Scoliosis is an abnormal sideways curvature of the spine that is usually painless, but can result in chronic back pain if left untreated. Severe cases in young children can cause deformities, impair development and be life-threatening.
Scoliosis is most often found in patients between 10 and 14 years old, though the condition can also affect infants. In infancy, boys are at higher risk for scoliosis than girls, but girls are at much higher risk for developing scoliosis after age 3. Regular checkups by the primary care physician are necessary to notice this problem at an early phase, with early treatment intervention.
In most people, the spine appears straight when viewed from behind. However, patients with scoliosis have one or more side–to–side spinal curvatures. Scoliosis is diagnosed when a patient has a spinal curvature greater than 10 degrees.
U.S. & World
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 ongoing back pain and breathing difficulties. In severe cases of scoliosis, surgery may be necessary to restore the spine.
Scoliosis is an abnormal sideways curvature of the spine that is typically found in children and adolescents. In most cases, scoliosis is painless. However, it can become gradually more severe if left untreated, resulting in chronic back pain. In young children, severe cases can cause deformities, impair development and be life-threatening.
In most people, the spine appears straight when viewed from behind, with the lower back bending slightly inward and the upper back bowing a little outward. However, scoliosis patients have one or more side–to–side spinal curvatures that can appear in the shape of an &s& or a &c.& Though this curve is not always visible, it can be seen from behind in many patients. This is especially true in severe cases.
Scoliosis, which comes from the Greek word for &crooked,& is usually diagnosed when a patient has a spinal curvature greater than 10 degrees. It is most often found in patients between 10 and 14 years old, although it can be present in infancy. Infant boys are at higher risk for scoliosis than girls, but girls are at much higher risk for developing scoliosis after age 3.
The cause of about 80 to 85 percent of all scoliosis cases is unknown (idiopathic), according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases. The most common form of scoliosis is known as adolescent idiopathic scoliosis, which occurs when a patient is 10 years old or older. Other forms of scoliosis include infantile idiopathic scoliosis (birth to 3 years) and juvenile idiopathic scoliosis (ages 3 to 10 years). Scoliosis is less common in adults.
In most cases, scoliosis is painless and develops gradually. It often worsens during growth spurts in children and teens. 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. 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 spine.
Risk factors and causes of scoliosis
The cause of most cases of scoliosis cases is unknown (idiopathic). Suspected causes of scoliosis include connective tissue disorders, muscle disorders, hormonal imbalance and abnormality of the nervous system. Spinal cord and brainstem abnormalities may also contribute to scoliosis. The condition can also be hereditary.
Physicians classify the causes of scoliosis curves into one of two categories:
- Nonstructural scoliosis. Also known as functional scoliosis, this involves a spine that is structurally normal yet appears curved. This is a temporary curve that changes, and is caused by an underlying condition such as difference in leg length, muscle spasms or inflammatory conditions such as appendicitis. Physicians usually treat this type of scoliosis by addressing the underlying condition. The term nonstructural scoliosis has also been used to describe cases involving a side–to–side curvature.
- Structural scoliosis. This is a fixed curve that is treated individually according to its cause. Some cases of structural scoliosis are the result of disease, such as the inherited connective tissue disorder known as Marfan's syndrome. In other cases, the curve occurs on its own. Other causes include neuromuscular diseases (such as cerebral palsy, poliomyelitis or muscular dystrophy), birth defects, injury, infection, tumors, metabolic diseases, rheumatic diseases or unknown factors. The term structural scoliosis has also been used to describe cases involving a twisting of the spine in three dimensions rather than a sideways curvature.
Certain factors are known to increase the risk for scoliosis, as well as the risk that the disorder will become more severe. These include:
- Sex. Girls ages 3 and older are more likely to have scoliosis than boys. In contrast, boys are more likely to have the disorder than girls before age 3.
- Age. The younger a child is when scoliosis begins, the more severe the condition is likely to become.
- Angle of the curve. The greater that angle of curve, the increased likelihood that the condition will get worse.
- Location. Curves in the middle to lower spine are less likely to worsen than those of the upper spine.
- Spinal problems at birth. Children who are born with scoliosis (congential scoliosis) may experience rapid worsening of the curve.
Signs and symptoms of scoliosis
In most patients, scoliosis causes few symptoms, if any. Some patients might not even be aware that they have the disorder, which is usually painless. However, some cases may present symptoms as the condition becomes more severe, including chronic back pain and breathing difficulties. In other situations, the spine may rotate so that ribs appear to be more prominent on one side of the body while the space between ribs narrows on the other side.
Typical symptoms associated with scoliosis include:
- Uneven shoulders
- Prominent shoulder blades
- Uneven waist
- Elevation of one hip above the other
- Tendency to lean to one side
Symptoms associated with more severe scoliosis include:
- Lung and heart damage. Severe scoliosis (a curve greater than 70 degrees) may cause the rib cage to press against the lungs, causing breathing difficulties. Very severe scoliosis (a curve greater than 100 degrees) can injure the lungs and heart, increasing the risk of lung infection and pneumonia.
- Bone loss. Scoliosis increases the risk of loss of bone density, a condition known as osteopenia. It also increases the risk for the bone–thinning disorder osteoporosis later in life.
- Back pain. Adults who had scoliosis as children are more likely to have chronic back pain as adults. In addition, untreated severe scoliosis can cause back pain.
- Emotional trauma. Some children and teens who wear a back brace may be vulnerable to social isolation brought on by feelings of low self–esteem.
Diagnosis methods for scoliosis
It is important to diagnose scoliosis early, so that worsening of the curvature can be prevented. In attempting to diagnose scoliosis, the physician will review a medical history and perform a physical examination.
In some cases, the signs of scoliosis are visibly obvious. The spine may be curved to one side or one shoulder blade may be noticeably higher than the other. The physician will also look to see if one side of the rib cage is higher than the other. 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,& and others resemble 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 (thoracolumbar).
- Direction. Curvature can bend to the left or the right.
- Angle. Physicians measure the angle of the curve using the vertebrae at the apex (top) of the curve as a starting point.
- Cause. Most cases of scoliosis are idiopathic or unknown.
- X-rays 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.
If the examination reveals significant curvature of the spine, the patient will be referred to an orthopedist, a physician who specializes in the diagnosis and treatment conditions related to the muscoskeletal system.
An orthopedist uses a measure called a Cobb angle in trying to diagnose the severity of a patient's spinal curvature. The Cobb angle measures the curvature of the spine in degrees and recommends treatment options based on this reading. Cobb angle measurements are taken with a device called a scoliometer. The results of these measurements will determine the method of treatment used:
Cobb Angle Measurement
10 to 15 degrees
No treatment necessary, aside from regular checkups until pubertal maturation and growth are complete
20 to 40 degrees
50 to 50 degrees
In about half of all U.S. states, scoliosis screening is mandatory for students in public schools. During these screenings, students perform a forward–bending test, in which they bend over with their knees straight while reaching 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.
Treatment options for scoliosis
According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, approximately three to five out of every 1,000 children develop curves in the spine that are large enough to require treatment. The primary treatment for scoliosis that requires therapy is the use of a back brace. These are either custom–made or made from a prefabricated mold. They are constructed of a lightweight material that usually is not visible under clothes. 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.
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.
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:
- Thoracolumbosacral orthosis (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 and is also known by various other names, including the New York, Wilmington, Miami or Boston brace.
- Milwaukee brace. This brace has a neck ring. It can be used to correct any curve in the spine.
- Charleston brace. 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.
In some cases, surgery is required to correct a severe spinal curvature. Surgical options include:
- Posterior spinal fusion and instrumentation. The most common surgical procedure for scoliosis, it involves removing tiny pieces of bone from the patient's pelvis (hipbone). These are then inserted between two or more vertebrae of the spine. Over time, the vertebrae and pieces of bone grow together, which provides stability and prevents further side–to–side curvature of the spine. In a process known as instrumentation, 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.
Scoliosis surgery generally takes between three and six hours, and the patient may stay in the hospital for about a week. Within a month, most patients are back in school. Patients can usually return to regular activities within three or four months. 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.
For young children born with severe cases of scoliosis that deform the chest and restrict the lungs, one treatment option may be a vertical expandable prosthetic titanium rib (VEPTR). The U.S. Food and Drug Administration (FDA) approved this device in 2004 to treat 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. According to the FDA, VEPTR should not be used for conditions other thn chest wall instability and cannot be used in certain populations, such as infants younger than 6 months or children who are skeletally mature (about 16 for boys, 14 for girls).
Some patients with scoliosis have used electrical stimulation of muscles or chiropractic manipulation to try to treat scoliosis. However, there is little evidence that these methods work. 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.
Questions for your doctor regarding scoliosis
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients (or parents) may wish to ask their doctor the following questions about scoliosis:
- How severe is my scoliosis?
- What is the likely cause of my scoliosis?
- What will happen if I leave it untreated?
- Should I wear a back brace? If so, which kind?
- How long will I have to wear the back brace?
- Will my scoliosis require surgery?
- If the scoliosis is severe, is a titanium rib an option?
- Do I have any restrictions on my activities because of my scoliosis?