What is Scoliosis?

The spine normally has curves. When viewed from the side (mid-sagittal), the anterior convexity of the cervical and lumbar spines is called lordosis. If this is increased beyond normal, it is called increased lordosis. Similarly, the thoracic spine normally has the opposite curvature (convex posteriorly when viewed from the side) or kyphosis.

Scoliosis is a lateral deviation in the normally straight vertical line of the spine when viewed from the front. It may or may not include rotation or deformity of the vertebrae. Abnormal curvatures may be congenital or acquired. Most cases are acquired. Scoliosis may be fixed or compensated. A fixed scoliosis is the result of change in the structure of the vertebrae. The associated rotation is in the direction of the convexity of the curve. Fixed scoliosis may be C-shaped or S-shaped. It cannot be eliminated by movement. Fixed scoliosis is further classified as to the cause (congenital, neuromuscular and idiopathic) and deformity present.

Neuromuscular and idiopathic are acquired forms of the disorder. Idiopathic scoliosis is the most common. There is no known cause. It may occur at any age. It is further divided according to age (infantile, juvenile, adolescent, or adult) of onset. It tends to run in families. Neuromuscular scoliosis results from muscular weakness, muscular imbalance or neurologic dysfunction and paralysis. Progression of the disease results in a more pronounced, rigid curve. Scoliosis occurs in both sexes. Females are affected more than males are.

Approximately one percent of the general population have some amount of scoliosis. It can occur at any age, but is most often noted during adolescence. Scoliosis may be associated with other abnormal curvatures such as kyphoscoliosis or lordoscoliosis.

A compensated scoliosis has a flexible segment above or below the major curve and tends to maintain normal body alignment. In many instances, it can be corrected by exercise. Large curvatures are associated with cardiopulmonary impairment and secondary restrictive lung disease.

Scheuermann's kyphosis is an abnormal curvature in the thoracic spine. Abnormal curvatures may be associated with other diseases. Neurofibromatosis, Marfan's syndrome and Ehlers - Danlos syndrome are associated with scoliosis. The abnormal curvatures tend to progress. The progression of the curve is related to the age of the individual, gender, the underlying cause and the degree of the curvature. The greatest progression tends to occur during the accelerated growth spurt of puberty.

How is it diagnosed?

Early diagnosis of scoliosis may prevent worsening of the condition. In attempting to diagnose scoliosis, the physician will compile a medical history and perform a physical examination. A medical history and exam that searches for other potential problems are especially important in identifying scoliosis. For example, congenital scoliosis is frequently associated with kidney problems. A physician who diagnoses congenital scoliosis may follow up by examining the kidneys. Conversely, a physician who finds a kidney problem in a young child will check the back for scoliosis. A physician may ask if there were difficulties during a pregnancy or at what age a child learned to walk.

In some cases, the signs of scoliosis are visibly obvious. The spine may be curved to one side or one shoulder blade may be noticeably higher than the other. The physician will also look to see if one side of the rib cage is higher than the other. Congenital scoliosis may be diagnosed in infancy when a vertebral defect is identified. When a neuromuscular disease such as muscular dystrophy or spina bifida is an underlying condition, physicians regularly check for the onset of scoliosis.

One of the first steps used to diagnose scoliosis is the Adams forward bending test. The patient bends forward from the waist with straight legs and the arms extended. The physician checks to see if the back is parallel to the floor, with neither side significantly higher than the other. This test is also used by some public schools that screen students for scoliosis.

When these physical tests indicate a potential problem, patients may have an x-ray of the spine. X-rays show spinal curvature and can also indicate the likelihood of progression in adolescents by whether or not they have finished growing. Other imaging tests, such as computed axial tomography (CAT scan) or magnetic resonance imaging (MRI) may also be used. A physician will consider the characteristics associated with the spinal curvature, including its shape, location on the spine, direction and angle. Physicians who detect mild curvature may not take x-rays, but only recheck the patient in a few months.

If the examination reveals significant curvature of the spine, the patient will be referred to an orthopedist, a physician who specializes in the diagnosis and treatment of conditions related to the skeletal system. An orthopedist uses a measure called a Cobb angle to diagnose the severity of a patient’s spinal curvature. The Cobb angle measures the curvature of the spine in degrees and recommends treatment options based on this reading. Cobb angle measurements are taken with a device called a scoliometer. The results of these measurements will determine the method of treatment used for idiopathic scoliosis:

Cobb Angle Measurement	Treatment
10 to 20 degrees	No treatment necessary, aside from regular checkups until pubertal maturation and growth are complete
25 to 45 degrees	Back brace
45 degrees or more	Surgery

The angle measurements used to treat other types of scoliosis may vary. Patients with neuromuscular scoliosis caused by muscular dystrophy cannot be treated with braces and may be advised to have surgery when their spinal curvature is less than 30 degrees. Muscular dystrophy patients progressively lose lung function and must have surgery while they still have enough lung capacity for the anesthesia and surgery.

How is Scoliosis treated?

Many cases of scoliosis are mild and require no treatment. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, about three to five out of every 1,000 children develop curves in the spine that are large enough to require treatment.

The primary treatment for scoliosis that requires therapy is the use of a back brace. These are either custom-made or made from a prefabricated mold. They are constructed of a lightweight material that usually is not visible under clothes.

Most patients wear a back brace for 18 to 20 hours each day. However, they likely will wear the brace less and less as their body gets closer to full adult size. Once the body has reached maturity, the patient no longer needs to wear the brace.

Back braces hold the spine in place and keep it from developing a greater curve than already exists. The brace is not designed to straighten the spine, but rather to help keep the spine from curving no more than an additional 5 to 10 degrees.

There are various types of back braces, and patients wear the brace that is appropriate given the severity of their curvature. Types of back braces include:

• Thoracolumbosacral orthosis (TLSO). This is a low-profile brace, which means that it comes up to a level under the arms and is comfortable to wear. It is worn by patients who have a curvature in the lower part of their back. The TLSO is worn under clothes and is also known by various other names, including the New York, Wilmington, Miami or Boston brace.
• Milwaukee brace. This brace has a neck ring. It can be used to correct any curve in the spine.
• Charleston brace. Also a low-profile brace, it bends the spine in an effort to straighten the curve and keep it from worsening. However, the brace puts the wearer’s body in an awkward position and can be worn only when the patient is sleeping.

If the scoliosis causes back pain, a physician may recommend treatments including medications such as analgesics or anti-inflammatories, modalities (physical agents) such as hydrotherapy or thermotherapy, or physical therapy.

In some cases, spinal surgery is required to correct a severe spinal curvature. Surgical options include:

• Posterior spinal fusion and instrumentation. The most common surgical procedure for scoliosis, it involves removing tiny pieces of bone from the patient’s pelvis (hipbone). These are then inserted between two or more vertebrae. Over time, the vertebrae and pieces of bone grow together, which provides stability and prevents further side-to-side curvature of the spine. In a process known as instrumentation, the surgeon will also use metal rods, hooks and wire to keep the spine straight while the bits of bone fuse together with the vertebrae. This process normally takes about a year. In addition, it can help reduce the spinal curvature by as much as 50 percent.
• Anterior spinal fusion. In some situations, surgery may involve the front of the spine. The surgeon performs the procedure through the chest cavity.

Scoliosis surgery generally takes between three and six hours, and the patient may stay in the hospital for about a week. Within a month, most patients are back in school. Patients can usually return to regular activities within three or four months. After one year, a patient typically can return to contact sports.

Within a year, the bone fusion will be complete, the metal rods that have been placed in the back will not substantially limit movement and the patient should be able to bend and move normally.

For young children born with severe cases of scoliosis that deform the chest and restrict the lungs, one treatment option may be a vertical expandable prosthetic titanium rib (VEPTR). The Food and Drug Administration (FDA) approved this device in 2004 to treat thoracic insufficiency syndrome, a congenital condition in which severe deformities of the spine, ribs and chest hinder lung development and breathing. The syndrome can include severe scoliosis.

VEPTR involves the surgical implantation of an adjustable curved metal rod to ribs near the spine. The goal is to support the chest and allow normal development. A surgeon adjusts or replaces the device periodically as the child grows. Eventually it can be removed. According to the FDA, VEPTR should not be used for conditions other than chest wall instability and cannot be used in certain populations, such as infants younger than 6 months or children who are skeletally mature (about age 16 years for boys, 14 for girls).

Some patients with scoliosis have used electrical stimulation of muscles or chiropractic manipulation to try to treat scoliosis. However, there is little evidence that these methods work.

Exercise cannot prevent scoliosis, but it may improve the health and well-being of patients with scoliosis. Parents and patients should consult their child’s physician about the most appropriate exercise regimen.

Medications

Soma (Carisoprodol)

What might complicate it?

Complications include progressive curvature, postural and neuromuscular problems, and heart and lung problems.

Predicted outcome

Most cases of scoliosis or kyphosis can be corrected with proper treatment.

Alternatives

No other conditions are indicated.

Appropriate specialists

Orthopedic surgeon, radiologist, physical therapist, cardiologist, and pulmonologist.

Last updated 12 July 2015