Scoliosis is an abnormal sideways curvature of the spine. It is typically found in children and adolescents and generally causes no pain except in severe cases. In young children it can cause deformities, hinder development and even become life threatening. In severe cases it also causes back pain.

Viewed from behind, in most people the spine appears straight, with the lower (lumbar) back bending slightly inward and the upper back (thoracic spine) bowing a little outward. Patients affected by scoliosis, have one or more side to side spinal curvatures appearing in the shape of an “s” or a “c”. The curve may not be clearly visible in all cases but is more pronounced in severe cases.

Scoliosis is derived from the Greek word for “crooked”. The patient with scoliosis will have a sideways spinal curve of more than 10 degrees. 10 to 14 years old children are generally diagnosed with this disease. In infancy, boys are more prone to scoliosis and girls are at a higher risk after age 3.

Scoliosis patients who wear a back brace over an extended period of time can usually prevent further curvature of the spine. Left untreated, scoliosis can become more severe, resulting in chronic back pain and breathing difficulties. In severe cases, spinal surgery may be necessary.

In most cases – up to about 80 to 85 percent- cause of scoliosis is unknown (idiopathic). The common forms are:

  • Adolescent idiopathic scoliosis
    It occurs when a patient is 10 years old or older and is the most common.
  • Infantile idiopathic scoliosis
    Common in age groups from birth to 3 years old.
  • Juvenile idiopathic scoliosis
    Found in children in age group 3 to 10 years.
  • Caused by other diseases
    It results from complications of other diseases like muscular dystrophy and cerebral palsy.

Scoliosis is less common in adults but may occur as a result of neuromuscular diseases or degenerative diseases such as osteoporosis. It can cause arthritis and structural changes such as spinal stenosis.

Generally, scoliosis is painless and develops gradually. The condition usually deteriorates during growth spurts in children and teens. Patients who wear a back brace over an extended period of time can usually prevent further damage to the spine.

Scoliosis becomes severe without treatment and causes chronic back pain and breathing difficulties due to decreased movement of the rib cage. Untreated scoliosis can also affect a person’s heart function and lead to damage in the joints of the spine and increasing pain during adulthood. In such cases, surgery may be necessary to restore the shape of the spine.

Scoliosis is an idiopathic disease because in most cases the cause is not known. Some of the causes could be:

  • Connective tissues disorders.
  • Muscle disorders.
  • Hormonal imbalance.
  • Abnormality of the nervous system.
  • Spinal cord and brain stem abnormalities.
  • Hereditary.

The causes of scoliosis curves are classified into one of two categories:

  • Functional scoliosis
    It is also called Nonstructural scoliosis because the spine is structurally normal but appears curved. This temporary curve that changes is caused by an underlying condition such as difference in leg length, muscle spasms or inflammatory conditions such as appendicitis. Cases involving a side-to-side curvature are also described as non-structural scoliosis. The treatment option for this type is to cure and remove the underlying cause.
    In this type the curve is fixed and treated individually according to its cause. It could be caused by diseases like:
  • Inherited connective tissue disorder or Marfan’s syndrome.
  • Neuro-muscular diseases- cerebral palsy, poliomyelitis, muscular dystrophy.
  • Birth defects.
  • Trauma.
  • Infection.
  • Tumors.
  • Metabolic diseases.
  • Rheumatic diseases.
  • Unknown factors.

Scoliosis could also result from old age diseases like osteoporosis. Cases involving a twisting of the spine in three dimensions rather than a sideways curvature are also labeled as scoliosis.

The factors mentioned here are known to increase the risk for scoliosis or increase its severity:

  • Gender
    Before age 3 boys are at a higher risk while after age 3 girls are at a higher risk for scoliosis.
  • Age
    Severity of scoliosis is directly related to age. Younger the age of onset- higher is the likelihood of its becoming severe.
  • Angle of the curve
    The greater the angle of the spinal curve- higher is the risk of its getting worse.
  • Location of curve
    Curves in the upper spine are more likely to worsen as compared to those in the middle or lower spine.
  • Congenital Scoliosis
    Children born with scoliosis are at a higher risk for its rapid deterioration.

Environmental factors such as poor posture or carrying heavy backpacks do not cause scoliosis, though they can lead to other problems.

In most cases the lack of any symptom or pain causes the patient not being aware of its onset. Only in severe cases, chronic back pain and breathing difficulties may be noticed. In some cases, spine may rotate causing the ribs to appear prominent on one side and narrowed space between the ribs on one side.
Typical symptoms of scoliosis are:

  • Uneven shoulders.
  • Prominent shoulder blades.
  • Uneven waist.
  • Gait disturbance with one hip elevated above the other.
  • Tendency to lean to one side.

Patients with severe scoliosis are likely to have:

  • Breathing disorders
    Patients with severe scoliosis (a curve greater than 70 degrees) may result in the rib cage pressing against the lungs, causing breathing difficulties. In severe cases (a curve greater than 100 degrees) the lungs and heart injury may occur, increasing the risk of lung infection and pneumonia.
  • Osteopenia
    Osteopenia or loss of bone density is likely to result from scoliosis. Osteoporosis (bone thinning disorder) may also result in later in life.
  • Back pain
    Children suffering from scoliosis are more likely to have chronic back pain as adults. Untreated severe scoliosis can cause back pain.
  • Emotional trauma
    Children and teens wearing a back brace may be vulnerable to social isolation brought on by low self-esteem.

Scoliosis must be diagnosed in its early stages only to prevent other potential problems. Previous medical history and physical examination of the patient is essential for this. Scoliosis is generally accompanied by other diseases. Congenital disease cases are also known to suffer from kidney disease. Thus a child suffering from kidney trouble needs to be assessed for scoliosis also. Problems during childbirth or delay in age for the child to learn walking may also be other symptoms.

  1. The signs of scoliosis are visibly obvious, in some cases. Other symptoms may include:
  2. A prominent one sided curve of the spine.
  3. One shoulder blade being noticeably higher than the other.
  4. One side of the rib cage being higher than the other.
  5. Changes in skin, such as coffee-with-milk-colored spots (known as “café au lait”), may suggest scoliosis caused by a birth defect.

A physician will diagnose a case of scoliosis based on a number of characteristics associated with the spinal curvature. These include:

  • Shape
    Some curves resemble a “c,” others an “s.” Curves may occur in two or three dimensions – a nonstructural curve is a side-to-side curve, and a structural curve is characterized by the twisting of the spine in three dimensions.
  • Location
    Curvature may appear in the upper back (thoracic), lower back (lumbar) or both (thoraco lumbar).
  • Direction
    Curvature can bend to the left or the right.
  • Angle
    Physicians measure the angle of the curve using the vertebrae at the apex of the curve as a starting point.
  • Cause
    Most cases of scoliosis are unknown.
  • X-rays
    These imaging tests may be recommended for patients who report chronic back pain or bowel and bladder control problems (which may indicate involvement of the central nervous system). Patients will stand with their backs to the x-ray machine.

An orthopedist-a physician who specializes in the diagnosis and treatment conditions related to the musco skeletal system treats cases suffering from scoliosis. There are 2 tests conducted to evaluate the severity of scoliosis.

Cobb Angle Measurements
An orthopedist uses a device called a scoliometer in trying to diagnose the severity of a patient’s spinal curvature. Scoliometer gives the Cobb angle readings. It measures the curvature of the spine in degrees and recommends treatment options based on this reading. The results of Cobb angle measurements will determine the method of treatment used:

Cobb Angle Measurement Treatment

  • 10 to 15 degrees:-

         No treatment necessary, aside from regular checkups until pubertal maturation and growth are complete

  • 20 to 40 degrees:-

                                  Back brace

  • 40 to 50:-

                                degrees Surgery

Adam’s Forward Bending Test
During initial screening, the individual performs a forward–bending test called Adam’s forward bending test. The test involves forward bending with knees straight while reaching with their fingertips toward their feet on the floor. A physician or nurse then looks at the student to see if a spinal curve is evident.

About 3 to 5 cases out of 1000 detected with scoliosis will require treatment. A back brace is used to treat the spinal curve.

A back brace is usually custom-made for each individual or made from a pre-fabricated mould. A light weight material is used to manufacture these and the brace is generally not noticeable when worn under the clothes.

Period of use
Most patients wear a back brace for 18 to 20 hours each day. However, they likely will wear the brace less and less as their body gets closer to full adult size. Once the body has reached maturity, the patient no longer needs to wear the brace.

Affect of Back Brace
Back braces hold the spine in place and keep it from developing a greater curve than already exists. The brace is not designed to straighten the spine, but rather to help keep the spine from curving no more than an additional 5 to 10 degrees.

The type of back brace used depends on the severity of the disease and the location of the curve. There are various types of back braces, and patients wear the brace that is appropriate given the severity of their curvature. Types of back braces include:

  • New York/Wilmington/Miami/Boston brace
    It is also known as the Thoraco Lumbo Sacral Orthosis or TLSO. This is a low-profile brace, which means that it comes up to a level under the arms and is comfortable to wear. It is worn by patients who have a curvature in the lower part of their back. The TLSO is worn under clothes.
  • Milwaukee brace
    This brace has a neck ring. It can be used to correct any curve in the spine.

  • Charleston brace
    This is also a low-profile brace. It bends the spine in an effort to straighten the curve and keep it from worsening. However, the brace puts the wearer’s body in an awkward position and can be worn only when the patient is sleeping.

Back brace is used to gradually correct the spinal curve.
Pain Management
Pain caused by scoliosis may be treated by using:

  1. Medications
    Such as analgesics or anti-inflammatory drugs.
  2. Physical agents
    Or modalities such as hydrotherapy or thermotherapy, or physical therapy.
  3. Interventional injections
    Adults with scoliosis due to osteoporosis who have failed conservative measures may not be considered suitable for spinal surgery. In such cases a pain specialist uses interventional injections for relieving pain.
  4. Spinal Surgery-
    A severely curved spinal curve may be corrected by spinal surgery. Surgical procedures undertaken may be:

  • Posterior spinal fusion and instrumentation
    It is the most common surgical procedure for scoliosis. It has 2 variations to the same procedure and the difference lies only in the use of additional devices during surgery.

 (I)Bone pieces insertion
It involves removing tiny pieces of bone from the patient’s pelvis (hipbone). These are then inserted between two or more vertebrae. Over time, the vertebrae and pieces of bone grow together, which provides stability and prevents further side-to-side curvature of the spine.

In this process the surgeon will also use metal rods, hooks and wire to keep the spine straight while the bits of bone fuse together with the vertebrae. This process normally takes about a year. In addition, it can help reduce the spinal curvature by as much as 50 percent.

  • Anterior spinal fusion-
    In some situations, surgery may involve the front of the spine. The surgeon performs the procedure through the chest cavity.
  • Period of Hospitalization
    The patient normally stays in the hospital for about a week. Other time schedules are:
  1. Scoliosis surgery generally takes between three and six hours.
  2. Within a month, most patients are back in school.
  3. Patients can usually return to regular activities within three or four months.
  4. After one year, a patient typically can return to contact sports.

Within a year, the bone fusion will be complete, the metal rods that have been placed in the back will not substantially limit movement and the patient should be able to bend and move normally.

  • Vertical Expandable Prosthetic Titanium Rib VEPTR
    This treatment is used for some young children born with severe cases of scoliosis that deform the chest and restrict the lungs. This is called Thoracic Insufficiency Syndrome, a congenital condition in which severe deformities of the spine, ribs and chest hinder lung development and breathing. The syndrome can include severe scoliosis.

VEPTR involves the surgical implantation of an adjustable curved metal rod to ribs near the spine. The goal is to support the chest and allow normal development. A surgeon adjusts or replaces the device periodically as the child grows. Eventually it can be removed. VEPTR should not be used for conditions other than chest wall instability and cannot be used in certain populations, such as infants younger than 6 months or children who are skeletally mature (about age 16 years for boys, 14 for girls).

  • Alternative Treatment Options
    Some patients with scoliosis are treated with electrical stimulation of muscles or chiropractic manipulation to try to treat scoliosis. However, there is insufficient scientific evidence available to support the efficiency of these methods.
  • Exercise
    Exercise cannot prevent scoliosis, but it may improve the health and well–being of patients with scoliosis. Patients should consult their physician about the most appropriate exercise regimen.

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