In scoliosis the spine is curved either from side to side or front to back, and/or may be rotated. It is typically classified as congenital (caused by vertebral anomalies present at birth), idiopathic (of unknown origin), or as having developed as a secondary symptom of another condition, such as cerebral palsy or spinal muscular atrophy.
The most common form of scoliosis is adolescent idiopathic scoliosis; the cause is essentially unknown. Scoliosis is more often diagnosed in females and often seen in patients with cerebral palsy or spina bifida, although this form of scoliosis is different from that in children without these conditions. In some cases, scoliosis exists at birth due to a congenital vertebral anomaly. Occasionally, development of scoliosis during adolescence is due to an underlying anomaly, such as a tethered spinal cord. Scoliosis often presents itself, or worsens, during the adolescence growth spurt.
Pain is common in adulthood, especially if left untreated. A primary symptom as well is cosmetic deformity. Pain can occur based on muscles trying to conform to the way the spine curves. This tyipically happens in larger curves. As the curve increases, there is more pressure in some prominent areas than others. This will also cause muscles to seize up and become sore.
The symptoms of scoliosis can include:
- Asymmetric size or location of breast in females
- Slow nerve action (in some cases)
- Uneven hip and shoulder levels
- Uneven musculature on one side of the spine
- A rib "hump" and/or a prominent shoulder blade, caused by rotation of the ribcage in thoracic scoliosis
- Unequal distance between arms and body
- Clothes that do not "hang right", ie. with uneven hemlines
Patients with scoliosis are examined to determine if there is an underlying cause. During a physical examination, the following is assessed:
- Skin for café au lait spots indicative of neurofibromatosis
- Feet for deformity
- Abdominal reflexes
- Muscle tone for spasticity
During the exam, the patient is asked to bend forward. If a hump is noted, then scoliosis is a possibility and the patient should be sent for an x-ray to confirm the diagnosis. The patient's gait is assessed, and there is an exam for signs of other abnormalities (e.g., spina bifida as evidenced by a dimple, hairy patch, lipoma, or hemangioma). A thorough neurological examination is also performed.
Full-length standing spine X rays are the standard method for evaluating severity and progression of scoliosis, and whether it is congenital or idiopathic (of unknown origin) in nature. In growing children, serial radiographs are obtained at 3-12 month intervals to follow curve progression. In some instances, MRI investigation is warranted. Degree of curvature is also measured using a separate test.
TreatmentThe traditional medical management of scoliosis is complex, determined by the severity of the curvature and skeletal maturity, which together predict the likelihood of progression. Conventional treatement options are bracing and surgery.
Bracing is done when the patient has bone growth remaining, and is generally implemented to hold the curve and prevent it from progressing to the point where surgery is necessary. Bracing involves fitting the patient with a device that covers the torso and in some cases extends to the neck. Bracing is mildly effective, as compliance is typically low, although newer braces tout better compliance rates and outcomes. Typically braces are only used for curves not grave enough to warrant surgery. They may also be used to prevent progression of more severe curves in young children. This gives the child time to grow before performing surgery which would prevent further growth in the part of the spine affected.
In infantile, and sometimes juvenile scoliosis, a body cast or plaster jacket may be used instead of a brace. It has been proven possible to permanently correct some cases of infantile scoliosis by using a series of plaster body casts applied under corrective traction, which help to mold infants’ soft bones and work with their infantile growth spurts.
Chiropractic and physical therapy have some degree of anecdotal success in treating scoliosis that is primarily neuromuscular in nature. However, non-surgical approaches will not address severe bone deformities associated with many cases of scoliosis. Chiropractors utilize joint mobilization techniques and therapeutic exercise to increase a scoliosis patient's flexibility and strength. Electronic muscle stimulation (EMS) is another therapeutic modality commonly utilized by chiropractors and physical therapists to reduce muscle spasms and strengthen atrophied muscles.
Surgery is usually indicated for curves that have a high likelihood of progression, curves that cause a significant amount of pain with some regularity, curves that would be cosmetically unacceptable as an adult, curves in patients with spina bifida and cerebral palsy that interfere with sitting and care, and curves that affect physiological functions such as breathing. Surgery for scoliosis is typically done by a spinal surgeon. It is usually impossible to completely straighten a scoliotic spine, but in most cases very good corrections are achieved.
Spinal fusion is the most widely performed surgery for scoliosis. In this procedure, bone is grafted to the vertebrae so that when it heals, one solid bone mass is formed and the vertebral column becomes rigid. This prevents worsening of the curve at the expense of spinal movement. This can be performed from the anterior (front) aspect of the spine by entering the thoracic or abdominal cavity, or performed from the back (posterior). A combination of both is used in more severe cases.
Modern spinal fusion systems are attempting to address imbalance and rotational defects. They involve a combination of rods, screws, hooks and wires fixing the spine and can apply safe, strong forces to the spine. Spinal fusion is rarely performed without this instrumentation. Modern spinal fusions generally have good outcomes with high degrees of correction and low rates of failure and infection. Patients with fused spines and permanent implants tend to have normal lives with unrestricted activities when they are younger. They are able to participate in recreational athletics, have natural childbirth and are generally satisfied with their treatment.
In cases where scoliosis has caused a significant deformity resulting in a rib hump, it is often possible to perform a surgery called a costoplasty in order to achieve a more pleasing cosmetic result. This procedure may be performed at any time after a fusion surgery, whether as part of the same operation or several years afterwards. The level of cosmetic success will depend on the extent to which the fused spine still rotates out into the ribcage. A rib hump is evidence there is still some rotational deformity to the spine. Specific weight training techniques can be used to influence this rotational deformity in the unfused parts of the spine. This leads to a marked decrease in pain and to some improvement in organ function, depending on the person's particular case and is to be recommended over any cosmetic surgical procedure. Spinal fusion remains the 'gold-standard' of surgical treatment for scoliosis.
Recently, new implants have been developed that aim to delay spinal fusion and allow more spinal growth in young children, including extendable rods that allow growth while still applying corrective forces and vertebral stapling, a method of retarding normal growth on the convex side of a curve, allowing the concave side to 'catch up.' For the youngest patients, whose thoracic insufficiency compromises their ability to breathe and applies significant cardiac pressure, ribcage implants that push the ribs apart on the concave side of the curve may be especially useful. These vertical expandable prosthetic titanium ribs (VEPTR) expand the thoracic cavity and straighten the spine in all three dimensions while allowing the spine to grow.