Your spine, or backbone, helps hold your body upright. Without it, you couldn't walk, run, or play sports.
If you look at yourself sideways in the mirror or look at a friend from the side, you'll notice that the back isn't flat like a piece of board. Instead, it curves in and out between your neck and lower back.
Someone with scoliosis may have a back that curves like an "S" or a "C." It may or may not be noticeable to others. While small curves generally do not cause problems, larger curves can cause discomfort.
Despite that gentle curve from the side, a healthy spine appears to run straight down the middle of the back. The trouble for someone with scoliosis is that the spine curves from side to side.
What Is Scoliosis?
The word scoliosis comes from a Greek word meaning crooked. If you have scoliosis, you're not alone. About three out of every 100 people have some form of scoliosis, though for many people it's not much of a problem. For a small number of people, the curve gets worse as they grow and they may need a brace or an operation to correct it.
Someone with scoliosis may have a back that curves like an "S" or a "C." It may or may not be noticeable to others. While small curves generally do not cause problems, larger curves can cause discomfort. The X-ray image to the right shows what scoliosis looks like.
No one knows what causes the most common type of scoliosis, which is called idiopathic (say: ih-dee-uh-pa-thik) scoliosis. (Idiopathic is a fancy word for "unknown cause.") Doctors do know scoliosis can run in families. So if a parent, sister or brother had scoliosis, you might have it, too.
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How Do I Find Out If My Child Has Scoliosis?
Sometimes scoliosis will be easily noticeable. A curved spine can cause someone's body to tilt to the left or right. Many kids with scoliosis have one shoulder blade that's higher than the other or an uneven waist with a tendency to lean to one side. You might notice these problems when a kid is trying on new clothes. If one pant leg is shorter than the other, a kid might have scoliosis. It's also possible that the kid does not have scoliosis, but one leg may be slightly shorter than the other or the ribs may be uneven.
You might get examined for scoliosis at school or during a doctor visit. In the United States, about half of the states require public schools to test for scoliosis. It's an easy test called the forward-bending test, and it doesn't hurt at all. It involves bending over, with straight knees, and reaching your fingertips toward your feet or the floor. Then, a doctor or nurse will look at your back to see if your spine curves or if your ribs are uneven.
Early onset scoliosis (EOS) is defined as scoliosis in children age 5 and under. It includes infantile idiopathic scoliosis and congenital scoliosis.
Infantile scoliosis is scoliosis that is first diagnosed in a child between birth and 3 years old. Many infantile curves will resolve without treatment, but those that don’t resolve can be very difficult to manage because of the growth that occurs through the spine as the young child gets older.
Sometimes Infantile scoliosis is associated with Thoracic Insufficiency Syndrome, which is defined as the inability of the thorax to support normal breathing or lung growth.
The thorax includes the spine, rib cage, and sternum (breast bone). There needs to be enough space in the thorax for the lungs to grow, and for breathing to occur. Initially, during the early stages of scoliosis — or from fused or absent ribs — the infant may not have any trouble breathing. As the deformity gets worse, breathing can become more difficult, making routine activities like play more difficult.
If the thorax doesn’t enlarge as the child grows, the lungs don’t grow normally, limiting the child’s capacity for breathing. Without an adequate ability to breathe, the child may develop growth and developmental delays.
Congenital scoliosis and congenital kyphosis refer to a spinal deformity caused by vertebrae that are malformed. The malformation occurs in the first six weeks of pregnancy. The abnormalities include vertebra that are not completely formed, vertebra that are fused (attached) together, and misshaped vertebra (wedging).
Because the vertebrae are abnormally shaped, there is an imbalance in the growth of bones of the spine. This growth imbalance results in a deformity that is described by the area of vertebrae that are malformed:
Scoliosis – a curve to the right or left; Kyphosis – rounding of the back; Lordosis – swaying of the back
Often the child has a combination of the deformities described above.
In the thoracic (chest) part of the spine, there are often anomalies of the ribs as well. For example, an extra thoracic vertebra might attach to an extra rib. Vertebrae that are connected together may be associated with ribs that are connected.
The most common type of scoliosis seen in children is adolescent idiopathic scoliosis (AIS). AIS is defined as scoliosis that occurs after 10 years of age, but the cause is not known (idiopathic). The time of highest risk for curve progression in AIS occurs around puberty when the growth rate is the fastest.
Causes of Adolescent Scoliosis
There are significant efforts being made toward finding the cause of AIS, but there are no well-accepted causes for this type of scoliosis. Most patients are otherwise healthy and have no previous medical history. There are many theories about the cause of AIS. Approximately 30% of AIS patients have some family history of scoliosis, and therefore there seems to be a genetic connection. Despite not knowing the exact cause, we currently have accurate methods to determine the risk for curve progression of scoliosis and good methods of treatment.
Often, children do not even notice that they have a spinal problem. In some cases, the child or parent may notice that one shoulder blade sticks out when asked to bend forward (often called a rib hump) or that one shoulder is higher than the other. Adolescent idiopathic scoliosis generally does not result in pain or neurologic symptoms but back pain, uneven hips and asymmetry at the waist and shoulders might be signs of AIS. Additionally, there sometimes is a visible curving of the spine when looking at the adolescent’s back. Many teens in general experience back pain due to taking part in many activities without having good core abdominal and back strength, as well as flexibility of the hamstrings. Often this can be relieved with physical therapy. Often this can be relieved with physical therapy.
The typical radiographic images that are obtained to define scoliosis include a standing X-ray of the entire spine looking both from the back as well as from the side. Your physician will be able to measure the radiographs to determine your curves magnitude, which is measured in degrees.
Growth is a very important determinant in the treatment of scoliosis and therefore the child's growth stage must be evaluated. One way in which we do this is by taking an X-ray of the child's hand to assess the growth plates. We also consider the child's age and the presence or absence of menstruation in female patients. We use all this information to figure out what phase of growth the child is in and to predict how much growing the child has left.
A spine specialist should monitor AIS regularly because of the possibility for the curvature to progress. Scoliosis progression can cause a permanent deformity and pain. If the scoliotic curve becomes excessively large, other serious physical difficulties can occur, including shortness of breath due to limited expansion of the lungs. If the curve affects the lumbar spine, there can be significant lower back and leg pain.
OrthoONE Pediatric Scoliosis and Spine utilizes ScoliScore to monitor AIS in applicable patient populations. ScoliScore has been developed to identify a genetic risk to the progression of a curve and helps predict curves that will or will not become larger.
Scoliosis treatment is based on curve progression. Observation, bracing and surgery are the three treatment options common for kids with AIS.
Observation is generally for patients whose curves are less than 25-30° who are still growing, or for curves less than 45° in patients who have completed their growth. Physicians often wish to observe the scoliosis every few years after patients complete their growth to make sure it does not progress into adulthood.
Bracing is recommended for patients with curves that measure between 25° and 40° during their growth phase. The goal is to prevent the curve from getting bigger. This is accomplished by correcting the curve while the patient is in the brace so that the curve does not progress with time. Growth plates on the vertebrae are more likely to grow symmetrically if they have equal pressure over their surface as the child grows. Straighter spines equalize pressure better than curved spines. Once the brace is discontinued, the goal is to maintain the curve at the magnitude present when the brace was started.
Even if slight curve progression occurs despite wearing the brace, surgical treatment may not be necessary if the curve remains below 50° at the end of growth. Braces are worn under the clothes and cannot be seen by others. Bracing is most effective when it is worn more than 18-22 hours per day. Your physician will often recommend removing the brace for bathing and sports. When bracing treatment is started, radiographs are usually performed with the brace on to ensure that the brace is effective in achieving some correction of the curve(s).
Alternative treatments to prevent curve progression or prevent further curve progression such as chiropractic medicine, physical therapy, yoga, etc. have not demonstrated any scientific value in the treatment of scoliosis. However, these and other methods can be utilized if they provide some physical benefit to the patient such as core strengthening, symptom relief, etc. These should not, however, be utilized as a primary treatment of scoliosis.
Surgical treatment is recommended for patients whose curves are greater than 45° while still growing, or are continuing to progress greater than 45° when growth stopped. The goal of surgical treatment is two-fold: first, to prevent curve progression and secondly to obtain some curve correction. Surgical treatment today utilizes metal implants that are attached to the spine, and then connected to a single rod or two rods. Implants are used to correct the spine and hold the spine in the corrected position until the instrumented segments fuse together as one bone.
The surgery is usually performed from the back of the spine (posterior approach) through a straight incision along the midline of the back. Following surgical treatment, no external bracing or casts are used. The hospital stay is generally between 5 and 7 days. The patient can perform regular daily activities and generally returns to school in 3-4 weeks.
A) Front and side X-rays of a patient with adolescent idiopathic scoliosis in her thoracic spine.
B) Post-surgical correction through a posterior approach using two rods and pedicle screws.
Information and figures adapted from Scoliosis Research Society