Scoliosis basically is a sideways curvature of spine which most often occurs during the growth spurt phase just before puberty. Many a times, scoliosis can also be caused by other health conditions like muscular dystrophy & cerebral palsy. However, the exact cause of scoliosis is still unknown. Most of the cases of scoliosis are generally mild, but some children are found to develop spine deformities which continue to grow & get more severe as they grow. Moreover, severe scoliosis can often be disabling in some cases. Especially, severe spine curvature can reduce amount of space with chest & thereby make it difficult for lungs to function properly. Children having mild scoliosis are closely monitored, most often with help of X-rays in order to see if curvature is getting worse. However, in many cases of scoliosis no treatment procedure is required. Nevertheless, some children will have to wear braces in order to stop the curvature from worsening, while many other children might need surgery so as to keep scoliosis from worsening & for straightening severe cases of scoliosis.
What is Scoliosis?
Scoliosis disorder causes abnormal curvature of spine or backbone. Spine normally is curved when observed from the side, but it would appear straight when it is looked upon from the front. Kyphosis is a curve in spine when observed from the side in which the spine appears to be bent forward. There also happens to be a normal kyphosis in the middle (thoracic) portion of spine. Lordosis is curvature which is seen from the side in which the spine appears to be bent backwards. Then, there is normal lordosis in cervical (upper) spine & lumbar (lower) spine. People with scoliosis are found to develop additional curves on either sides of the body & which cause bones of spine to twist upon each other & thereby form a “C” or “S” shape in spine. Moreover, scoliosis is about twice as common among girls than boys. Although, scoliosis can be seen among people of all ages, it is most common among those who are about 10 years of age. Scoliosis is also hereditary in the sense that people with scoliosis are more likely to have offspring with scoliosis, but then there is absolutely no correlation between severity of scoliosis-related spinal curves from one generation to the other.
Scoliosis is found to affect about 2 percent of females & about 0.5 percent of males. Cause of scoliosis is generally unknown in most cases, & therefore called idiopathic. Type of scoliosis, including idiopathic scoliosis is normally described as based upon the age of the patient in majority cases of scoliosis.
- It is called Infantile Idiopathic Scoliosis when the patient is less than 3 years of age.
- Scoliosis which has developed between 3 – 10 years of age is called Juvenile Idiopathic Scoliosis.
- Scoliosis patients who are between 10 – 18 years of age (above 10 years), are called Adolescent Idiopathic Scoliosis.
More than 80 percent of the total number of scoliosis cases is found to be idiopathic scoliosis cases & a majority of these cases are among adolescent girls. Most common location of scoliosis among these patients is located within the thoracic spine region.
Idiopathic scoliosis along with its subtypes, comprise of over 80 percent of all scoliosis cases. However, there are 3 other main types of scoliosis that are mentioned below.
- Functional Scoliosis – Spine is normal in this type of scoliosis, but an abnormal curve is found to develop due to a problem located somewhere else in the body. This could also be caused because of one leg being shorter than the other or due to muscle spasms happening within the back region.
- Neuromuscular Scoliosis – There is a problem when bones of the spine are formed in this type of scoliosis. Either these bones of spine fail to completely form or they have failed to separate from one another during the fetal development stage. Commonly found to develop among people with other disorders including those with birth defects, cerebral palsy, muscular dystrophy or Marfan syndrome which is a connective tissue disease that is inherited. People with these conditions most often develop a long “C” shaped curve in spine & also have weak muscles which are unable to hold the spine straight. In case this curve is present at birth, it is called congenital scoliosis. Congenital scoliosis is often far more severe & therefore requires more aggressive treatment than other types of scoliosis.
- Degenerative Scoliosis – Unlike several other forms of scoliosis which are found among children & teens, degenerative scoliosis normally occurs in older adults. This is basically caused by changes in spine mainly due to arthritis known as spondylosis. Weakening of soft tissue & normal ligaments of spine combined with abnormal bone spurs can often lead to abnormal curvature of spine. Moreover, spine can also be affected by osteoporosis, disc degeneration & vertebral compression fractures so as to cause this condition. Other potential causes of degenerative scoliosis include spinal tumors like osteoid osteoma. This is generally a noncancerous (benign) tumor which occurs in spine & causes pain. Pain caused by these tumors can make people lean in the opposite direction in order to reduce amount of pressure exerted on the tumor. This will eventually lead to deformity in spine.
Surgeons are unable to find out what actually causes the most common type of Scoliosis. However, it involves some hereditary factors, as this disorder leans to run in generations of families. The most common types & causes of Scoliosis are listed below:
- Congenital Scoliosis: It is caused by an abnormality in bone which is present by birth.
- Degenerative Scoliosis: This condition may appear from traumatic bone disintegration, generally caused from an injury, prior surgery of back, or osteoporosis (thinning of bones).
- Neuromuscular Scoliosis: It is a result of abnormal nerves. Frequently seen in patients with cerebral palsy or in people with several conditions that are accompanied by, or outcome in cases of dreadful paralysis.
- Idiopathic Scoliosis: It is the most common type of Scoliosis. Idiopathic Scoliosis has no particular identifiable cause. There exist many theories, but none of them have been found to be conclusive. However, there is strong evidence that this condition of Scoliosis is inherited.
Common Risk Factors Associated with Scoliosis
- Age – Age is a huge risk factor for scoliosis as signs & symptoms often begin between 9 – 15 years of age.
- Sex – Moreover, being a female also increases risk of developing scoliosis along with the fact that females have high risk of worsening spine curvature than males.
- Family History – Family history of scoliosis increases risk of other members developing scoliosis, although several individual developing this problem do not have any family members with scoliosis.
Signs & symptoms of scoliosis generally include the following.
- Uneven shoulders
- Uneven waist
- One shoulder blade appearing more prominent than the other
- One hip higher than the other
The most common symptom of scoliosis is an abnormal curve of spine which gets worse as the spine will twist or rotate in addition to curving side to side. This will eventually cause the ribs on one side of the body to stick out when compared to the other side. Quite often, this may be a mild change first noticed by a family member or friend. This change in curve of spine typically occurs very slowly & therefore is easy to miss until it has become a severe physical deformity. Scoliosis can also cause the head to appear off center & leaning to one side or cause one shoulder or hip to be higher than the other side. Some severe cases which display the rib cage sticking out may also make it more difficult for lungs & heart to function properly. This will usually end up by causing shortness of breath along with pain in chest. However, in most cases, scoliosis is not painful, but certain types of scoliosis can cause abdominal pain, neck pain, rib pain, back pain & muscle spasms. Additionally, there are many other causes of nonspecific pains which doctors would like to look for in order to rule out other diseases.
Whenever scoliosis is suspected for a person, he or she must visit a doctor for examination. Doctors however would begin by asking the usual questions which include whether there is any family history of scoliosis or if the patient has been feeling any weakness, pain or any other medical problem.
- Physical Examination – This involves taking a look at the curvature of spine from the front, back & sides. Patients will be asked to undress from waist up so as to better see any abnormal curves. Patients will then have to bend over & try to touch their toes. It is because this position can make display of curvature more obvious. Doctors will next also take a look at the symmetry of the body by seeing if both shoulders & both hips are at the same height. Any type of changes in skin will also be identified & which can effectively suggest scoliosis due to birth defects. Moreover, doctors will also check the patient’s reflexes, muscle strength & range of motion.
- Checking Progression of Scoliosis – Prospect of more growth which is remaining in a patient increases chances of scoliosis getting worse. When this is the case, doctors may measure the patient’s weight & height for comparison during future visits. Other clues to the amount of remaining growth include signs of puberty like presence of breasts or pubic hair & whether the girl patient has begun her menstrual periods. When the doctor makes sure that the patient is having scoliosis, he/she may either be asked to return for additional examinations after several months so as to see if there are any changes.
- Imaging Tests – Doctors may also decide to obtain X-rays of the spine. When X-rays are obtained, doctors can measurements from them so as to determine the size of curve which is present. This will also help doctors decide as to which type of treatment, if any can be beneficial. Moreover, measurements from future visits will also help them compare so as to see if the curve is getting any worse. It is very important that doctors come to know as to how much of further growth is left with the patient. They may also decide to take additional X-rays of wrist, hand or pelvis which can help them determine how much more will the patient grow. Whenever doctors find any change in functioning of nerves, they may also order other imaging tests for the patient’s back including CT scan or MRI in order to take a closer look at the nerves & bones of the spine.
Most often it is the patient’s primary-care doctor or pediatric physician who notices this problem relating to spine & subsequently consults a neurosurgeon or orthopedic surgeon who is specializing in spine surgery. Additionally, a rehabilitation expert and/or a physical therapist may also be consulted. Some patients may also require an occupational therapist or neurologist as part of the scoliosis treatment team.
Treatment Options for Scoliosis
Treatment options for scoliosis are based upon severity of curves & chances of curves getting worse over time. Then there are certain types of scoliosis which have greater chances of getting worse. Therefore, it is the type of scoliosis which also helps doctors determine as to the proper type of treatment in individual cases. However, there are three main categories of treatment for scoliosis, namely observation, bracing & surgery. Consequently, there are treatments available which do not require surgery, but in certain cases surgery may be the best treatment option.
Functional scoliosis is generally caused by an abnormality which is present somewhere else in the body. This type of scoliosis is normally treated by addressing the abnormality, like treating a difference in leg length discrepancy. For this purpose a small wedge is placed within the shoe in order to help even out leg length & thereby prevent spine from curving. However, there is no direct treatment of spine simply because spine is normal in these people.
This type of scoliosis is caused by abnormal development of bones within the spine. Neuromuscular scoliosis has the greatest chances of getting worse. Moreover, observation & bracing do not normally work well for people having this type of scoliosis. However, majority of people having neuromuscular scoliosis will eventually require surgery in order to stop scoliosis curve from getting worse.
Most often, treatment of idiopathic scoliosis is usually based upon the age when it has developed.
- Infantile Idiopathic Scoliosis – In numerous cases of infantile idiopathic scoliosis, patient will generally improve without any kind of treatment. However, X-rays should be obtained & measurements can be compared during future visits in order to determine if the curve is getting any worse. Moreover, bracing is not usually effective in these cases.
- Juvenile Idiopathic Scoliosis – This type of scoliosis has the highest risk of getting worse of all idiopathic scoliosis types. Bracing can however be tried early in these cases in case spinal curvature is not very severe. Goal of the treatment is however to prevent curve from worsening until the time patient stops growing. However, since spinal curving starts early among these patients, they still have a long time to grow & therefore there is a higher chance that they require more aggressive forms of treatment including surgery.
- Adolescent Idiopathic Scoliosis – This is one of the most common forms of scoliosis. It can also be observed & effectively followed with routine X-rays & measurements in case the curvature is small when first diagnosed. In case the curvature or Cobb angle stays below 20 – 25 degrees, no other treatment is required. Cobb angle or method is a way to measure the degree of curvature. Adolescent idiopathic scoliosis patient must also return to consult the doctor every 3 – 4 months in order to check if there is any worsening of the spinal curve. Additionally, X-rays must also be repeated every year in order to obtain new measurements & compare them so as to check them for progression of the spinal curve. Moreover, if the curvature is between 25 – 40 degrees & the patient is still growing, bracing is generally recommended in such cases. However, bracing is not recommended for patients who have completed their growth phase. Surgery is however invariably recommended if the curvature is found to be greater than 40 degrees.
Typically, scoliosis is not associated with back pain. However, painful symptoms can be effectively lessened with exercises, massage, physical therapy & yoga (refrain from twisting pressure on spine) in some scoliosis patients with back pain. These activities will also help strengthen back muscles. Medical treatments are however limited to pain relievers like NSAIDs or non-steroidal anti-inflammatory drugs & anti-inflammatory injections. Moreover, these treatments do not offer any cure for scoliosis & will not in any way correct abnormal spinal curvature.
There are many different type of braces available for scoliosis patients. Some of these are required to be worn 24 hours every day & are supposed to be removed only for showering or bathing. Other types of scoliosis braces can be worn only during the night. Ability of a brace to work depends upon how sincerely the patient follows instructions provided by doctors regarding wearing braces. However, braces are not designed to correct spinal curvature. They are generally meant to slow or stop curvature from getting worse along with proper back brace management treatment. Chronic or intermittent discomfort is a side effect of any type of treatment which is used for slowing or correcting spinal curvature.
Doctors usually recommend wearing a brace when children’s bones are still growing & they are having moderate scoliosis. Most common type of scoliosis brace is made of plastic & is nicely contoured in order to conform to the shape of the patient’s body. This is a close-fitting brace which is almost invisible under the garment as it snugly fits under arms & around the rib cage, low back & hip areas. Most braces are worn 24/7, day & night. Effectiveness of the brace increases with the number of hours it is worn each day. Children wearing braces usually participate in most activities with just a few restrictions. However, if necessary, they can also take the brace off so as to participate in sporting & other physical activities. Moreover, braces are generally discontinued after the bones have stopped growing. This typically occurs in the following conditions.
- Usually about 2 years after the girl child has begun to menstruate
- When boys will need to shave everyday
- When the patient is having no further changes in height
In case spinal curvature stays below 40 degrees by the time patient has finished with growing, it is most likely not to get worse later in life. However, in cases where curvature is greater than 40 degrees, it is likely to continue getting worse by 1 – 2 degrees each year, for the rest of the patient’s life as a long-term effect of scoliosis. Moreover, in case this is not prevented from deteriorating, the patient would eventually be at risk for lung or heart problems. Typically, severe scoliosis progresses with time. Therefore, doctors quite often suggest scoliosis surgery in order to reduce severity of spinal curvature & prevent it from worsening.
Goal of surgery for scoliosis is to correct & stabilize spinal curvature, reduce pain & restore a more normal appearance & curvature to the spinal column. Surgery for scoliosis generally involves correcting the spinal curve to as close to normal as possible & performing spinal fusion in order to hold the correction in place. This is possibly achieved with a combination of rods, hooks & screws which are attached to bones of spine in order to hold them in place. For this purpose, surgeons place bone graft around bones which are to be fused so as to help them grow together & fill to become solid. This process will also prevent curvature from worsening at this junction of spine. However, in most scoliosis surgery cases, screws & rods will remain within spine & will not be removed anytime. There are several different techniques available to surgeons for performing fusion surgery for scoliosis. In case scoliosis is rapidly progressing at a young age, surgeons can also install a metallic rod which can adjust in length as the child is growing. This piece of adjustable rod is attached to the top & bottom sections of spinal curvature & is usually lengthened every 6 months as required. Entire procedure can also be performed from a single incision at the back of spine or combined with another incision along the side or front. However, this decision is entirely based upon the severity & location of the spinal curve.
Recovery from surgery & scar formation however varies from one person to another. Doctors normally use medications in order to control patient’s initial pain following surgery. Patients are most likely to be out of bed in a wheelchair on the first day following surgery & will work with physical therapists & they will assist them in walking after surgery. It is quite important to improve muscle strength as patients continue to recover. Physical therapists will also help patients perform exercises for reenergizing muscles & which would also help them overcome pain. Typically, scoliosis surgery means that young patients would miss about 6 weeks of school & may take almost 6 months to get back to normal activities, even though time for recovery generally varies between individuals.
Risks & Complications for Scoliosis Surgery
As with all types of surgeries, there are risks & complications involved with scoliosis surgery. However, amount of risk partially depends upon the patient’s age, degree of spinal curvature, cause of curve & the amount of correction attempted by the surgeon.
In most cases of scoliosis surgery, surgeons usually use a technique known as neuromonitoring during the treatment procedure. This technique allows surgeons to monitor function of the nerves & spinal cord during surgery. Whenever patients are placed at increased risk of damage, thanks to this technique, surgeons are alerted & they can subsequently adjust the procedure so as to reduce those risks. Small risk of infection which is involved with all types of surgical interventions is effectively decreased with use of antibiotics, but then it can still occur in some cases. Other potential risks associated with scoliosis surgery include bleeding, injury to nerves or blood vessels, continued progression of curvature following surgery, broken screws or rods & need for further surgery.
When tumors like osteoid osteoma is the primary cause of scoliosis, surgery so as to remove the tumor is generally able to correct the spinal curvature.
People suffering from degenerative scoliosis will most often have more complaints of leg pain & back pain. These are generally related to arthritis in the spine & due to compression of nerve roots which lead to the legs. Non-operative treatments for this condition include exercises, physical therapy & gentle chiropractic which can help relieve symptoms in some cases. People failing to improve with these treatments may often benefit from surgeries. X-rays & MRI images are therefore obtained so as to plan for surgery. Surgical techniques adapted in these cases merely include just decompression or removal of bone spurs which are compressing nerves. However, in some cases spinal fusion may be necessary to stabilize spine & to possibly correct abnormal curvature.
- Alternative Treatments for Scoliosis – There are many types of alternative treatments which are described for scoliosis. These include certain exercises, stretches, physical therapy, massage, diet therapy, herbal treatments & nutritional supplements like L-Selenomethionine. Moreover, a mattress which is composed of cool gel, memory foam & latex in which height of head & foot of the bed is adjustable is recommended by some patients & clinicians. Latex mattresses infused with gel are found to retain lesser heat than latex alone & are commonly termed Gel Memory Foam. However, scoliosis patients are advised to discuss alternative treatments, especially exercises, with doctors before starting them. Along with these, medical treatments are mainly over-the-counter pain medications whenever required.
School screening programs which are regularly conducted have helped in identifying many cases of scoliosis in early stages. Having identified scoliosis early allows people to be either treated with observation or bracing in order to avoid need for surgery in many cases. Most people with scoliosis go on to live a fully productive & normal life. Moreover, people with scoliosis are perfectly able to get pregnant & have children without any increased risk for complications. However, they must take care as they may be at increased risk for additional lower back pain during the pregnancy. Generally, prognosis worsens as the degree of spinal curvature increases.
Latest advances in surgery nowadays allow for less invasive surgical techniques which incur less pain & require shorter period of time for recovery. Time for recovery following scoliosis surgery depends upon the specific procedure which is performed. Some procedures may require extended stay at the hospital along with in-patient stay in a rehabilitation facility for several weeks, while others may be able to quickly recover & not require services of any rehabilitation facility. However, these techniques are still in the developmental stage, but then initial results have been very promising.
While most patients with scoliosis have milder forms of the disorder, it may still at times cause complications including the following.
- Lung & Heart Damage – Rib cage may press against lungs & heart in severe cases of scoliosis. This will eventually make it more difficult for the patient to breathe & also hard for the heart to pump.
- Back Problems – Adults who had initially developed scoliosis as children are more likely to experience chronic back pain than common people forming the general population.
- Appearance – Worsening scoliosis can cause more noticeable changes in patients. These include prominent ribs, unleveled shoulders, uneven hips, & shift of waist & trunk to the sides. This can consequently make people with scoliosis more self-conscious about their appearance.
Untreated scoliosis can occasionally lead to deformity of spine which is severely painful & can result in the patient being unable to work or even walk normally. It is quite rare that scoliosis may compromise breathing so as to cause death. Complications of infection & pain may also rarely occur with surgery for scoliosis. Sometimes patients are also too optimistic about treatments. They are however advised to discuss their expectations with doctors & follow it up so as to better understand long-term prognosis & effects of treatment.
Life expectancy of scoliosis patients has been reported to be reduced by about 14 years in some cases. This especially includes those patients who were having more severe Cobb angle which was left untreated. However, not all specialists agree with this controversial finding. There are many other clinicians who either choose to avoid any controversy & say nothing or as some of them suggest that most scoliosis patients would live a near-normal life span. However, every individual with scoliosis must ask the treating surgeon about life expectancy & potential quality of life in future with or without any scoliosis treatment options.
As of now, there is no cure available for scoliosis. However, there are a number of good treatment options as mentioned above. Moreover, researchers are also trying to find causes of different types of idiopathic scoliosis conditions. Hopefully, this will lead to better treatments or even a cure as such. Since the cause of idiopathic scoliosis is unknown, there is no way to prevent the problem at present. Many doctors speculate that performing certain exercises like yoga & pilates, which twist the spine or move the torque, will only make scoliosis worse. Performing gymnastic activities like doing back bends, carrying weight on one side of the body like backpacks on one shoulder & using trampoline are ways which can only potentially make scoliosis worse.
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