 20 degrees. The diagnosis is confirmed by measuring the lateral curvature of the spine on an x-ray that is taken of the entire spine. Scoliosis is defined as a curve measuring at least 10 degrees on x-ray.

Initial imaging evaluation of a patient suspected of having scoliosis is a standing posterior-anterior (back to front) radiograph of the entire spine. Modern radiographic techniques minimize radiation exposure. When a curve is present, it is measured and discussed in terms of degrees. Most curves measure from 10 to 40 degrees in magnitude. Although radiographic measurements are used to decide treatment, a small degree of error exists when comparing radiographs. A change of 5 degrees in measurements is usually needed to document an actual change in curve progression.

Further diagnostic testing may be indicated if:

• There are abnormalities on the neurological exam
• There is an atypical appearance of the curve
• The curve magnitude has increased rapidly
• Congenital or juvenile scoliosis: usually screening MRI

How Is Scoliosis Classified?

• Infantile Scoliosis: children less than 3 years
• Juvenile Scoliosis: between the ages of 3-10 years
• Adolescent Scoliosis: onset after the age of 10 years

Nonstructural Scoliosis (also called functional scoliosis): A structurally normal spine appears curved due to a secondary condition (leg length discrepancy, inflammation, spasm, etc). This type of scoliosis generally resolved when the underlying condition is treated.

Structural Scoliosis: A structurally abnormal spine with a fixed lateral curvature. Possible causes include idiopathic (unknown origin), disease (neuromuscular, metabolic), congenital, and post-traumatic.

Curve Type:

• Thoracic Curve: One of the most common patterns in idiopathic scoliosis, 90% occur on the right side Thoracolumbar Curve: Also quite common pattern in idiopathic scoliosis, 80% occur on the right side
• Lumbar Curve: Less visible on physical examination, 70% occur on the left side
• Double Major Curve: Right thoracic and left lumbar curves are equal in size

Why Is it Important to Treat Scoliosis?

While patients with mild to moderate curves will usually have no pain or limitations from the scoliosis, severe progressive scoliosis will continue to worsen over time. Severe scoliosis will compromise heart and lung function if progression continues to greater than 90 degrees. Additionally, there is often unacceptable cosmetic appearance once the curve has reached a severe level. The goals of treatment in scoliosis center around avoiding curve progression.

Risk Factors for Curve Progression

• Female sex (10:1 female:male ratio for curves over 30 degrees)
• Thoracic or double major curves
• Curves that are greater than 20 degrees
• Skeletal immaturity (younger age)/premenarchal females (have not yet had their period)

Management of Scoliosis

There are generally three available options used in the treatment of scoliosis: observation, bracing, and surgical correction. The majority of scoliosis cases are detected early, and are treated successfully with non-operative methods.

For curves between 10-25 degrees and in the absence of progression, the recommended treatment is observation. Generally, patients will return to the orthopaedic clinic for follow-up radiographs and clinical examination every six months until growth is complete.

Bracing is usually indicated for patients with curves greater than 25 degrees with potential growth remaining. Occasionally, patients with curves measuring between 20-25 degrees should be put in a brace if there has been rapid progression. For more information about bracing, please visit our page on Bracing. The goal of bracing is to diminish or prevent the progression of scoliosis, and it is currently the only accepted non-surgical treatment modality. The brace that is commonly used in the treatment of scoliosis is the Boston TLSO (thoracolumbosacral orthosis). Other braces include the nighttime Providence brace, the Milwaukee brace, and the Charleston brace.

Bracing generally quite successful in the management of scoliosis, and is continued until growth is complete. Modern TLSO's are constructed of lightweight plastic and are low-profile-they can be concealed easily under clothes. A well-molded brace should correct the spinal deformity by 50% when worn properly. Alternative treatments, including physical therapy, electrical stimulation, and chiropractic manipulation have not been shown to alter the natural history of scoliosis.

Surgical intervention is generally recommended for curves that are greater than 40-45 degrees. The goal of surgical intervention is to correct and improve spinal deformity and reduce the risk of curve progression. Surgical techniques have improved dramatically over the last several years. The surgery will depend on the specific curve but will usually consist of either an anterior or posterior spinal fusion with instrumentation.

Management options are usually determined by the:

• Degree or magnitude of the curve
• Age of the patient
• Skeletal maturity and remaining growth
• Individual preferences of the patient and family