Scoliosis

Scoliosis is a musculoskeletal disorder in which the spine, or backbone, is curved laterally. The bones that make up the spine are called vertebrae. Some people who have scoliosis require treatment. Other people, who have milder curves, may only need to visit their doctor for periodic observation.

Types

The most common types of scoliosis include the following:

• Idiopathic
• Neuromuscular
• Congenital
• Degenerative

Idiopathic scoliosis can be structural or non-structural. In structural idiopathic scoliosis, the vertebrae and discs are wedged. Non-structural scoliosis is a temporary reaction to pain or an underlying condition such as posture or inflammation, and the vertebrae and discs are shaped normally.

Scoliosis is also categorized by the age range of the patient (infantile, juvenile, adolescent, and adult).

Symptoms

The symptoms of scoliosis include uneven shoulder blades or hip bones, prominent shoulder blade or ribs on one side, uneven waist, back pain, and muscle fatigue.

Causes

In 70% to 80% of people with scoliosis, the cause is unknown. This type of scoliosis, known as idiopathic scoliosis, is much more common in females than in males.

Neuromuscular scoliosis can be part of conditions such as Marfan syndrome, Ehlers-Danlos syndrome, spina bifida, Charcot-Marie Tooth, cerebral palsy, Poliomyelitis, Parkinson's disease, multiple sclerosis, and Duchenne's muscular dystrophy.

Congenital scoliosis can be caused by a failure of vertebral formation or by a failure of segmentation during embryonic formation. [1]

Additionally, spinal tumors and trauma can cause scoliosis. But, perhaps the largest number of non-adolescent idiopathic scoliosis cases are caused by age related degeneration of the bone and discs of the spine.

Diagnosis

Scoliosis is evaluated in several steps:

• Medical history
• Physical examination This involves examination of the back, chest, pelvis, legs, feet, and skin. The doctor checks if the patient's shoulders are level, whether the head is centered, and whether opposite sides of the body look level. The doctor also examines the back muscles while the patient is bending forward to see if one side of the rib cage is higher than the other. If there is a significant asymmetry (difference between opposite sides of the body), an orthopedic spine specialist (a doctor who has experience treating people with scoliosis) is consulted. Certain changes in the skin, such as so-called café au lait (coffee-with-milk-colored) spots, can suggest that the scoliosis is caused by a birth defect.
• X-ray evaluation This is performed in patients with significant spinal curves, unusual back pain, or signs of involvement of the central nervous system (brain and spinal cord), such as bowel and bladder controlproblems.
• Curve measurement In this test, the doctor measures the curve on the x-ray image. She finds the vertebrae at the beginning and end of the curve and measures the angle of the curve (see "Curve Patterns" diagram). Curves that are greater than 20 degrees require treatment.

Doctors group curves of the spine by their location, shape, pattern, and cause. They use this information to decide how best to treat the scoliosis.

• Location To identify a curve's location, doctors find the apex of the curve (the vertebra within the curve that is the most off-center); the location of the apex is the "location" of the curve. A thoracic curve has its apex in the thoracic area (the part of the spine to which the ribs attach). A lumbar curve has its apex in the lower back. A thoracolumbar curve has its apex where the thoracic and lumbar vertebrae join (see "Normal Spine" diagram).
• Shape The curve is usually “S”- or “C”-shaped.
• Pattern Curves frequently follow patterns that have been studied in previous patients (see "Curve Patterns" diagram). The larger the curve is, the more likely it will progress (depending on the amount of growth remaining).

Illustration showing curvature in the thoracic, lumbar, thoracolumbar, regions, and double curvature of the spine. Source:National Institute of Arthritis and Musculoskeletal and Skin Diseases

Illustration showing side and back view of normal spine, and location of separate areas: 1st cervical; 1st thoracic; 1st lumbar; invertebral disk; sacrum; and coccyx. Source: National Institute of Arthritis and Musculoskeletal and Skin Diseases

Treatment

Many children who are sent to the doctor by a school scoliosis screening program have very mild spinal curves that do not need treatment.

Treatment of children depends on age, how much more he or she is likely to grow, the degree and pattern of the curve, and the type of scoliosis. Sometimes only monitoring is needed for worsening of symptoms. Treatment typically consists of bracing, therapy or surgery.

• Observation– Doctors follow patients without treatment and re-examine them every four to six months when the patient is still growing and has a curve of less than 25 degrees.
• Bracing–This is done in the following situations:
  • the child is still growing and has an idiopathic curve that is more than 25 to 30 degrees;
  • the child has at least 2 years of growth remaining, has an idiopathic curve that is between 20 and 29 degrees, and, if a girl, has not had her first menstrual period; or
  • the child is still growing and has an idiopathic curve between 20 and 29 degrees that is getting worse.

As a child nears the end of growth, the indications for bracing depends on how the curve affects the child's appearance, whether the curve is getting worse, and the size of the curve.

• Therapy–Often this is done by a physical therapist. This is usually only done if the pain is such that therapeutic techniques are warranted.
• Surgery–This is done if the curve is worsening as the child grows or when the curve is more than 45 degrees. Usually the surgery involves insertion of metal rods and screws or other hardware to fix the bones to each other and stop and correct any ill movements

Choosing a brace

Brace selection depends on the type of curve and whether the patient will follow directions on how many hours a day to wear the brace. There are two main types of braces. Braces are either custom-made or made from a prefabricated mold. All must be selected for the specific curve problem and fitted to each patient.

• Milwaukee brace–Patients can wear this brace to correct any curve in the spine. This brace has a neck ring.
• Thoracolumbosacral orthosis (TLSO)–Patients can wear this brace to correct curves whose apex is at or below the eighth thoracic vertebra (see "Normal Spine" diagram). The TLSO is an underarm brace, which means that it fits under the arm and around the rib cage, lower back, and hips.

Choice of surgery

Many surgical techniques can be used to correct the curves of scoliosis. The main surgical procedure is correction, stabilization, and fusion of the curve. Fusion is the joining of two or more vertebrae. Surgeons can choose different ways to straighten the spine and also different implants to keep the spine stable after surgery. (Implants are devices that remain in the patient after surgery to keep the spine aligned.) The decision about the type of implant depends on the cost; the size of the implant, which depends on the size of the patient; the shape of the implant; its safety; and the experience of the surgeon.

Alternative treatments

Some people have tried other ways to treat scoliosis, including manipulation by a chiropractor, electrical stimulation, dietary supplements, and corrective exercises. So far, studies of the following treatments have not been shown to prevent worsening of the curve:

• Chiropractic manipulation
• Electrical stimulation
• Nutritional supplementation
• Exercise –Studies have shown that exercise alone will not stop progressive curves.

Chances of Developing Scoliosis

Of every 1,000 children, 3 to 5 develop spinal curves that are considered large enough to need treatment. Adolescent idiopathic scoliosis is the most common type and occurs after the age of 10 years. Girls are more likely than boys to have this type of scoliosis.

Idiopathic scoliosis is rare in children younger than 10 years of age. Early onset or infantile idiopathic scoliosis occurs in children less than 3 years old. It is more common in Europe than in the United States. Juvenile idiopathic scoliosis occurs in children between the ages of 3 years and 10 years.

Living with Scoliosis

For many, scoliosis does not greatly affect daily life or lifespan. Moderate or severe curves can affect lifestyle and cause other medical issues. Chronic back pain can be a problem, especially during pregnancy or manual labor. Proper posture, fitness, and good body mechanics are often needed.

Research

Researchers are looking for the cause of idiopathic scoliosis. They have studied genetics, growth, structural and biochemical alterations in the discs and muscles, and central nervous system changes. The changes in the discs and muscles seem to be a result of scoliosis and not the cause. Scientists are still hopeful that studying changes in the central nervous system in people with idiopathic scoliosis may reveal a cause of this disorder.

Researchers continue to examine how a variety of braces, surgical procedures, and surgical instruments can be used to straighten the spine or to prevent further curvature. They are also studying the long-term effects of a scoliosis fusion and the long-term effects of untreated scoliosis.

External Links

National Scoliosis Foundation

The Scoliosis Association, Inc.

Scoliosis Research Society