Scoliosis

What Is Scoliosis? What Causes Scoliosis?

Scoliosis is a condition in which the spine bends to the side abnormally; either to the right or left. The curvature can be moderate to severe. Any part of the spine can be bent in scoliosis; but the most common regions are the chest area (thoracic scoliosis) or the lower part of the back (lumbar scoliosis).

According to the National Health Service (NHS), UK, in 80% of cases there is no known cause - it is idiopathic.

The majority of children with scoliosis require no treatment, as the condition resolves on its own as the child grows. Those who do require treatment use a back brace, which is usually effective. A very small number of patients with scoliosis may require surgery. If left untreated, the condition can lead to serious spine, chest, pelvis, heart and lung damage.

According to Medilexicon's medical dictionary scoliosis is:

Abnormal lateral and rotational curvature of the vertebral column. Depending on the etiology, there may be one curve, or primary and secondary compensatory curves; scoliosis may be "fixed" as a result of muscle and/or bone deformity or "mobile" as a result of unequal muscle contraction.

What are the signs and symptoms of scoliosis?

A symptom is something the patient senses and describes, while a sign is something other people, such as the doctor notice. For example, drowsiness may be a symptom while dilated pupils may be a sign.

Scoliosis signs and symptoms in children:

• Shoulders may not be of the same height (one is higher than the other)
• Head is not centered directly above the pelvis
• Ribcage is not symmetrical; ribs may be at different heights
• A shoulder blade is higher and more prominent than the other
• One hip is more prominent than the other
• Clothes do not hang properly
• The individual may lean to one side
• Uneven leg lengths

Scoliosis signs and symptoms in babies:

• A bulge on one side of the chest
• The baby might be consistently lying curved to one side

In more severe cases the heart and lungs may not work properly and the patient may experience shortness of breath and chest pain.

Some types of scoliosis can cause back pain.

In the vast majority of cases scoliosis is not painful.

What are the risk factors for scoliosis?

A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2.

Age - scoliosis signs and symptoms often start during a growth spurt that occurs just before puberty.
Gender - females have a higher risk of worsening symptoms.

Genetics - people with scoliosis are more likely to have close relatives with the same condition than other people.

What are the Causes of Scoliosis?

• Idiopathic scoliosis (unknown cause) - in about 80% of cases the cause is unknown.
• Neuromuscular conditions - these are conditions that affect the nerves and muscles. About 20% of scoliosis cases are caused by neuromuscular conditions, such as cerebral palsy or muscular dystrophy. In such cases the child may not be able to walk to stay upright, further preventing the spins from growing properly.
• Congenital scoliosis (present at birth) - this is rare and occurs because of the bones in the spine developing abnormally when the fetus is developing in the uterus (womb).
• Leg length - if one leg is longer than the other the individual may develop scoliosis.
• Other causes - bad posture, using backpacks or satchels, and exercise may also cause scoliosis.

How is Scoliosis Diagnosed?

Most commonly the doctor will carry out a physical examination of the spine, ribs, hips and shoulders. In most cases the initial diagnosis is made by a GP (general practitioner) or school nurse, who will then refer the patient to an orthopedic specialist (skeletal system and associated muscles, joints, and ligaments specialist doctor).

Imaging scans - the specialist will order an X-ray to confirm the diagnosis of scoliosis, as well as determining the shape, direction, location and angle of the curve.

If there are further symptoms, such as back pain, or if symptoms are severe an MRI (magnetic resonance imaging) or CT (computed tomography) scan may be ordered.

Bone scan - radioactive material is injected into the bloodstream. This material travels to the parts of the bones that are affected, and show up on a special instrument called a scanner.

What are the Treatment Options for Scoliosis?

The majority of children with scoliosis have mild curves and don't generally need treatment with a brace or surgery. In such cases the doctor will recommended regular follow-ups every four to six months so that the curvature of the spine can be monitored.

The following factors will be borne in mind by the doctor when deciding on treatment:

• Gender - females are more likely to have progressive scoliosis (gradually getting worse) than males.
• Severity of the curve - the larger the curve the greater the risk is of it worsening over time. Curve pattern - S-shaped curved, also called 'double curves' tend to get worse over time, as opposed to C-shaped curves.
• Where the curve is (location) - if a curve is located in the thoracic (center) part of the spine it is more likely to get worse over time compared to curves in the lower or upper section.
• Bone maturity - the risk of curve progression is much lower if the patient's bones have stopped growing. Braces are much more effective while bones are growing.

Casting - in early cases the child's spine may have to be guided back into its normal position as it grows. This can be done with a brace made of plaster of Paris - it is attached to the outside of the patient's body. This is worn all the time (without removing it). Because the child is growing he/she will need regular cast changes.

Braces - if the patient has moderate scoliosis and the bones are still growing the doctor may recommend a brace. This will prevent further curvature, but will not cure or reverse it. Braces are usually worn all the time, even at night. The more hours per day the patient wears the brace the more effective it tends to be. The brace does not generally restrict what the child can do. If the child wishes to take part in a physical activity, the braces can be taken off (check with the doctor).

When the bones stop growing the use of braces is discontinued.

There are two types of braces:

• Thoracolumbosacral orthosis (TLSO) (Low-profile brace or underarm brace) - it is contoured to conform to the body and is made of modern plastic materials. As this brace fits under the arms, around the rib cage, and lower back and hips it is not usually visibly detectable under clothing.
• Milwaukee brace - this brace has a neck ring with rests for the chin and the back of the head; it is a full-torso brace. It has a flat bar in the front and two flat bars behind. This type of brace is only ever used when the TLSO is not possible or not effective.

Surgery (spinal fusion) - in severe cases the scoliosis can progress over time. In such cases the physician may advise on spinal fusion. This is a type of surgery which reduces the spinal curvature and stops it from progressing (getting worse). At least two vertebrae (spine bones) are connected with new bone grafts. Sometimes metal rods, hooks, screws or wires may be used to hold a part of the spine straight while the bone heals. This type of operation should only ever be done by an expert in this kind of surgery.

The operation lasts from about 4 to 8 hours. After surgery the child is transferred to an ICU (intensive care unit) where they will be given intravenous fluid and pain relief. In most cases the child will leave the ICU within 24 hours, but may have to remain for about a week to 10 days in hospital.

Children can usually go back to school after 4 to 6 weeks, and can take part in sports approximately a year after surgery. In some cases a back brace is needed to support the spine for about six months.

The patient will need to return to hospital every six months to have the rods lengthened - this is usually an outpatient procedure (patient does not spend the night in hospital). The rods will be surgically removed when the spine has grown.

Risks - the doctor will only recommend spinal fusion if the benefits of it are thought to outweigh the risks. The following risks exist:

• Rod displacement - a rod may move from its correct position. According to the National Health Service (NHS), UK, this happens in about 1 in every 20 cases of spinal fusion. Although not uncomfortable, the patient may need further surgery.
• Pseudarthrosis - one of the bones used to fuse the spine into place does not graft properly. This occurs in between 1% to 5% of cases. Some patients may experience mild discomfort, and also some loss of correction of the curvature of the spine. Further surgery may be needed.
• Infection - approximately 1% to 2% of spinal fusion patients develop an infection after the operation. This is usually effectively treated with medication (antibiotics).
• Nerve damage - according to the National Health Service (NHS), UK, in about 1 or 2 cases per 1,000, spinal fusion surgery will result in damage to the nerves in the spine. Results can range from mild, with just numbness in one or both legs, to paraplegia (loss of all lower bodily functions). A neurologist is present during the operation to minimize the risk.

What are the Possible Complications of Scoliosis?

If the scoliosis is treated complication are extremely rare. The following complications are possible for untreated scoliosis:

• Kyphosis - in severe cases the upper spine may twist, resulting in a hunched or rounded back. The patient may have back pain.
• Lung and heart problems - if the curve is 70 degrees or more, the rib cage can push against the heart and lungs, causing chest pains and breathing problems. The heart may have problems pumping blood around the body. If the curve is 100 degrees or more the rib cage can cause physical damage.
• Back problems - children with scoliosis are more likely to suffer from long-term (chronic) back problems when they are adults, compared to other people.
• Arthritis - is the scoliosis is left untreated the risk of developing arthritis in the spine is higher.