In a normal spine the vertebrae are stacked in a straight, forward-facing direction. When the vertebrae have a lateral (side to side), C or S-shaped curve greater than 10 degrees the individual is said to have developed scoliosis. This debilitating, progressive condition affects between seven and twelve million Americans who are usually otherwise healthy. Scoliosis is most often located in the upper back (thoracic spine) but can also develop in the lower back (lumbar spine). It is also sometimes found in the area between the upper back and lower back known as the thoracolumbar spine. Scoliosis appears most often in the thoracic spine of individuals (girls more than boys) who are ten to fifteen years of age, and to a much lesser extent in children and adults.
The condition primarily impacts the body’s musculoskeletal system (spine, ribs, and pelvis). As scoliosis progresses during the adolescent growth spurt and into adulthood it can affect the individual’s pulmonary and cardiac function, as well as his or her neurological, digestive, and hormonal systems. Scoliosis can manifest itself in rib deformity, shortness of breath, back and hip pain, chronic fatigue, acute headaches, mood swings, and menstrual disturbances. It had been believed that once the individual reached skeletal maturity (stopped growing) increases in the curvature would end. Recent research, however, has indicated that the increase in curvature most often continues into adulthood.
Q: How does an individual develop scoliosis?
A: Approximately twenty percent of scoliosis cases can be attributed to one or more of the following: spinal injury, congenital spine defect (fetal spine fails to form properly), genetic abnormality/hereditary scoliosis, spina bifida, cerebral palsy, muscular dystrophy, vertebral deformity/spine muscle atrophy, spine tumor, infection, unequal limb growth, back muscle spasms, etc.
For the remaining eighty percent of cases the cause is unknown. In this situation the individual is said to have idiopathic scoliosis. There are four categories of idiopathic scoliosis:
- Infantile idiopathic scoliosis – the condition develops when the child is less than three years old
- Juvenile idiopathic scoliosis – the condition develops when the child is between 3 and 9 years of age
- Adolescent idiopathic scoliosis – the condition develops when the individual is between 10 and 18 years of age
- Adult idiopathic scoliosis – this condition develops when the individual is past the age of a 18 years. There are two forms of adult idiopathic scoliosis. The first is a continuation of adolescent idiopathic scoliosis that may or may not have been recognized and/or treated. The second is degenerative (de novo) scoliosis that develops in the lumbar spine in the middle to late adult years. The causes include traumatic injury, osteoarthritis or rheumatoid arthritis, or a degeneration of the intervertebral discs and facet joints of the spine. De novo scoliosis usually appears in association with a narrowing of spaces in the spine (spinal stenosis) which can put pressure on the spinal cord and/or spinal nerves resulting in back and leg pain.
Q: What are the symptoms of scoliosis?
A: In some instances a scoliosis curve is very noticeable. In other cases there are a number of visual indicators to suggest the presence of scoliosis including:
- The spine curvature is evident upon radiographic examination
- Shoulder or hip height is asymmetric
- There is a difference in shoulder blade height or position
- There is a difference in the way the arms hang beside the body when the individual is standing straight
Pain in the back or legs is not usually associated with idiopathic scoliosis until the spinal curve reaches an exaggerated stage (greater than 40 degrees). If you suspect a child may be developing scoliosis it is always wise to consult a spine specialist for a determination and/or confirmation of the condition. The specialist’s examination will usually include an x-ray of the spine in the standing position, and if deemed necessary CAT-scan or MRI evaluation. If scoliosis is evident, the specialist will measure the degree of the curvature (Cobb angle) and then prescribe a course of treatment.
Q: Does the scoliosis curve always go in one direction?
A: The scoliosis curve pattern varies according to spine region:
- Thoracic spine – the predominant curve (90%) is to the right side
- Thoracolumbar spine – the predominant curve (70%) is to the left side
- Lumbar spine – the predominant curve (80%) is to the left right side
- A protruding rib or uneven rib cage
- Curves that occur on both the right and left sides are known as double major curves
Q: What are the treatment options for the of scoliosis?
A: There are three basic treatment options for scoliosis that are based on the degree of spinal curvature: observation and measurement, bracing and surgery. Until the scoliosis curve reaches 25 degrees conventional wisdom suggests that the curvature be periodically monitored (including x-rays) and measured. Most school districts now have mandatory student scoliosis screening in the fourth through eighth grades to facilitate early detection. Once a curve has been detected it is recommended that the individual undergo a thorough examination and begin a rehabilitation program that takes into consideration the child’s age (spinal maturity), severity and location of the curvature, gender and if other health conditions are present. The rehab program usually includes physical therapy and/or exercises designed to maintain a healthy back. It will not, however, reduce the curve angle or retard curve progression.
Bracing is deemed appropriate when the curve exceeds 25 degrees. If the curve exceeds 40 or more degrees corrective surgery may be recommended. Early detection of scoliosis is essential for treatment option success.
Q: What type of bracing is most appropriate?
A: The subject of bracing is not without controversy. There are reports that provide evidence of bracing success in preventing progression and, in some cases, substantial correction. However, there are other reports that indicate bracing does not serve a therapeutic purpose. While the correction issue can be debated, it is generally agreed that bracing can retard curve progression. Depending on the individual’s age and degree of curvature custom-designed braces made from plastic or other synthetic material are intended to be worn 23 hours/day, while others are to be worn only at night. The spine specialist may select a bracing option from the following alternatives:
- A thoracolumbrosacral orthosis (TLSO) brace (Boston brace, Milwaukee brace (used for high thoracic curves), etc.)
- Charleston scoliosis brace – worn only at night, studies have shown comparable outcomes to TLSO braces
- Risser jacket – brace should be worn 23 hours/day
- Providence brace – designed to be worn at night
- Copes scoliosis brace – a dynamic brace that is frequently adjusted to achieve treatment objectives
- Rosenberger brace – low-profile TLSO brace intended to improve patient instructional compliance
- SpineCor Dynamic Corrective Brace – effectiveness being evaluated
Q: When should the surgery option be considered?
A: Scoliosis surgery is indicated when a growing child or adolescent has a highly progressive curve greater than 40 degrees, the patient is experiencing severe pain, or the scoliosis curve is greater than 50 degrees accompanied by severe trunk asymmetry. The surgeon most often uses spinal fusion techniques and a variety of instrumentation alternatives including rods, screws, hooks, wires, etc. to reduce and stabilize the scoliosis curve. The particular surgical approach the surgeon selects is function of the following:
- Spinal maturity—is the patient’s spine still growing?
- Degree of pain experienced and impact on the patient’s health and lifestyle
- Degree and extent of the curvature
- The spine region (s) in which the curve occurs
- Success or failure of previous treatment alternatives
- Estimate of probable progression following surgery
Summary: Scoliosis is a frequently occurring spinal abnormality that negatively affects the quality of life of young Americans, but can also affect individuals of all ages. Although treatment alternatives continue to be refined, early detection and treatment of the condition continues to be of critical importance.
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