Scoliosis

Alternative names
Spinal curvature; Kyphoscoliosis

Definition
Scoliosis is a lateral (away from the middle) or sideways curvature of the spine.

Causes, incidence, and risk factors

There are three general causes of scoliosis: congenital, usually related to a problem with the formation of vertebrae or fused ribs during prenatal development; neuromuscular (poor muscle control or muscular weakness or paralysis due to diseases like cerebral palsy, muscular dystrophy, spina bifida and polio); and idiopathic (of unknown cause), which appears in a previously straight spine.

The idiopathic form in adolescents is the most common and may have a genetic predisposition. Most cases occur in girls and curves generally worsen during growth spurts. There are also infantile and juvenile forms that are less common and affect a similar number of boys and girls.

Scoliosis may be suspected when one shoulder appears to be higher than the other, or the pelvis appears to be tilted. It is often unnoticeable to an untrained observer, however.

Routine scoliosis screening is now done in junior high school/middle school and many early cases are detected that previously would have gone undetected until they were more advanced.

There may be fatigue in the spine after prolonged sitting or standing. Pain will become persistent if irritation of ligaments results. The greater the initial curve of the spine, the greater the chance for progression of the condition after growth is complete. Severe scoliosis (curves in the spine greater than 100 degrees) may cause breathing (respiratory) problems.

Symptoms

     
  • the spine curving abnormally to the side (laterally)  
  • shoulders and/or hips appearing uneven  
  • backache or low-back pain  
  • fatigue

Note: Kyphoscoliosis also involves abnormal front-to-back curvature, with a “rounded back” appearance. See kyphosis.

Signs and tests

The physical examination will include a forward bending test that will help the practitioner define the curve. There will also be a thorough neurologic exam to look for any changes in strength, sensation, or reflexes.

Tests may include:

     
  • spine X-rays (taken from the front and the side)  
  • scoliometer measurements (a device for measuring the curvature of the spine)  
  • MRI (if there are any neurologic changes noted on the exam or if there is something unusual in the X-ray )

Treatment

The treatment is determined by the cause of the scoliosis, the size and location of the curve, and the stage of bone growth (how near the growth centers are to closure). Most cases of adolescent idiopathic scoliosis require no treatment (less than 20 degrees) but should be followed at regular intervals (often every 6 months).

As curves progress above 25 to 30 degrees in a child who is still growing, bracing is usually recommended to help slow the progression of the curve. Their are many different kinds of braces used which have names such as the Boston Brace, Wilmington Brace, Milwaukee Brace and Charleston Brace, named for the centers where they were developed.

Each brace a different appearance and there are different ways of using each type properly. The selection of a brace and the manner in which it is used is determined by many factors, including the specific characteristics of your curve, and will be decided on by you and your doctor.

A back brace does not reverse the curve; rather the spine is straightened by the brace from asymmetric pressure, and can be adjusted with growth. Bracing is not effective in congenital or neuromuscular scoliosis and is less effective in infantile and juvenile idiopathic scoliosis.

Curves of 40 degrees or greater usually require surgery because curves this large have a high risk of progressing even after bone growth stops.

Surgical correction involves correcting the curve (although not all the way) and fusing the bones in the curve together. The bones are held in place with one or two metal rods held down with hooks and screws until the bone heals together. Sometimes surgery is performed through an incision in the back and sometime through an incision on the abdomen or beneath the ribs. A brace may be required to stabilize the spine after surgery.

The limitations imposed by the treatments are often emotionally difficult and may threaten self-image, especially of teenagers. Emotional support is important for adjustment to the limitations of treatment.

Physical therapists and orthotists (orthopedic appliance specialists) can be helpful in explaining the treatments and ensuring a comfortable fit of the brace to increase compliance with the treatment plan.

Support Groups
The stress of illness can often be helped by joining a support group where members share common experiences and problems. See scoliosis - support group.

Expectations (prognosis)

The outcome depends on the cause, location, and severity of the curve. The greater the curve, the greater the chance of progression after growth has stopped.

Mild cases treated with bracing alone do very well. People with these kinds of conditions tend not to have long-term problems, except maybe an increased incidence of low back pain when they get older. People with surgically corrected idiopathic scoliosis also do very well and can lead active, healthy lives.

Patients with neuromuscular scoliosis by definition have another serious disorder (like cerebral palsy or muscular dystrophy) so their goals are much different. Often the goal of surgery is simply to allow a child to be able to sit upright in a wheelchair.

Babies with congenital scoliosis have a wide variety of underlying deformities and management of this disease is difficult and often requires many surgeries.

Complications

     
  • emotional problems or lowered self-esteem may occur as a result of the condition or its treatment (specifically bracing)  
  • spinal cord or nerve damage from surgery or severe, uncorrected curve  
  • failure of the bone to fuse (very rare in idiopathic scoliosis)  
  • spine infection after surgery  
  • low back arthritis and pain as an adult  
  • respiratory dysfunction from severe curve

Calling your health care provider

Call your child’s health care provider if you suspect that he or she may have scoliosis.

Johns Hopkins patient information

Last revised: December 8, 2012
by Brenda A. Kuper, M.D.

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