What is Scoliosis?
The typical spine of a human body runs straight down the centerline of the back with very little to no lateral curves. The backbone of a patient with scoliosis, however, will curve to one side or the other. A lateral curvature of 10 degrees is considered scoliosis. The curve may develop as a “C” or “S” shape. An “S” shaped curvature, also known as a “double curve”, is more likely to worsen over time than a “C” shaped curvature. The position of the curve along the spine can also determine the severity of the condition. A curve at the center (thoracic) section of the spine is most likely to worsen over time and require treatment.
The type of scoliosis a patient has is usually characterized by two main factors:
- The age at which the patient was first affected.
- The underlying cause of the curvature.
Both have influencing effects on treatment options.
Functional Scoliosis Vs. Structural Scoliosis
Nonstructural Scoliosis, also known as “functional scoliosis”, involves a temporary change in spinal curvature due to underlying conditions such as muscle spasms, limb length discrepancy, or inflammatory conditions. Once the underlying issues have been resolved, nonstructural scoliosis typically corrects itself and disappears with time.
Structural Scoliosis is a fixed lateral curve in the spine often related to a disease or disorder and can not be reversed without spinal treatment. Common causes of structural scoliosis are connective tissue disorders (such as Marfan Syndrome), neuromuscular diseases (such as Cerebral Palsy or Muscular Dystrophy), genetic disorders (such as neurofibromatosis), metabolic diseases, and some arthritic diseases. Structural scoliosis can also be caused by injury, abnormal growth, tumors, or infection.
Risk Factors, Underlying Causes, & Treatment Options
Idiopathic Scoliosis is by far the most common form of scoliosis accounting for more than 80% of all cases.AANS “Idiopathic” means that there is no known cause for the condition. Adolescent Idiopathic Scoliosis, also known as AIS, is the most common and is typically diagnosed during puberty.
Neuromuscular Scoliosis is caused by poor muscle control, weakness, or paralysis due to an underlying neurological or muscular disorder such as spina bifida, cerebral palsy, or muscular dystrophy. Neuromuscular scoliosis occurs when the supporting muscles are unable to maintain proper alignment of the spine and is likely to worsen over time.
Congenital Scoliosis refers to abnormal spinal development which occurs when vertebrae fail to form properly, creating “extra” segments or when vertebrae that are supposed to be separate are fused together during fetal development.
The term “congenital” means “present at birth”, as this condition usually develops within the first six weeks of embryonic formation. Since genetic studies have yet to yield evidence of congenital scoliosis being inherited, it is generally regarded as an anatomical anomaly. The extent of congenital scoliosis varies; while some patients are only affected in one segment of the spinal column, more serious cases can affect nearly every level of the spine.
A high rate of concurrent spinal deformities are associated with congenital scoliosis—such as lordosis (abnormal backward-bending curvature) and kyphosis (abnormal forward-bending curvature). Congenital scoliosis can also be associated with additional complications affecting the kidney, bladder, and heart.
Approximately 75-90% of these curves will eventually require treatment.
Degenerative Scoliosis, also known as adult onset scoliosis, is the result of wear and tear on the spinal discs and joints of the vertebral column—known as facet joints. Most cases typically involve the lower section, or “lumbar” spine, although it can affect the upper section (thoracic) as well.
Typically, pain associated with this condition is not caused by the spinal curve, but by the degeneration and degradation of the spine itself. For this reason, the course of treatment for degenerative scoliosis is usually focused on relieving symptoms.
Scoliosis by Age Group
Infantile Scoliosis (Birth to age 3)
Infantile scoliosis normally develops within the first 6 months of birth and is typically found by a pediatrician during a standard physical examination. If scoliosis is suspected, a series of x-rays will be ordered to determine the precise measurements and severity of the curvature. Additional tests, such as a neurological exam or spinal MRI, may be ordered to ensure the spinal cord is not affected by another condition—such as plagiocephaly which affects the nervous system.
Treatment: Mild cases (10-25 degrees of curvature) of infantile scoliosis are usually treated with observation. This entails regular visits to an orthopaedic surgeon who will monitor and track changes in the curve. Many cases of infantile scoliosis are mild and can resolve themselves. However, in more severe cases, curves can grow larger and can become disabling without treatment. In these cases, bracing or casting is often required. In rare cases, surgery may be recommended.
Treatment for infantile scoliosis is generally successful and most children grow up to live normal, healthy lives without limitations.
Juvenile Scoliosis (Ages 4 to 10)
Spine growth begins to slow during this time in a child’s life. This makes it more likely for their condition to worsen over time and less likely for it to resolve on its own. Treatment is often required.
According to the Scoliosis Research Society, approximately 20% of children 10 and under with a curve greater than 20 degrees will have an underlying spinal condition. There is a particularly high incidence of Syringomyelia (a cyst along the spinal cord) and a malformation known as Arnold-Chiari (the brainstem is lower than normal). These conditions, among others, can be detected on an MRI and can be the underlying cause of juvenile scoliosis. In cases such as these, the patient may be referred to a pediatric neurosurgeon.
Treatment: Similar to infantile scoliosis, observation is normally the first method of treatment for juvenile scoliosis. Bracing or casting may be used to correct the curvature in the spine. More severe conditions may require surgery to address spinal deformities or abnormal spinal growth.
Several studies have shown a favorable long term outcome for residual curves that have minimal truncal imbalance, measure less than 40 degrees, and are treated non-surgically. Patients who underwent a surgical fusion procedure that left two or more motion segments free at the bottom of the spine also demonstrated favorable long term outcomes. However, long term studies have shown that curves that exceed 60 degrees have a likelihood of continued progression over the ensuing 3 to 4 decades and may require more treatment.
Adolescent Scoliosis (Ages 11 to 18)
This is by far the most common type of scoliosis affecting as many as 4 in every 100 adolescents. During puberty, adolescents experience “growth spurts” in which the body begins to grow rapidly. Scoliosis curves tend to grow larger and progress during this period, but will generally slow down as the body reaches skeletal maturity. However, some curves can progress well into adulthood—especially those greater than 50 degrees.
The cause of adolescent scoliosis is often unknown. This is referred to as “idiopathic” or adolescent idiopathic scoliosis (AIS). While there is no known cause for this condition at this time, there are significant efforts being made toward identifying the cause.
Some researchers believe that AIS may be the result of a combination of genetic and environmental factors. Other studies have suggested that the abnormal spinal curvature may be related to hormonal problems, abnormal bone or muscle growth, or nervous system abnormalities.
Treatment: This group has the best outlook in that the spinal curves are least likely to progress causing long term issues. However, each case must be evaluated individually to determine how much spine growth is left. X-rays of the spine, pelvis, and hand/wrist are used in correlation with the Risser Grading System to measure potential growth. The Risser grading system rates a child’s skeletal maturity on a scale of 0 to 5. Patients with a rating of 0 and 1 are still rapidly growing, while a rating of 4 to 5 means that growth has stopped. Physicians can use this information to calculate the risk of curve progression and help determine the best course of treatment. Treatment options include observation, bracing, and surgery.
Observation is used for patients whose curves are less than 20 to 30 degrees while still growing and in patients with less than 45 degrees who have finished their growth. Curves greater than 50 degrees are likely to progress into adulthood at a rate of .5 to 2 degrees per year. For this reason, these patients should be monitored well into adulthood.
Bracing is used to halt or slow the progression of the curve in hopes of avoiding surgery. Fortunately, scoliosis braces have evolved over the years in design and function. This has resulted in a more comfortable, lower profile braces that are proven more effective compared to their predecessors. According to a BrAIST study, the amount of time a brace is worn directly correlates to its effectiveness. The study found that patients who wore the brace 13+ hours a day had a success rate of 90% or higher.
Surgical treatment is often recommended for patients with curves 45 degrees or greater during growth or greater than 50 degrees when growth has stopped.
The main goal of surgical treatment is to prevent curve progression while obtaining some curve correction. This is done utilizing metal implants which are attached to the spine and connected to rods. The implants are used to correct the spine and hold it in place as the affected spine segments are fused together as one bone. This type of procedure is called surgical stabilization.
Typical post-surgery timeline: (Timelines may vary)
- 3 to 6 days- Hospital stay
- 10 to 14 days- Most children will no longer need pain medications
- 3 to 4 weeks- Patient can perform regular everyday activities and may attend school
- 3 to 6 months- Depending on level of physical activities, full participation is allowed
Adult Scoliosis (Ages 18 and older)
Scoliosis discovered after a patient has reached full skeletal maturity is known as “adult scoliosis”. Some cases are the result of pediatric scoliosis that has gone undetected and are caused by unknown reasons. However, adult scoliosis is more commonly caused by normal wear and tear on the spine.
Symptoms of adult scoliosis may include:
- Lower back pain and stiffness
- Cramping, numbness, and shooting pain the legs
- Fatigue or weakness in the lower back and legs
- Uneven alignment of the hips and pelvis
- Height loss
Treatment: Since the growth process has already completed, the main focus of treatment for adult scoliosis is usually focused on managing symptoms that affect daily activities.
Many patients with adult scoliosis do not have disabling symptoms and can be treated through non-operative means.
Scoliosis Treatment Options
Non-surgical treatment may include:
- OTC (over-the-counter) pain relievers
- Strengthening exercises that target core muscles of the abdomen and the back
- Bracing (Used occasionally for pain relief. Constant use of a brace can weaken core muscles and cause further damage.)
- Nerve block injections or epidurals
Surgical treatment is reserved for patients with severely restricted functional capabilities that result in a substantially reduced quality of life. This includes patients with disabling back and/or leg pain or spinal imbalance. These patients have exhausted all other means of non-operative treatments.
The primary goals of surgical intervention are to reduce pain, restore spinal balance, relieve nerve pressure, and correct the alignment of the spine.
Surgical treatment may include:
- Microdiscectomy (also known as microdecompression) is a surgical procedure that involves removing a small part of the bone over the nerve root and/or the disc material under the nerve root to relieve pressure on the nerve.
- Spinal Fusion is used to correct problems with the vertebrae of the spine. The basic concept of this procedure is to fuse together two or more vertebrae so they eventually fuse into a single, solid bone. This procedure is used to reduce painful motion and restore stability to the spine.
- Spinal Osteotomy is a spinal deformity correction surgery that involves cutting and reshaping the bone to restore balance, stability, and alignment to the spine. This is accomplished by removing a piece of bone from a section of your spine to realign the spine into proper positioning.
- Surgical Stabilization involves utilizing metal implants which are attached to the spine and connected to a single rod or two rods. The implants are used to correct the spine and hold it in place as the affected spinal segments are fused together as one bone.
- Vertebral Column Resection is reserved for the most severe spinal deformities and when other operative measures have failed. This procedure involves the removal of spinal segments including the body of the vertebra and the posterior elements such as the lamina, transverse process, and ribs (for thoracic spine procedures). There is some increased risk with this procedure as the spine is completely disarticulated.
Scoliosis can come in many different forms ranging from mild to severe cases. However, with early detection and proper treatment methods, this disorder does not have to keep you from living your life to the fullest. Contact us today to learn how we can help you get your health back on track.
View the table below for a more detailed overview of the structure of the spinal column.