Scoliosis

Unfortunately, spinal stenosis cannot be cured, and nothing can stop or reverse the progression of spinal cord damage caused by aging

• Our spine is an engineering marvel that supports our weight and ties our body together.
  • The spine consists of a column of small bones (vertebrae) that range in size from 2-3 inches to 5-6 inches in diameter.
  • It is divided into anatomical sections. These are the
    • cervical spine (neck), which has seven vertebrae;
    • thoracic spine (upper back), which has 12 vertebrae to which the ribs are attached;
    • lumbar spine (lower back), which has five vertebrae;
    • sacrum, which consists of five bones that are fused or stuck together; and
    • coccyx, which is made up of four tiny bones.
  • When viewed from the front, the normal spine appears to be straight, but when viewed from the side, the normal spine has two gentle S curves. One curves outward in the upper back (called kyphosis by physicians), and the other curves inward in the lower back (known as lordosis).

Scoliosis is an abnormal curvature of the spine. In scoliosis, the spine curves to the side when viewed from the front, and each involved vertebra also twists on the next one in a corkscrew fashion. This twisting is known as rotoscoliosis. This may cause one shoulder to be higher than the other or one side of the ribcage or lower back to be more prominent (humpback). If there is both a sidewise curvature and an increase in the outward curvature of the upper back, this condition is called kyphoscoliosis. It is more common in children with neuromuscular diseases. A curve with a right-sided prominence is called dextroscoliosis, and a left-sided prominence is levoscoliosis. Generally, children with idiopathic (of unknown cause) scoliosis have two sidewise curves in opposite directions, but these may not be of the same size or severity.

There are multiple types of scoliosis, classified by age of onset and/or cause. These include the following:

• Congenital scoliosis is present at birth and is caused by vertebrae that are not properly formed before birth. Part of a vertebra may be missing or wedge-shaped, and/or abnormal bony bridges between two or more vertebrae may be present.
• With infantile scoliosis, patients are younger than 3 years of age. It is more common in boys and may resolve on its own with only observation. Generally, this type of scoliosis has less of a rotational component than other types.
• Juvenile scoliosis is seen in children 3-10 years of age. It is more common in girls than boys and is at the greatest risk of progression of all types, with the highest risk of progression in girls.
• Idiopathic scoliosis is the most common type of scoliosis. This type is seen in children 11-16 years of age. It is also more common in girls, and they are at higher risk of progression of the curvature. The term idiopathic refers to any medical condition that arises spontaneously without a known cause.
• Neuromuscular scoliosis is caused by several associated disease processes that affect the neurologic or muscular systems. This may include cerebral palsy, muscular dystrophy, metabolic diseases, and connective tissue disorders such as Marfan's syndrome. The age of onset is variable and depends on the disease process.
• Adult-acquired scoliosis is due to acquired degenerative changes as the spine ages in patients over the age of 18.

In most cases, the cause of scoliosis is unknown (what doctors call idiopathic). The non-idiopathic types generally fall into two groups:

• Nonstructural (functional): This type of scoliosis is a temporary condition when the spine is otherwise normal. The curvature occurs as the result of another problem (from one leg being shorter than another, muscle spasms due to a soft tissue injury, ruptured disc, or abdominal problems, such as appendicitis).
• Structural: In this type of scoliosis, the spine is not normal. This may be due to abnormally shaped vertebrae or neuromuscular diseases.
  • About 30% of children with idiopathic scoliosis have a family history of the condition, but the exact hereditary (genetic) association is not known at this time.

Risk factors for idiopathic scoliosis and its progression (worsening of the curvature) include the following:

• Female gender
• Family history of scoliosis
• Bone age is significantly less than chronologic age
• Progression of the curve despite bracing or the child not wearing the brace (called noncompliance)
• Presence of scoliosis before puberty, due to the longer time span until completion of bone growth: Generally, the greatest risk of scoliosis progression is in the two years after the onset of puberty, during the time of the rapid adolescent growth spurt. In girls, this is generally in the two years immediately after the age of the first menstrual period (called menarche), usually beginning around age 12. As puberty is generally later in boys, their growth spurt begins around age 13.

These signs and symptoms may be seen with idiopathic scoliosis:

• The head may be off-center and does not line up with the pelvis.
• One hip or shoulder may be higher than the other.
• The child may walk with a rolling gait.
• The opposite sides of the body may not appear level.
• The child may experience back pain or tire easily during activities that require excessive trunk (chest and belly) movement.
• One side of the rib cage or lower back may seem more prominent (humpback).
• The chest may seem sunken on one side, or in girls, one breast may seem smaller than the other.
• The child may appear to have an uneven waist.

The physical deformities may not be readily apparent, as adolescents tend to be more modest as they mature and the parents may not see the child's back unless a bathing suit or similar attire is worn.

Idiopathic scoliosis usually becomes apparent around 10 years of age, just as the child begins puberty. It is usually seen at an earlier age in girls than boys, as girls generally enter puberty at a younger age than boys. Most school systems have screening programs that look for scoliosis, generally performed in grades five or six, when the child is 10-12 years of age. The child is usually examined by a specially trained screening nurse. The most common school screening test is while wearing a T-shirt, the child stands with his or her feet straight ahead with knees locked and then slowly bends over to touch the toes. The examiner then sights the spine from the pelvis to the head. If one side of the rib cage and/or lower back is more prominent (sits higher) or if the trunk curves off to the side, this is a positive test. The child is then referred for medical follow-up to his/her primary-care provider or pediatrician. At the medical follow-up visit, a more extensive version of the screening test will be done by the physician, with the child undressed from the waist up. An examination of the neurologic (nerves) and muscle systems will be completed at the same time in order to determine if the child has any underlying diseases that may be causing scoliosis.

Scoliosis X-rays

X-rays with special scoliosis views can measure the extent of the curvature. These are done using a special long X-ray image that goes from the base of the skull to the upper pelvis. Both back to front (posterior/anterior) and side view (lateral) images are done. The examining physician and/or a radiologist (physician specializing in X-rays) will take measurements of the spine at specific points around the curves seen on the X-rays in order to determine the spinal angles (called the Cobb angle measurement). Curves with a Cobb angle of greater than 10 degrees are a cause for greater concern and require referral to a pediatric spine surgeon. An X-ray of the hand and wrist may be obtained in order to determine the bone age of the child to help to predict how many years of bone growth is to be expected, as the patient's chronologic age (age in years) may not be the same as the bone age. By looking at specific growth areas on the spinal films, bone maturity, and the amount of growth remaining can also be estimated. Children with a bone age younger than chronologic age are at particular risk for the progression of scoliosis.

Scoliosis is treated by pediatric spine surgeons, including

• orthopedic surgeons and neurosurgeons with specialty training (usually a fellowship after completion of a residency) in pediatric spine surgery.
• Physical therapists may work with patients and families for instruction in exercise programs to be done along with a bracing program and rehabilitation after scoliosis surgery.
• Patients with neuromuscular diseases will also be followed by a pediatric neurologist.
• Some children may benefit from short-term counseling with a mental health care provider if they are having difficulty coping with the need for bracing or surgery.
• Support groups are available, both in-person (in many towns) and online for children with scoliosis.

Depending on the degree of the curvature and whether it gets worse over time, the pediatric spine surgeon may recommend treatment other than observation alone. The majority of cases of scoliosis do not require treatment or may be treated with bracing alone until spine growth is complete.

• If the curve is less than 25°, no treatment is required, and the child can be seen every four to six months for a physical examination and scoliosis imaging.
• If the curve is more than 25° but less than 40°, a custom scoliosis brace may be used for treatment. The type and length of the brace depend on the location of the curve(s). Generally, the brace will enclose the upper pelvis. Curves that involve mainly the lumbar spine (low back) and lower thoracic spine (mid-back) will be treated with a brace that ends under the arms at the upper end. Curves that involve the upper thoracic spine may require a brace that goes up to the level of the chin with a ring about the neck.
• Curves that are more than 45° will need to be evaluated for the possibility of surgical correction.
• Treatment options depend more on how likely it is that the curve will worsen than on the angle of the curve itself. A child with a 20° curve and four more years of remaining growth may require treatment, while a child with a 29° of curvature who has stopped growing may not require treatment. The bone age as compared to chronologic age, as well as monitoring for the rate of progression of scoliosis, can help to determine the treatment options.

Children with severe scoliosis that involves the thoracic spine (greater than 50°) are at risk for problems with their heart and lungs due to decreased space in the chest cavity for these organs as a result of the collapse of the chest cavity itself.

If the child is treated with bracing, it is important to follow the timetable for brace wear determined by the spine surgeon. Braces are generally worn for 18-23 hours per day. They may be worn for sleeping and removed for showering and sports. In a few select cases, for specific types of curves treated with special bending braces, bracing may be done only during nighttime/sleeping. The spine surgeon will determine if this is an option for your child.

Successful bracing will maintain the position of the spinal curves until the child has stopped growing but will not correct the curvature.

Your child will be taught exercises to do while in the brace by a physical therapist. It is important to follow the instructions of the therapist.

If the child will not cooperate with wearing a brace, a body cast may be considered, as it cannot be removed.

Chiropractic adjustments will not correct or reverse idiopathic scoliosis.

Surgical treatment of idiopathic scoliosis is indicated for curves that are greater than 50°, progressing rapidly despite bracing, or which are expected to progress beyond the end of bone growth; decreased heart or lung function due to loss of chest space (capacity); compression of the abdominal (belly) organs due to loss of abdominal space; severe cosmetic deformity; loss of balanced position of the head and/or body over the pelvis; and/or escalating back pain. The goals of surgery are to release the soft tissues holding the bones of the spine in the incorrect position, restore the position of the spinal bones to as close to normal alignment as possible, and maintain the corrected position by stabilizing the spine with a combination of metal plates, screws, hooks, wires, and/or rods, and bone grafting to fuse the bones of the spine together permanently. Corrective surgery may be done from the front (anterior approach) of the spine, the back (posterior approach) of the spine, or a combined procedure. The majority of scoliosis surgeries are done from the back of the spine. If both anterior and posterior approaches are necessary, they may be done on the same day or two different days with a recovery period of a few days in between, depending on the extent of the individual surgical procedures required.

A newer technique (called thoracoscopy) for approaching the upper (thoracic) spine from the front through the chest uses a fiberoptic scope and special instruments to release and fuse the spine. This may be suitable for some patients with a curvature involving the upper back (thoracic spine) and avoids a large incision (called a thoracotomy) into the chest. The pediatric spine surgeon will determine if this is an option for your child. If a thoracotomy is necessary, the spine surgeon may work with a chest (thoracic) surgeon to open and close the chest. If a surgical approach through the chest is carried out, a chest tube to reinflate the lung(s) will be used. A combination of plates and screws into the bones (if surgery is necessary from the front of the spine, or screws into the spinal bones attached to rods near the spine if the spine is approached from the back) are used to stabilize the spine while waiting for the bones of the spine to fuse.

A bone graft obtained for the back of the patient's (called autologous bone) pelvis (iliac crest bone graft) and/or various types of human donor bone grafts (called allograft bone) and synthetic bone grafts are placed around the bones of the spine to encourage the spine to fuse in the corrected position.

A cell saver device is often used to recover blood lost during the procedure so that it can be returned to the patient.

The spinal fusion procedure may be done using medications to reduce the patient's blood pressure in order to reduce blood loss and other medications that may reduce bleeding after the surgery is completed. These measures may allow the patient to avoid or reduce the need for donor blood transfusions.

Immediately following the surgery, the child may need to be in the intensive-care unit (especially if a chest tube was necessary) for 24-48 hours to stabilize fluid balance and to monitor heart, lung, and kidney function closely.

• A brace or cast is usually not necessary after surgery if metal hardware to stabilize the spine was used.
• The patient is usually out of bed and walking in the morning after surgery.
• A physical therapist will assist the patient with safe walking techniques, and an occupational therapist will work with the patient to achieve independence in activities of daily living, such as dressing and personal hygiene, before discharge to home.
• The hospital stay is usually four to seven days.

After surgery

• The first postoperative visit with the surgeon is at 10-14 days after surgery, and any skin sutures or staples are removed within 14 days.
• Additional postoperative visits are as recommended by your surgeon but are generally at four to six weeks, three months, six months, nine months, and 12 months after surgery. X-rays of the spine are usually done at each postoperative visit.
• The fusion is usually solid by six months after surgery but may require up to 12 months.
• The patient returns to school by three to four weeks after surgery.
• Most patients resume all of their customary activities, except sports, by three to six months after surgery and return to non-contact sports after nine months.

If your child is referred by the school for a scoliosis evaluation, you should make an appointment to see your primary-care provider or pediatrician within the next month or so. Physicians in these specialties can then evaluate your child and decide whether your child should be monitored with a repeat examination or referred to a pediatric spine specialist for further evaluation. If your child requires bracing, he/she will be followed by a spine surgeon.

• Follow-up examinations and X-rays are generally obtained every three to six months to monitor the child for worsening of the curves.
• Children who require bracing will be seen regularly by an orthotist (brace maker) for adjustments. The timetable for these adjustments varies depending on the child's rate of growth. During the periods of rapid growth during puberty, these adjustments will be at more frequent intervals and may require new construction of all or part of the brace. If your child is treated with a brace, you should follow the instructions provided by your doctor for its use.
• Follow-up intervals after surgery are determined by the type and extent of the surgery, and the surgeon will give you instructions regarding follow-up evaluations.

Scoliosis is not preventable. At this time, we do not understand what causes the condition in the majority of children.

• Massage,
• yoga,
• chiropractic treatments,
• osteopathic adjustments, and
• exercises without bracing will not prevent scoliosis, correct the curvature, or slow the progress of scoliosis.

Other home remedies include:

• vitamins,
• calcium supplements,
• stretching,
• body wraps,
• muscle stimulators, and
• other home remedies will not prevent or cure idiopathic scoliosis.

With early screening and detection, the prognosis for children with idiopathic scoliosis is excellent. Most children with idiopathic scoliosis are initially treated with observation. When needed, bracing will usually prevent worsening of the curvatures and allow the patient to avoid surgery.

With proper treatment, whether by bracing or surgery, the vast majority of children with scoliosis will go on to lead normal, independent lives, be gainfully employed in many kinds of active careers, participate in noncontact sports, have healthy pregnancies, raise families, and have the same life expectancy as people without scoliosis.

You may find more information on the Internet or by contacting the following organizations:

National Scoliosis Foundation
5 Cabot Place
Stoughton, MA 02072
Tel: 800-673-6922
Fax: 781-341-8333
Email: [email protected]
http://www.scoliosis.org

This nonprofit voluntary organization provides pamphlets, a newsletter, and other informational material on childhood and adult scoliosis. The foundation also provides support-group information and lists of doctors in each state who specialize in scoliosis.

The Scoliosis Research Society
555 East Wells Street, Suite 100
Milwaukee, WI 53202-3823
Tel: 414-289-9107
Fax: 414-276-3349
Email: [email protected]
http://www.srs.org/patients-and-families
http://www.srs.org

The society is a professional organization for orthopedic surgeons interested in scoliosis. It provides pamphlets about the diagnosis and treatment of scoliosis. Price information for ordering pamphlets is available from the society. The society also can provide referrals to physicians.

American Physical Therapy Association
1111 North Fairfax St.
Alexandria, VA 22314-1488
Tel: 1-800-999-2782
Fax: 703/684-7343
http://www.apta.org