An Overview of Scoliosis

Scoliosis is an abnormal "S-shaped" curve of the spine that is usually diagnosed in childhood or early adolescence. Besides having an uneven waistline and/or one shoulder that appears higher than another, a person with scoliosis may look like they are leaning to one side. Rarely, severe cases of scoliosis may cause rib deformity and breathing problems.

In order to diagnose scoliosis, your doctor will first perform a medical history and physical exam, followed by an imaging test, usually an X-ray to start. Treatment for scoliosis varies from person to person, but may entail observation, bracing, or in severe cases, surgery.

Experts generally divide the causes of scoliosis into three main categories—idiopathic, congenital, and neuromuscular.

Idiopathic scoliosis is the most common form of scoliosis (around 85 percent of cases). The word "idiopathic" simply means that the precise cause is not known; although, experts believe that genetics may play a role in some cases.

Idiopathic scoliosis is further classified by age group:

• Infantile (birth to 2 years)
• Juvenile (3 to 9 years)
• Adolescent (10 years or older): this is the most common type of scoliosis, occurring just at the growth spurt of puberty.
• Adult (a progression of adolescent idiopathic scoliosis)

Congenital scoliosis is rare and is the result of an abnormality of the development of the vertebrae (the bones of the spine). For instance, one or more vertebrae may fail to form or may not form normally.

While congenital scoliosis may occur on its own, sometimes it's associated with other health issues, such as bladder, kidney, or nervous system problems.

Examples of such syndromes include:

• Marfan syndrome
• Ehlers-Danlos syndrome
• Osteochondrodystrophy (dwarfism)
• Neurofibromatosis type 1

Neuromuscular scoliosis develops as a result of an underlying nervous or muscular system disorder. The spine curvature occurs because various nerves and muscles cannot maintain proper spine alignment.

Examples of common conditions associated with neuromuscular scoliosis include:

• Cerebral palsy
• Spina bifida
• Spinal cord injury

Besides idiopathic, congenital, and neuromuscular scoliosis, here are two additional categories that scoliosis may fit into:

• Degenerative scoliosis is most common in people age 65 years or older and occurs as a result of the degeneration ("wear and tear") of the joints and discs of the spine. This type of scoliosis is most common in the lumbar spine (lower part of the back) and may be associated with back pain and nerve symptoms like tingling and/or numbness.
• Functional scoliosis occurs when there is a problem with another part of the body that is making the spine appear curved, even though structurally it is normal. For example, a discrepancy in leg length can make the spine seem curved, as can muscle spasms and inflammation from appendicitis or pneumonia.

Here are some of the more common signs of scoliosis:

• Uneven shoulders, arms, rib cages, and/or hips (meaning one is higher than the other)
• A shoulder blade that sticks out farther than the other
• A person's body may appear to be leaning to one side
• A person's head may not seem like it is centered right above the pelvis

If scoliosis progresses, the spine deformity may press on adjacent nerves, leading to weakness, numbness, and electric shock-like sensations in the legs. Walking or posture abnormalities may also occur. Rarely, if the lungs are unable to expand due to ribcage deformity, breathing problems may occur.

The diagnosis of scoliosis is generally made from a medical history, physical exam, and one or more imaging tests.

During the medical history, a doctor will inquire about a person's past medical history, family history, and when he or she first noticed problems with their (or their child's) spine. He will also ask about symptoms, including whether a person's "potential scoliosis" causes any emotional distress and/or affects daily activities.

During the physical exam, a doctor will carefully inspect a person's spine to determine whether there is any lateral curvature present, which means that the vertebral column bends from side-to-side. This may be evident by an asymmetry of the person's hips or shoulders.

In addition to a lateral curvature, a doctor will also look for a rotational or twisting spine deformity, which is also present in scoliosis, although often more subtle.

In order to do this, a doctor will perform the Adam's forward bend test. During this test, a person is observed from the back while he or she bends forward at the waist until their spine is parallel to the floor. The test is positive if an asymmetry is present, like if a rib sticks out on one side of the body (called a "rib hump.")

The next step, after inspection of the spine, is to use a tool called a scoliometer to determine the angle of trunk rotation (ATR). While a person is bent at the waist (the same position as the Adam's forward bend test), the scoliometer is run along the person's spine from top to bottom. If the measurement of the scoliometer is 10 degrees or greater than an imaging test is required.

Various imaging tests may be used to diagnose scoliosis. Doctors almost always start with an X-ray, where the Cobb angle—a measurement of the spine curvature—is calculated. A Cobb angle of at least 10 degrees is necessary to diagnose scoliosis.

Besides measuring the Cobb angle, imaging tests, like a magnetic resonance imaging (MRI) of the spine, may be used for better visualizing the spinal curvature and for diagnosing a specific type of scoliosis, like degenerative scoliosis.

Scoliosis treatment is a subject that has been the cause of great debate for many years and so, unfortunately, there is not a definitive answer for all cases.

In addition, the treatment of scoliosis really varies from person to person, depending on factors like age, the severity of the curve, the likelihood of the curve worsening, and the impact the condition is having on a person's quality of life and daily functioning. For instance, mild scoliosis generally requires no treatment. However, scoliosis that causes breathing problems does.

That said, the three basic scoliosis treatment options are as follows:

Patients are observed when the curvature of the spine is minimal (the cutoff is debatable, but depending on the age of the patient, the stage of skeletal development and symptoms, it is somewhere between 20 and 30 degrees of curvature).

Over this cutoff, more aggressive scoliosis treatment is usually pursued. When being observed, patients are seen by a spine specialist about every six months until skeletal maturity is reached.

Braces will help control any worsening of spine curvature but do little to correct an existing deformity. Bracing is most effective for scoliosis treatment when used in children that are rapidly growing and have worsening scoliosis curves.

Surgery is often the best options for more severe curves. Depending on the site of the curve, the degree of curvature, a patient's specific symptoms, and the type of scoliosis, different surgical procedures may be performed:

• Spinal Fusion is a procedure in which a surgeon fuses vertebrae in a more normal anatomic position.
• Microdecompression is a minimally invasive procedure that helps relieve pressure on nerves. Since this procedure may worsen your curve, especially if you go into the procedure with a curve that is greater than 30 degrees, this type of surgery is generally done only at one vertebral level—not multiple levels.
• Surgical stabilization entails using various instruments—screws, wires, anchoring hooks, and rods—to stabilize the spine so it can fuse in the right position.
• Osteotomy involves removing and realigning vertebrae to allow for proper spine alignment

For congenital scoliosis, a surgeon may recommend a type of surgery where growth rods are attached to the spine above and below the curve. These growth rods correct the spine as it continues to grow.

Studies are investigating the effectiveness of many other scoliosis treatments, including electrical stimulation, chiropractic manipulation, and physical therapy. However, the jury is still out on these therapies, as the research backing up their effectiveness is lacking. That said, for individual patients, one or more of these therapies may provide some relief.

While it may seem alarming to hear that you or your child's spine has a side-to-side curve, it's important to remember that not every person with scoliosis needs treatment.

Be at ease too knowing that scoliosis is not your or your child's fault. Scoliosis is not caused by wearing a heavy backpack or poor posture, and scoliosis should not limit your life plans, including playing sports, exercising, or undergoing pregnancy.