Scoliosis

Signs and Symptoms

Everyone's spine has natural curves. These curves round our shoulders and make the lower back curve slightly inward. But some people have spines that also curve from side to side, a condition called scoliosis. On an X-ray, the spine of a person with scoliosis looks more like an "S" or a "C" than a straight line. Some of the bones in a scoliotic spine also may have rotated slightly, making the person's waist or shoulders appear uneven. Scoliosis affects approximately 2 percent of the population. However, scoliosis runs in families. If someone in a family has scoliosis, the likelihood of another family member having it is much higher -- approximately 20 percent.

Scoliosis is defined as curvature of the spine greater than 10 degrees, as measured on an X-ray. Anything less is simply due to normal variation and consider scoliosis.

Scoliosis may be divided into five principal types:

• Idiopathic Scoliosis -- This is the most common form of scoliosis. The name idiopathic means "the cause is unknown." Those with this type of scoliosis are otherwise healthy and normal, and the spine shows no abnormality of the bones themselves on X-rays or by looking at it directly in the operating room. While the overall incidence is equal in females and males, progressive or severe idiopathic scoliosis is about six to seven times more frequent in females.

• Congenital Scoliosis -- Congenital means that a person is "born with" scoliosis. Congenital scoliosis is caused by an abnormality of one or more vertebrae where they fail to form properly. This can be seen on X-ray and directly in the operating room.

• Neuromuscular Scoliosis -- This type of scoliosis occurs in people who have a disease of the nervous system, such as cerebral palsy.

• Syndromic Scoliosis -- This type of scoliosis occurs in people with a syndrome, such as Marfan syndrome or one of the skeletal dysplasias such as achondroplasia.

• Postural Scoliosis -- Also known as "hysterical scoliosis," postural scoliosis may be a result of pain, as a patient tilts to relieve the pain. It can be reversed by relieving the pain or by having the patient lie flat. X-rays don't show any abnormality of the vertebrae.

Progressive, severe scoliosis can produce three major problems:

• If the part of the spine that is in the chest, called the thoracic spine, curves more than 60 degrees, the volume of the chest can be reduced, potentially compromising the function of the heart and lungs. For example, the heart may have to work harder to pump the normal volume of blood or the affected individual may have shortness of breath.

• Severe curvature of the lower half of the spine that connects the chest with the pelvis, known as the lumbar spine, may push the contents of the abdomen against the chest and interfere indirectly with heart and lung function. Curvature of the lumbar spine also may alter sitting balance and posture.

• Severe curvature of either the thoracic or the lumbar spine, or both, eventually becomes visible to others. The resulting tilting and twisting of the back, shoulders and pelvis may produce an appearance that the individual finds unacceptable. If idiopathic scoliosis affects a girl around the time of puberty, when body image is developing hand-in-hand with self-esteem, the condition can pose significant psychological and emotional challenges.

Idiopathic scoliosis may also involve pain, which is more common in adults with scoliosis.

Diagnosis

Uneven ribs and shoulder imbalance may be the first noticeable signs of scoliosis. The diagnosis of scoliosis is based upon X-ray of the spine.

If a person with scoliosis is suspected of having an underlying disease, other tests may be necessary. Symptoms of possible underlying diseases include:

• Significant pain
• Colored markings
• A hairy patch on the skin
• A deformity of the foot

Certain types of scoliosis also are associated with other diseases, such as kidney disease. In addition to having an X-ray, other tests may be done to check for signs of underlying diseases, such as an ultrasound to look for kidney disease and a magnetic resonance imaging (MRI) scan to look for an abnormality of the nervous system.

Treatment

Most spine curves in children with scoliosis will remain small and need only to be watched by an orthopedist for any sign of progression. If a curve does progress, an orthopedic brace can be used to prevent it from getting worse. Children undergoing treatment with orthopedic braces can continue to participate in a full range of physical and social activities.

If the curve of the spine is severe when first seen, or if treatment with a brace does not control the curve, surgery may be necessary. Adult scoliosis may be the result of the progression of a condition that actually began in childhood and wasn't diagnosed or treated while the person was still growing. Surgery for scoliosis is an effective and reliable technique for stopping progression of deformity, and for reducing deformity within the spinal column.

There is no clear evidence that untreated scoliosis, or scoliosis treated with bracing or spinal fusion, will increase the risk of back pain or arthritis in the long term. The younger a child, or the more she or he has to grow, the greater the risk of scoliosis progressing. After puberty, curves under 50 degrees are not likely to get worse. For this reason, the ultimate goal of scoliosis management is to keep curves under 50 degrees until the child has matured. Children with curves under 50 degrees typically grow up into adults with no significant problems related to scoliosis.

Scoliosis treatment is based on the degree of curvature of the spine, viewed from the front or back by X-ray. The following are general guidelines for treatment.

Less Than 10 Degrees

This is not scoliosis. Scoliosis is defined as spinal curvature greater than 10 degrees. Curvature under 10 degrees is considered a normal variation, just as there is a normal range for weight and for height.

10 Degrees to 30 Degrees

In this range, scoliosis is observed to see if it progresses.

30 Degrees to 50 Degrees

In this range, bracing is the standard of care in the United States. The scoliosis brace is known as a TLSO, which stands for thoraco-lumbar spinal orthotic. The idea behind bracing is to stop or slow progression of the curve so that it stays under 50 degrees. An X-ray of a brace shows that the brace can straighten the spine, but the spine will return to its original curvature when the brace is removed. The two principal types used are the Milwaukee brace, developed by Dr. Walter Blount of Milwaukee and the Boston brace, developed by Dr. John Hall of Boston. Brace treatment successfully stops curve progression in about 80 percent of children.

More Than 50 Degrees

Beyond 50 degrees, the spine loses its ability to compensate and progression becomes inevitable even after the child is mature. The only way to stop progression at this stage is a surgery called spinal fusion. Think of the vertebrae as beads on a string. The spine bends between the vertebrae as a string bends between the beads, causing the beads to move. The way to stop the beads from moving is to stick them together. Spinal fusion surgery joins the vertebrae.