Scoliosis

Scoliosis is a condition in which the spine twists away from the normal midline position. As the spine is the central support of the skeleton.

Summary

• Scoliosis is a condition in which the spine twists away from the normal midline position.
• This results in chest wall shape changes, typically a prominence near the shoulder blades, with a shoulder becoming unlevel and an asymmetrical waistline.
• Idiopathic scoliosis is the most common form of the disorder and affects teenagers as they go through their growth spurt.
• Severe scoliosis is more common in girls than boys.

What is scoliosis?

Scoliosis is a three-dimensional deformity of the spinal column. It includes rotation, bending to the left or right and a change in the normal forward bending shape of the spine. As the spine is the central support of the skeleton, it has an effect on the attachments.

This results in a change in:

• the shoulder position often leading to one lower than the other
• changes in the chest appearance with prominences both in the front and back as the rib cage rotates round. Often breast size asymmetry is the presenting complaint in girls.
• pelvic asymmetry with one “hip” more prominent than the other.

What causes it?

There are many different types of scoliosis with different causes.

The most common causes are:

• Idiopathic scoliosis – this is the most common form of scoliosis. The cause thereof is unknown, but is thought to be a subtle loss of neurological balance control. It typically occurs in tall slim girls, who are slightly lax (double-jointed). This manifests around 10–12 years old when they start their growth spurt and the scoliosis can rapidly progress over months. There is a genetic component. Should the mother or sister have scoliosis, the chances of the child developing it are twice that of the normal population.
• Congenital scoliosis – this is present at birth. It is caused by malformation of the spine during pregnancy. Frequently there is a hemivertebrae, which is an incompletely formed vertebral body. Less commonly there may be failure of segmentation, with two or more vertebrae fused together. This allows asymmetrical growth, namely more growth on one side than the other, resulting in the scoliosis. This is often associated with other birth defects, commonly kidney and heart problems.
• Neuromuscular scoliosis – this can develop in children who have a neurological disorder such as cerebral palsy, spina bifida and muscular dystrophy. The spine curves in a long c-shape because the children’s trunks are too weak to support their bodies.
• Adult or degenerative scoliosis – this becomes apparent later in life. This may be degeneration of a previously unrecognised scoliosis from childhood. More commonly it is due to asymetrical disc degeneration and facet joint destruction due to the ageing process with resultant instability and progressive deformity. This is usually in the lumbar spine and presents with back and leg (nerve entrapment) pain.
• Many parents think that a heavy schoolbag can cause scoliosis, but there is no evidence to support this.

What are the symptoms?

• chest cage asymmetry with a posterior chest wall prominence
• shoulders or waist appears uneven
• reduced spinal range of motion
• short torso (disproportionate) to leg length
• in some cases back pain

How is it diagnosed?

The doctor will take a pertinent history and perform a physical examination which will include a bending forward test. This exaggerates the chest wall prominence and demonstrates the scoliosis.

A mom can screen for scoliosis in her child by looking for shoulder blade asymmetry when the child bends forward and touches its toes.

Other tests may include:

• Plumb line test – this is a visual test to see if the spine is straight. A weight on a string is held at the middle of the neck and dropped down. The plumb line will fall to the left or right instead of the middle of the buttocks, indicating imbalance.
• Scoliometer – a scoliometer measures the size of the curve or hump and is used when doing the forward bend test. This quantifies the amount of rotation.
• X-ray – this shows exactly where the scoliosis affects the spine and the extent of the curve.

How is it treated?

Treatment will depend on the severity of the curve and the risk of the curve getting worse.

Treatment options include:

• Observation – mild forms of scoliosis where the curve is less than 20 degrees must be followed up during the rapid growth years to allow intervention should it progress.
• Bracing – for curves between 25 and 40 degrees bracing is an option. Bracing does not reduce the scoliosis, but prevents the curve from getting worse. To be effective the corrective brace has to be worn 20 out of 24 hours, which includes sleeping in the brace. Unfortunately in our climate bracing compliance tends to be poor with a resultant poor outcome. It has a very limited role in congenital scoliosis. It may be useful for temporary control in young neuromuscular scoliosis patients until they are tall enough for definitive surgery.
• Surgery – for severe cases in which the curve is greater than 40 to 50 degrees and neuromuscular scoliosis, surgery will be needed to correct and stabilise the curve. Extensive spinal fusion is required where metal rods, hooks, screws or wires are implanted to hold the spine in the corrected position. The bone is prepared to encourage the formation of a solid column, namely fusion. This makes the chosen area completely stiff, but much better positioned. After surgery patients will walk without a brace. They will be off school for at least 6 weeks, up to 3 months depending on the particular case. Participation in sports will only be possible within six to nine months and contact sport must be avoided permanently. Risks of surgery include infection, failure of the fusion process to occur and neurological injury (paraplegia as a worst cage scenario). Thankfully these complications are rare

What is the prognosis?

Prognosis depends on individual factors, such as the age at which scoliosis were discovered, severity of the curve, and when treatment started.

If left untreated scoliosis can lead to serious complications.

Complications

• Lung and heart damage – in severe scoliosis, in which the curve is greater than 70 degrees, there will be effects on the lungs, which will affect breathing. At 100 degrees the annual mortality is twice that of the average population. Should there be longstanding lung damage, secondary heart damage will occur.
• Back problems – adults who have had scoliosis as children are at greater risk of developing chronic back pain. Untreated scoliosis may cause arthritis of the spine.
• Low body image and self-esteem – during childhood and teenage year’s children may develop a low body image due to the deformity created by scoliosis.

When to call your doctor

Call your doctor if your child develops any of the symptoms that might indicate scoliosis.

Sources: Health24, Mayo Clinic, Medicinenet.com,Spineuniverse.com

Dr RN Dunn, Consultant Spine and Orthopaedic Surgeon