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Scoliosis - Symptoms, Causes, Diagnosis, Risk Factors And Treatment

By Geetika Sachdev

By definition, scoliosis is a deviation of the normal vertical line of the spine, consisting of a lateral curvature with the rotation of the vertebrae within the curve. Typically, for scoliosis to be considered, there should be at least 10° of spinal angulation on the posterior-anterior radiograph associated with vertebral rotation [1] .

Scoliosis can be broadly classified as congenital, neuromuscular, syndrome-related, idiopathic and spinal curvature due to secondary reasons. Congenital scoliosis is generally due to an abnormality in the vertebrae that causes the mechanical deviation of the normal spine alignment. This medical condition can also occur due to neurological conditions such as cerebral palsy or muscular abnormalities.

Sometimes, scoliosis can also happen due to little or no rotation of the spine and without bony abnormalities. In such cases, scoliosis is the result of pain, spinal cord deformities, tumours or infection [1] .

Read on to find out more about its symptoms, diagnosis and treatment.

Symptoms Of Scoliosis

Generally, young age at onset (younger than 10 years), rapid curve progression and presence of neurological symptoms help in identifying non-idiopathic scoliosis [1] . In most cases, patients have a spinal deformity or more likely chest wall and back symmetry. When the scoliosis is in the advanced stage, adolescent girls can sometimes notice a difference in their breast sizes. Other prominent symptoms include shoulder asymmetry and overall posture imbalance in the coronal plane.

While it may not be a common symptom, but back pain is not unusual. Sometimes, patients with idiopathic scoliosis can have back pain and posterior chest wall pain on the side of the rib. Lower back pain is common in adolescents [2] . With any spinal condition, a doctor must be particular about neurological problems such as weakness, sensory changes, problems of balance, gait and coordination.

Causes And Risk Factors Of Scoliosis

While it is difficult for doctors to pinpoint the exact causes, it is believed that it could have hereditary factors, since the disorder runs in families. Other types of scoliosis could be caused by the following:

  • Neuromuscular conditions such as cerebral palsy or muscular dystrophy
  • Birth defects that affect the development of bones of the spine
  • Injuries or infections of the spine

Diagnosis Of Scoliosis

First of all, the patient's physical examination begins with checking for any changes in the overall appearance, skin and neuromuscular system before evaluation of the back's shape. The height is measured to monitor skeletal growth and to check the risk of scoliotic curve progression. Besides, those patients who are tall and have long fingers plus an increased arm span to height ratio must also be checked.

A neurological examination is also done to check for balance, reflexes and motor testing in all muscle groups, including sensory testing of the lower extremities, back and chest. When examining the back of a patient, the medical practitioner also inspects the shoulders and hips for symmetry. Lastly, the classic screening test for scoliosis, the forward bending test is performed by making the patient bend forward at the waist with knees straight and palms together [1] [3] .

The examiner should look for any asymmetry in the contours of the back resulting from the rotational deformity of the spine. In classic thoracic scoliosis with the apex of the curve to the right, the patient's right side is prominent. While this is most easily seen in the thoracic spine, it is important to look in the lumbar region for prominence as well. The inability to perform this test due to pain in the back or hamstring tightness can suggest other pathology, including mechanical back pain, disc herniation, spondylolysis or infection.

Next, once scoliosis is suspected, a standing posterior-anterior radiograph is obtained. Besides observing the curve, attention must also be paid to the vertebral bodies on the radiographs. A scoliotic curve without rotation must be investigated for other causes, including tumours, intraspinal pathology and nerve root irritation [4] .

Treatment Of Scoliosis

The treatment of scoliosis is based on the type of scoliosis, the magnitude of the curve, the number of years of growth remaining and the patient's opinion about the shape of their back.

Most children with scoliosis have mild curves and generally do not require treatment with braces or surgery. Of course, they do need to get regularly checked every four to six months to see if there are any changes in the curvature of the spine. While treatment differs in the case of mild, moderate or severe curves, here are a few factors to keep in mind:

  • Girls have a higher risk of progression than boys.
  • Larger curves generally get worse with time.
  • Double curves, also called S-shaped curves, worsen more than C-shaped curves.
  • The location of the curve also plays an important role. Curves in the centre section of the spine worsen more than upper and lower portions.
  • If the child's bones have stopped growing, the risk of curve progression is much lower.

Adoloscent Idiopathic Scoliosis (AIS) is the most common type of scoliosis. The treatment options for AIS include observation, braces and surgery. While many other factors must be considered, the general goal is to keep curves under 50° at maturity. Typically, observation is recommended for immature patients with curves of less than 25°. Orthotic management is recommended for immature patients with progressing curves between 25° and 50° [5] .

1. Braces

In case a child's bones are still growing and he/she has been diagnosed with moderate scoliosis, it is important to wear a brace. While a brace does not cure or reverse the condition, but it helps to prevent the progression of the curve.

In most cases, the brace is made of plastic and contoured to conform to the body. Braces are generally worn both day and night and its effectiveness increases based on the number of hours it's wo[6] rn .

Braces are generally discontinued after bones stop growing in either of the cases - two years after girls start to menstruate, when boys need to shave daily and when there are no further changes in height.

2. Casting

Casting is another treatment for scoliosis and helps to prevent the curve from getting larger, especially when children are young and growing at a rapid pace. The cast works like a brace but can't be removed. This method is generally used when a brace is not as effective.

3. Surgery

In the case of severe scoliosis, surgery is suggested to reduce the severity of the spinal curve and to prevent it from getting worse - this is called spinal fusion. This surgery involves connecting two or more bones in the spine together so that they can't move independently. If scoliosis progresses rapidly at a young age, surgeons can put a rod that can adjust in length as the child grows [7] .

Strategies include fusion with and without instrumentation from the anterior, the posterior or both depending on the curve type, age and surgeon preference. The techniques for the correction and fusion change quickly; long-term results have not been obtained for the newest techniques. However, with older technology, good results have been found in a 20-year follow-up period [8] .

Complications Of Scoliosis

Scoliosis can lead to the following complications sometimes:

  • Lung and heart damage: In severe cases, the rib cage may press against the heart and lungs. This can lead to difficulty in breathing and make it harder for the heart to pump.
  • Appearance: When scoliosis worsens, it can lead to changes in the physical appearance, such as unlevel shoulders, prominent ribs, shift of the waist and trunk to the side and uneven hips.
  • Back problems: Adults who had scoliosis during their younger days are more likely to have chronic back pain issues.
View Article References
  1. [1] Morrissy RT, Weinstein SL. Lovell and Winter’s Pediatric Orthopaedics. Philadelphia: Lippincott Williams & Wilkins; 2006. pp. 693–762.
  2. [2] Ramirez N, Johnston CE, Browne RH. The prevalence of back pain in children who have idiopathic scoliosis. J Bone Joint Surg Am. 1997;79:364–368.
  3. [3] Adams W. London: Churchill Livingston; 1865. Lectures on Pathology and Treatment of Lateral and Other Forms of Curvature of the Spine.
  4. [4] Grossman TW, Mazur JM, Cummings RJ. An evaluation of the Adams forward bend test and the scoliometer in a scoliosis school screening setting. J Pediatric Orthop. 1995;15:535–538.
  5. [5] Nachemson AL, Peterson LE. Effectiveness of treatment with a brace in girls who have adolescent idiopathic scoliosis. A prospective, controlled study based on data from the Brace Study of the Scoliosis Research Society. J Bone Joint Surg Am. 1995;77:815–822.
  6. [6] Rowe DE, Bernstein SM, Riddick MF, Adler F, Emans JB, Gardner-Bonneau D. A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis. J Bone Joint Surg Am. 1997;79:664–674.
  7. [7] Citron N, Edgar MA, Sheehy J, Thomas DG. Intramedullary spinal cord tumours presenting as scoliosis. J Bone Joint Surg Br. 1984;66:513–517.
  8. [8] Dickson JH, Mirkovic S, et al. Results of operative treatment of idiopathic scoliosis in adults. J Bone Joint Surg Am. 1995;77:513–523.

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