What Is Scoliosis?
The spine is supposed to have some curves—when looked at from the side. There are natural curves in and out at the cervical, thoracic, and lumbar regions. You can see these curves in the image below: Look at the illustration on the left (labeled the lateral view). These natural curves position the head over the pelvis and work as shock absorbers to distribute mechanical stress during movement.
Scoliosis in Children Is Complex But Rare
Scoliosis is a complex three-dimensional disease.
To understand this concept, think about this: in some cases of scoliosis, as the spine curves abnormally, the involved vertebrae are forced to rotate.
If rotation occurs at the thoracic level of the spine (that’s the mid-back), vertebral turning impacts the rib cage and may result in rib prominence on the opposite side of the curve.
In severe cases, lung and heart function can be compromised. Fortunately, severe cases of scoliosis are not as prevalent as smaller curves.
In the United States, 3 to 5 children out of 1,000 will develop scoliotic curves large enough to warrant treatment. In fact, the worldwide prevalence of scoliosis, including all forms of the disease, is only 1%.
Types of Scoliosis that Affect Children
There are 3 types of scoliosis that affect children:
- infantile scoliosis
- juvenile scoliosis
- adolescent idiopathic scoliosis
Infantile scoliosis occurs before age three and is seen more frequently in boys. Although neurologic involvement is possible, many resolve spontaneously. Some may progress to severe deformity.
Juvenile scoliosis is found more frequently in girls between the ages of 3 and 10. These curves are at a high risk for progression and often require surgical intervention.
Adolescent scoliosis, also termed adolescent idiopathic scoliosis (AIS), occurs between age 10 and skeletal maturity. AIS may start at the onset of puberty or becomes apparent during an adolescent growth spurt. Females are at higher risk, often requiring surgical treatment, if non-operative treatment fails to halt curvature.
Scoliosis can be congenital, meaning it was caused by a vertebral defect discovered at birth. Idiopathic scoliosis simply means the scoliosis occurred without known cause.
Early diagnosis and treatment helps to prevent curve progression and deformity. Scoliosis left untreated may progress, leaving the spine abnormally curved, stiff, and sometimes rigid. This makes treatment difficult and increases the risks for serious complications.
Medical and Family History: First Step in Scoliosis Diagnosis
The patient, parents, and physician discuss the medical and family history. The physician looks for any underlying medical condition that might be causing scoliosis. A family history of the disease or other attributing medical disorders is noted.
The patient’s age, onset of puberty, or menarche (girls) helps to determine the number of years remaining until the child reaches adulthood, at which time curve progression may cease.
A thorough physical examination reveals a lot about the health and general fitness of the patient. The exam provides a baseline from which the physician can measure the patient’s progress during treatment. The physician will observe the patient standing (front and back) and look for any asymmetric abnormalities in the shoulders, rib cage, waist, and pelvis.
Patients with scoliosis may present humpback, one hip higher than the other, or listing to one side.
In severe scoliosis, cardiopulmonary (heart/lung) function is tested. The physical examination also includes:
- Adam’s Forward Bending Test requires the patient to bend forward at the waist. Viewed posteriorly (from behind), scoliosis is suspected if a thoracic (mid-back) or lumbar (lower back) prominence is apparent.
- A rib hump can be measured in degrees using aScoliometer. While the patient is bent at the waist, the scoliometer is placed over the rib hump.
- Leg length is measured and compared to determine discrepancy.
- A plumb line held posteriorly at the 7th cervical vertebra (C7) is allowed to hang below the buttocks. In a normal spine, the line passes through the gluteal crease (middle of buttocks). In scoliosis, the scoliotic portions of the spine may fall to the right or left of the line.
- Palpation determines spinal abnormalities by feel. The ribs (thoracic) or lumbar muscles may feel more prominent on one side of the spine than the other.
- Range of motion measures the degree to which a patient can perform movements of flexion, extension, lateral bending, and spinal rotation. The doctor also notes asymmetry.
Patients are assessed for underlying neurological problems that may be causing scoliosis. The following symptoms are assessed:
- paresthesias (eg, tingling)
- extremity sensation and motor function
- muscle spasm
- bowel/bladder changes.
Radiographs (X-rays) Show the Scoliotic Curve
X-rays indicate if the scoliotic curves are structural (major) or non-structural (minor).
To see the entire length of the spine, the doctor will have the patient stand. Two views are typically taken in x-rays for scoliosis: PA (posterior-anterior, or back to front) and lateral (side) x-rays.
Sdie bending AP (anterior-posteriod, or front to back) x-rays are sometimes done to assess spinal flexiblity.
Examples of Images Showing Scoliosis
Congenital Thoracic Curve
Spinal bone maturity helps to determine curve progression. The Risser Sign radiographically observes the iliac crest growth plate, a fan-shaped part of the pelvis. At maturity, the crest has fused with the pelvis. A hand x-ray can also give information as to skeletal maturation.
If the child still has growing left to do, that indicates that the curve may continue to progress (get worse).
Scoliosis in Children: Curve Classification
In childhood scoliosis (as well as adult scoliosis), curves are classified according to pattern (shape) and magnitude (severity). Classifying the curve helps the doctor determine the best treatment plan.
- King Classification divides scoliotic curves into one of five patterns. For example, King Type III curves are primarily single thoracic curves, the most common occurring in adolescent idiopathic scoliosis.
- Cobb Angle Measurement uses a standard full-length AP x-ray. Geometric calculations determine the angle of the curve in degrees.
- Nash-Moe technique measures pedicle rotation by dividing the vertebral body into segments. The segment into which the pedicle is located quantifies rotation.
Treatments for Scoliosis in Children
A treatment plan is determined by the child’s age, remaining growth potential, curve pattern and magnitude, anticipated rate of progression, and appearance.
Spinal Bracing for Scoliosis
In the past, plaster casting was routinely used to treat scoliosis. Today plaster jackets are used to treat some cases of infantile scoliosis. Casting is generally not used today except in countries where bracing is not available.
Bracing is the standard treatment today used to prevent curve progression and improve deformity.
Typically bracing is prescribed for children with smaller curves ranging from 20 to 40 degrees. Bracing may temporarily correct the scoliosis but does not cure the disease.
Children and teenagers may find bracing difficult because the brace can be uncomfortable, hot, rigid, unattractive, and must be worn 16 to 23 hours a day. Although well disguised under clothing, it can make a child self-conscious.
Bracing is usually not prescribed when the curve is greater than 40 degrees. Certain types of curves do not respond to bracing, such as high thoracic curves. In those situations, surgical intervention may be warranted.
Surgery to Correct Scoliosis
Scoliotic curves greater than 45-50 degrees are usually treated surgically. Rods, bars, wires, screws, and other types of medically designed hardware are used to surgically control and correct scoliosis. These procedures may enable the child to sit upright, thereby reducing the risk for cardiopulmonary complication. Furthermore, instrumentation (hardware) may increase the child’s ability to be mobile. These devices are meant to hold the spine straight while the process of fusion occurs.
In infantile and juvenile scoliosis, rods may be implanted without bone grafts. Bone grafts facilitate fusion. Later in life, spinal instrumentation and fusion provide a more permanent treatment.
Adolescent scoliosis may be treated surgically using spinal instrumentation and fusion, when necessary.
The goals of spinal instrumentation include:
- stabilization of spinal segments
- deformity correction within safe parameters
- enchancing spinal fusion
Scoliosis: Pre-operative and Post-Operative X-Rays
Recovery from Scoliosis Treatment
Whether the treatment course is conservative or surgical, it is important to closely follow the physician and/or physical therapist’s instructions. Discuss any concerns about activity restrictions with your child’s doctor. He or shewill be able to suggest safe alternatives.
Physical therapy may be incorporated into the treatment plan to build strength, flexibility, and increase range of motion. The therapist may provide the patient a customized home exercise program.
If the patient undergoes surgery, written instructions and prescriptions for necessary medication are given prior to release from the hospital. The patient’s care continues during follow-up visits with his or her surgeon.
Childhood scoliosis is complex, but the doctor will develop a treatment plan that addresses the curve and any other symptoms.