Scoliosis is a condition that can affect the spines of many children, teenagers and adults. The human spine features many natural curvatures which help our bodies to move and be flexible.
Scoliosis is not a diseaseu2014it is a descriptive term. All spines have curves. Some curvature in the neck, upper trunk and lower trunk is normal. Humans need these spinal curves to help the upper body maintain proper balance and alignment over the pelvis. However, when there are abnormal side-to-side (lateral) curves in the spinal column, we refer to this as scoliosis.
Scoliosis affects 2% of women and 0.5% of men in the general population. There are many causes of scoliosis, including congenital spine deformities, genetic conditions, neuromuscular problems and limb length inequality. Other causes for scoliosis include cerebral palsy, spina bifida, muscular dystrophy, spinal muscular atrophy and tumors. Over 80% of scoliosis cases, however, are idiopathic, which means that there is no known cause. Most idiopathic scoliosis cases are found in otherwise healthy people.
Idiopathic scoliosis is broken down into four categories based on age: (1) infantile: children ages 3 and under, (2) juvenile: 3-9 years old, (3) adolescent: 10-18 years old, and (4) adult: after skeletal maturity. The most common form of scoliosis, representing approximately 80% of idiopathic scoliosis cases, is Adolescent Idiopathic Scoliosis (AIS), which develops in young adults around the onset of puberty.
People with a family history of spinal deformity are at greater risk for developing scoliosis. Early detection is essential. There are several different “warning signs” to look for to help determine if scoliosis is present:
Shoulders are different heightsu2014one shoulder blade is more prominent than the other
- Head is not centered directly above the pelvis
- Appearance of a raised, prominent hip
- Rib cages are at different heights
- Uneven waist
- Changes in look or texture of skin overlying the spine (dimples, hairy patches, color changes)
- Leaning of entire body to one side
A standard exam that is often used by pediatricians and in initial school screenings is called the Adam’s Forward Bend Test. Most schools test children in the fifth or sixth grade, and the Adam’s Forward Bend Test can be administered easily by school nurses or parent volunteers. For this test, the patient is asked to lean forward with his or her feet together and bend 90 degrees at the waist. The examiner can then easily view from this angle any asymmetry of the trunk or any abnormal spinal curvatures. It should be noted that this is a simple screening test that can detect potential problems, but cannot determine accurately the exact severity of the deformity.
Once suspected, scoliosis is usually confirmed with an x-ray, spinal radiograph, CT scan, MRI or bone scan of the spine. The curve is then measured by the Cobb Method and is discussed in terms of degrees. Generally speaking, a curve is considered significant if it is greater than 25 to 30 degrees. Curves exceeding 45 to 50 degrees are considered severe and often require more aggressive treatment.
Once it has been determined that a patient has scoliosis, there are several things to take into consideration when discussing treatment options:
- Spinal maturityu2014is the patient’s spine still growing and changing?
- Degree and extent of curvatureu2014how severe is the curve and how does it affect the patient’s lifestyle?
- Location of curveu2014according to the Scoliosis Research Society, thoracic (upper spine) curves are more likely to progress than thoracolumbar (middle spine) or lumbar (lower spine) curves.
- Potential for progressionu2014patients who have large curves prior to their adolescent growth spurts are more likely to experience curve progression.
After this complex set of variables is analyzed, treatment options are discussed. There are three basic types of treatments for scoliosis: (1) observation, (2) orthopaedic bracing, or (3) surgery.
Observation is appropriate for small curves, curves that are at low risk of progression, and those with a natural history that is favorable at the completion of growth. These decisions are based on the expected natural history of a given curve. For example, if a child is diagnosed with a curve of 25 to 40 degrees and has completed growth (i.e., boys older than 17, girls older than 15), then observation is appropriate. Statistically, these curves are at low risk of progression and are not likely to cause problems in adulthood. Follow-up x-ray once per year for several years would then confirm that the curve is not progressing after completion of growth. As an adult, an x-ray every five years, or if there are symptoms, is sufficient.
If scoliosis is present with a spinal curve of about 25 to 40 degrees and the patient is still growing, the doctor may recommend a brace. The purpose of wearing the brace is to keep the curve in the spine from getting worse as the patient continues to grow; however, it’s usually not intended to reduce the amount of curve already present.
There are several different kinds of braces commonly prescribed for children and adolescents with scoliosis. Each is typically constructed of plastic and contoured specifically to the body, with strategically placed padding and straps that place resistance as needed on particular spinal curves.
The goal of bracing is to try and keep the curve from progressing. If the curve in the spine is more than 25 degrees and the patient still has a lot of growing to do, the scoliosis curvature could rapidly get worse.
Whether bracing actually works is controversial. Some clinical studies support the use of bracing in young patients whose curves are at risk of progressing. According to several studies conducted by the Scoliosis Research Society (SRS), bracing successfully stops curve progression in 74% to 93% of female patients with idiopathic scoliosis, depending on the type of brace used and the duration of use1.
Because bracing is designed to halt the progression of the curve, it’s generally not recommended for treating scoliosis in young people who are skeletally mature or almost mature. Once skeletal growth has reached a certain point, or if the curve has become too severe (typically more than 40-50 degrees), bracing is generally not as effective. Bracing also is typically not recommended for treating adult scoliosis. Corrective surgery (spinal fusion with instrumentation) may be recommended in these instances.
There are several different approaches that a surgeon will use to correct spinal deformity such as scoliosis and kyphosis, including the traditional posterior approach, an anterior approach, or both. The anterior approach to scoliosis means that the surgeon will approach the spinal column from the front of the spine rather than through the back.
Technically speaking, the actual surgical incision and approach to the spine is through the side of the chest or abdomen (stomach area) rather than down the front of the body, as many patients would envision it. The anterior approach allows surgeons to remove discs from the front of the spine, place corrective spinal instrumentation and perform a spinal fusion.
The choice of an open anterior approach to the spine is based on a number of different factors including the type of scoliosis, location of the curvature of spine, ease of approach to the area of the curve, and the preference of the surgeon. There are certain types of scoliosis curves, such as those involving the thoracolumbar spine, that are especially amenable to the anterior approach. The surgeon may be able to fuse a shorter segment of the spine using the anterior approach, preserving more motion in the spinal column.
Anterior instrumentation techniques can produce very powerful correction of spinal deformities. However, this approach is more difficult than the standard posterior approach.
The incision is made on the patient’s side. Depending on the part of the spine that requires correction, this may be over the chest wall or lower down along the abdomen. The surgeon deflates the lung and removes a rib in order to reach the spine. Most patients find it interesting that the rib will grow back over time, especially if the patient is young. For lower incisions, the surgeon may need to detach the diaphragm to gain access to the spine, especially for thoracolumbar curves and those in the lumbar spine.
Once the surface of the spinal column is exposed, the surgeon will often remove the disc material from between the vertebra involved in the curve. This will increase the flexibility of the curve and provide a large surface area for spinal fusion. Disc removal is an important adjunct to the anterior correction of scoliosis.
Placing instrumentation in the front of the spine completes correction of the spinal deformity. This usually consists of placing a vertebral body screw at each vertebral level involved in the curve. These screws are then attached to a single or double rod at each level. A combination of compression along the rod, and rotation of the rod will produce correction of the spinal deformity.
After the final adjustment and tightening of the instrumentation, a fusion is performed. The bony surface between the vertebral bodies is roughened and bone graft is packed into the space between the vertebral bodies. There are a variety of different sources for bone graft including the removed rib, the crest of the pelvis, allograft bone, and other bone substitutes.
The most frequently performed surgery for idiopathic adolescent scoliosis involves posterior spinal instrumentation with fusion. This kind of surgery is performed through the patient’s back while the patient lies on his or her stomach. The posterior approach was designed to correct the abnormal curves in the spine that occur in the condition known as “scoliosis.” The posterior approach is the most traditional approach to the spine for spinal surgery. The majority of spinal operations are done using this approach.
An incision is made down the middle of the back. The location and length of the incision depend on the location of the curve and the extent of the exposure that are required to correct it. The incision is often made slightly longer than the length of the planned fusion. Correction of the scoliosis requires that the surgeon be able to “grab on” to the spine. There are a variety of ways to do this. Technically, the surgeon may choose to use hooks that attach to the back of the spine on the lamina, pedicle screws that are placed into the pedicle in the middle of the spine, wires, or other devices. Once these connection points are established, then a rod that has been bent or contoured into a more normal alignment for the spine can be attached and correction performed.
Many patients are aware that their curves are slowly getting worse up until the time that they have surgery. Often they want to know how much their abnormal curve can be corrected at the time of surgery. It is important to remember that the goals of fusion surgery for scoliosis include both correcting the curve, and stopping it from getting worse later on. In many instances of adult scoliosis, stopping the curve from getting worse later on is a more important goal of surgery.
Correction of scoliosis in adults is very different than the correction of scoliosis in children. The causes of scoliosis are different in adults, and the flexibility of the spine is usually significantly decreased with age. As a result, adults who undergo spinal fusions can normally expect less than 50% correction of their original curve, whereas the same curve in a child may be 80% correctable. Complete correction of the curve is rarely possible in adults, especially when the curve is quite large originally.
It is not unusual for curves to get slightly worse after being corrected at the time of surgery. This is because the curve settles into a new position as the fusion is occurring. After six months, the fusion should be solid and the curve should not change significantly from that point on. However, even after a solid fusion has developed, slight curves at the top and the bottom of the major curve that are not included in the spinal fusion may get slightly worse.
If the curve continues to get significantly worse after surgery, this is often a sign that a fusion between the vertebral bodies has not occurred. As a result, there is still some motion between the vertebral segments that were meant to be fused together. A lack of fusion at one or more vertebral body levels is called a “pseudoarthrosis”, which means a false joint. This can be a significant problem after spine surgery and may require further operations in order to correct the problem. One of the best things that patients can do in order to avoid the chance of developing a pseudoarthrosis is not to smoke before and after their surgery. Smoking cigarettes, chewing tobacco, or using a nicotine patch has been shown to interfere with the blood flow to the area that is trying to fuse together. This significantly decreases the chances of a solid fusion occurring.
However, an alternative method of minimizing the incorrect curvature of the spine caused by scoliosis is using the cr17 Hurricane, a groundbreaking medical therapeutic device which delivers rapid and effective myofascial release. Also used in physical therapy, the cr17 incorporates a concentrated level of vibration and percussion in a single device. When combined with the Camara Myofascial Method, a series of protocols designed to facilitate positive change in the physiological, neurological and biomechanical aspects of the body, these tools can significantly improve the scoliosis condition which can enhance the body’s functionality. When suffering with scoliosis, which is an improper lateral or sideways curve of the spine, the torso can be pulled into a twisting position and can cause pain, stress on the body’s internal organs, biomechanical issues and in some cases, even shortening the life span of an individual. One of the problems caused by scoliosis is that the muscle is overly compressed and tightened on the concave or curved-in side of the spine. On the other side of the curve, the convex side, the muscles are overly elongated and stretched. As a result, both sets of muscles are in spasm and are pulling on the spine improperly.