Scoliosis refers to a curvature of the spine to the side. True scoliosis is also associated with a twisting or rotation of the spine. Scoliosis is generally not painful. When a person is viewed from the front or from behind, the spine is normally straight. The shoulders and pelvis are normally level and parallel to the ground when standing. When a person bends forward, the ribs appear level and symmetric.
With scoliosis, alterations in this normal anatomy occur. The shoulders may be uneven (asymetric) with one shoulder being higher than the other. The pelvis may also be uneven, resulting in skin creases on one flank and uneveness in the hem-line or belt line. With rotation, one rib protrudes further from the body than the other. Curvature of the spine may develop as a single curve to a side (shaped like the letter C) or as two curves, side to side, (shaped like the letter S).
Scoliosis can occur in the mid (thoracic) spine, the low (lumbar) spine, or both areas at the same time. The severity of the scoliosis is measured in degrees by comparing the curves to “normal” angles. Curves can range in size from as little as 10 degrees to severe cases of more than 100 degrees. The amount of curve in the spine helps your doctor decide what treatment to suggest.
Adolescent Idiopathic Scoliosis
While scoliosis can be diagnosed in infants and young children, most cases of scoliosis are first discovered and treated in older children and adolescents (ages 10-15), particularly during puberty when the curvature becomes more noticeable. When an adolescent has scoliosis with no known cause, doctors call the condition adolescent idiopathic scoliosis. This form of scoliosis can affect a child who is healthy and not having nerve, muscle, or other spine problems. It is the most common form of spinal deformity doctors see, affecting about three percent of the general population.
Scoliosis that occurs (or is discovered) after puberty is called “adult scoliosis.” Adult scoliosis can be the result of untreated or unrecognized childhood scoliosis, or it can arise during adulthood. The most common cause of adult scoliosis is usually degeneration.
Degenerative adult scoliosis occurs when the combination of age and deterioration of the spine leads to the development of a scoliosis curve in the spine. Degenerative scoliosis usually starts after the age of 40. In older patients, particularly women, it is also often related to osteoporosis (loss of bone mass). The osteoporosis weakens the bone, making it more likely to deteriorate. The combination of these changes causes the spine to lose its ability to maintain a normal shape. The spine begins to “sag” and as the condition progresses, a scoliotic curve can slowly develop.
Whenever possible, nonsurgical treatments are chosen first. If the patient’s curve is minor (less than 15-20 degrees), the doctor will likely choose to monitor the curve for progression. The patient will normally have X-rays taken every four to six months during rapid growth years, and then once a year.
Adolescents and adults with scoliosis may work with a physical therapist. A well-rounded rehabilitation program assists in calming pain and inflammation, improving mobility and strength, and helping with daily activities. Adolescents with idiopathic scoliosis should be encouraged to continue their normal activities, including sports.
Exercise has not proven helpful for changing the curves of scoliosis. However, it can be helpful by addressing pain, posture, and spinal stabilization. Therapy sessions may be scheduled each week for four to six weeks.
The goals of physical therapy are to learn ways to manage the symptoms of scoliosis, improve spine posture and maximize spinal stabilization.
Bracing is usually considered with curves between 25 and 40 degrees-particularly if the patient is still growing and the curve is likely to get bigger. It is important that the patient wear the brace daily for the number of hours prescribed by the doctor. Scoliosis often affects more than one area of the spine. A brace can be used to support all the curved areas that need to be protected from progression.
Sometimes an adolescent might feel self-conscious about wearing a brace. Though the brace can help the curve from getting worse, it may take some time for the patient (and caregiver) to get used to it. Adults tend to be less concerned about what their peers think, but adolescence is a time when appearance is often of great importance. Listen to the child’s concerns and look for ways to help overcome feelings about appearance.
A spinal brace may provide some pain relief. In adults, it will not cause the spine to straighten. Once you have reached skeletal maturity, bracing is used for pain relief rather than prevention. If there is a difference in the length of your legs (or if the scoliosis causes you to walk somewhat crooked), special shoe inserts, called orthotics, or a simple shoe lift may reduce your back pain.
Surgery is generally only considered in patients who have continual pain, difficulty breathing, significant disfigurement, or a steadily worsening curve angle. After skeletal maturity occurs, curves that are less than 30 degrees tend not to progress and, therefore, do not require surgery. Curves above 100 degrees are rare, but they can be life threatening if the spine twists the body to the point it puts pressure on the heart and lungs.If a curve is 45 degrees or more, surgery is more likely to be considered. The main surgery for scoliosis is spinal fusion with instrumentation. Nearly all surgeries will use some type of rods in order to help straighten the spine.
The surgeon may use a posterior approach, which involves going into the spine through the back, or an anterior approach, which is performed from the front or side. The operation can be performed from both the front and the back (a combined approach). The choice depends upon the flexibility of the spine, the location and degree of the curve, and whether there is pressure on any of the nerve roots. The age of the patient is a factor in deciding which type of surgery is used. Patients whose spines are immature are more likely to require combined anterior and posterior fusion.
An explanation of the surgical options for scoliosis are listed below. For a detailed explanation of the individual treatments (fusion, instrumentation), please visit the Surgical Treatments section of the web site.
1. Anterior Fusion with Instrumentation
An incision is made in the chest or flank, and the intervertebral discs are removed in the area of the curve to make it flexible. Screws can be placed in the vertebrae, and then connected by a metal rod. A bone graft is put in place of the discs that were removed so that the vertebra sitting next to each other will fuse together. The screws attaching the metal rod are tightened down, straightening the curve.
2. Posterior Fusion with Instrumentation
This approach is done through the back. Anchors are attached to the spine in the form of hooks, screws, or wires. These anchors are attached to spinal rods that straighten the spine. Bone grafting is done to fuse all instrumented vertebrae.
3. Combined Anterior/Posterior Fusion with Instrumentation
This surgery is actually two operations-one through the front, and the other through the back. The two operations may be staged on separate days or as part of one longer surgery. Staged procedures require one to two additional days in the hospital compared to a single surgical procedure.
Scoliosis Case Study
Standing radiograph (Image A) of a 12 year old girl with idiopathic scoliosis. Her thoracic curve measures 49 degrees from T6 to T11. Her lumbar curve measures 22 degrees from T11 to L3. She is skeletally immature - her Risser sign is 0.
Her left bending film (Image B) reveals that the lumbar curve is very flexible and corrects to 0 degrees. Her right bending film (Image C) shows that the thoracic curve is less flexible, correcting to only 25 degrees.
The goal is to fuse and instrument the spine from the top stable and neutral vertebra to the bottom one. The blue vertebra are the stable/neutral ones (stable means falling on the plumb line, and neutral means having no rotation.)
AP (Image D) and lateral (Image E) radiographs show the spine being fused between the stable/neutral vertebra. Note that the curve is not fully corrected, but the spinal alignment is normal.