What is scoliosis?
What is scoliosis?
Anatomy of the Spine and Spinal Cord
The spine is composed of 33 vertebrae connected to each other with disks, joints, and soft tissues.
The vertebral column maintains our upright standing posture, and supports the movement of forward, backward and side bending as well as rotations. Additionally, each vertebra has posterior bony elements to protect the spinal cord.
Nerves travel through the spinal cord and act like electric cables to deliver the signals from the brain to the body, arms and legs. Nerves are responsible for motor activities and sensation. They also carry signals for the bowel and bladder control.
What is Scoliosis?
Scoliosis means sideways curvature of the spine. In addition, the spine rotates around itself.
When a person's body is viewed from the back, a normal spine looks straight. However, when a spine with scoliosis is viewed from the back, it is curvy. This curvature can be a single curve in one region of the spine or multiple curves in various parts of the spinal column can be present.
In contrast, the spine is not straight when viewed from the side. The spine has its normal sagittal curvatures. A slight gibbosity (kyphosis) in the upper thoracic region, and an inward curvature (lordosis) in the lower back are normally present. Scoliosis may also effect this normal curvates of the lateral plane.
Scoliosis can be seen at all ages. Very young children and elderly adults may be diagnosed with scoliosis. Scoliosis may be due to formation and segmentation anomalies of the bony vertebra or neuromuscular system disorders. Yet, the most common type is idiopathic scoliosis.
Scoliosis is not a separate illness by itself. Rather, it is a sign, such as a "fever". Scoliosis, like a fever, can occur because of various diseases. The most common type of scoliosis is “idiopathic,” which means “of unknown cause.” It is 8 to 10 times more common in girls than boys.
Signs and Symptoms of Scoliosis
- In standing position;
- One shoulder may be higher than the other
- One scapula may be higher or more prominent than the other
- When the arms are shrugged to the sides, the space between the arm and the body may be greater on one side.
- One hip may appear higher or more prominent than the other.
- The projection of the head may not be on the midline of the hips. (off-balance)
- One leg appears longer
- Asymmetry of the waist
- Clothing hangs unevenly
When the patient is viewed from the back and asked to bend forward until the spine is parallel to the ground, one side of the back may appear higher than the other (hump appearance).
What Causes Scoliosis?
Scoliosis may be due to several underlying diseases. However, the most common type of scoliosis is “idiopathic,” which means “of unknown cause.” Researchers have isolated some genes thought to cause scoliosis. However, no pattern of genetic transmission has been identified until now, and it is commonly thought that not only genetics but environmental factors (e.g., growth) play a role in the etiology of scoliosis.
The second most common type of scoliosis is neuromuscular scoliosis, a result of neural or muscular disorders such as: cerebral palsy, poliomyelitis, Duchenne muscular dystrophy, etc.
The third most common type of scoliosis is congenital scoliosis, which displays vertebral anomalies.
Other less-common causes of scoliosis include:
- connective tissue disorders
- vertebral fractures
- spinal infections
- spinal tumors
- metabolic diseases
- rheumatologic diseases
Idiopathic Scoliosis Types
Subtypes of idiopathic scoliosis:
Idiopathic scoliosis is categorized by the age at which it begins to develop. Each age group has unique needs and challenges associated with treatment:
Infantile idiopathic scoliosis: Ages 0-3
Juvenile idiopathic scoliosis: Ages 4–9
Adolescent idiopathic scoliosis: Ages 10–18
How is Scoliosis Diagnosed?
Certain physical changes indicate scoliosis. Yet, clinical examination is not enough to properly evaluate a scoliosis patient.
Besides clinical examination, radiographic analyses and health-related quality-of-life questionnaires should be performed.
Whenever necessary, heart and lung examinations are also included in the analysis.
Scoliosis Radiographs
Clinical examination, radiographic analyses and health-related quality-of-life questionnaires should be performed for the diagnosis of scoliosis.
Standing anterior-posterior and sagittal radiographs are used to measure the degree of scoliosis, or the angle of scoliosis. Manual or computerized measurements of the angle of scoliosis is done by using the Cobb method.
The bony landmarks on the radiographs are used to measure the Cobb angle. Therefore, the measured degree may slightly differ among observers. Even the same person can measure the angle differently when measuring the same X-ray at different times. These differences should be no more than 5 degrees in manual measurements and no more than 3 degrees in computerized measurements. For double and triple curves, scoliosis degrees are measured instead of a one particular degree.
Scoliosis and Health Related Quality of Life Questionnaires (HRQoL)
HRQoL questionnaires are necessary to analyze a curve’s effect on an individual.
Standardized questions are used to evaluate the patient’s pain and function scores, perception of self image, and mental health scores.
Therefore, in addition to measuring the angle and degree of scoliosis, the individual’s life with scoliosis is analyzed.
What are the other factors affecting the surgery desicion?
· The affected part of the spine
· The presence of increased or decreased kyphosis
· Residual potantial for growing
· Patient’s alignment and balance
· The HQRoL scores of the patients
· Pain (Rare in adolescents, more common in adults)
· Personal factors
Scoliosis Imaging
How are scoliosis radiographies obtained?
Scoliosis is a three-dimensional deformity. A one-sided X-ray is not enough for thorough scoliosis analysis. At minimum, two-sided radiographs are required. Anterior-posterior and sagittal X-rays are taken on a routine basis.
In a proper X-ray, all vertebra from the upper vertebra on the neck to the ilium should be clearly seen on a single cassette. The analysis could become difficult or impossible from the partitioned radiographs.
Another important aspect of scoliosis radiographs is that these X-rays should be taken in a standing position. In standing position, the actual curve positions are observed better due to the gravitational forces.
What are the advantages of EOS?
EOS is the brand name of a device that is scientifically known as the bi-planar slot scanner. The low-radiation mechanism (90% less radiation exposure) of this device won the Nobel prize in physics.
EOS provides 90 percent less radiation exposure compared to standard X-ray devices.
A full body image from head to toe is created in one single radiograph. For instance, a leg-length discrepancy in children often indicates pediatric scoliosis. In these cases, a footpad support might prevent scoliosis progression or resolve the curvature. Since the leg-length discrepancy measurement is possible with EOS, this etiology can be easily found.
In adult scoliosis and deformities, knees and hips are playing an important role and considered the continuation of the spine. EOS provides a better analysis of the relationship of the spine, pelvis, and the lower extremities, which is important especially in the sagittal plane.
In summary, the EOS device provides a better 3D analysis with lower radiation exposure, helping surgeons make more accurate decisions in the treatment and planning of scoliosis. Few centers in the world have the EOS device.
Types of Scoliosis
Scoliosis may assume various shapes and occur in different parts of the spine depending on the underlying primary illness. The spinal curves may differ among individuals even when the same disease causes scoliosis.
Interestingly, everyone's scoliosis has a distinct shape and response to treatment. Therefore, unexpected results may be obtained in the natural course and treatment of some patients.
Considering the variable characteristics of scoliosis, the diseases that can cause scoliosis are listed below in order of frequency:
· Idiopathic scoliosis: This is the most common type of scoliosis. It is named "idiopathic" (of unknown cause) because its cause has not yet been explained.
· Neuromuscular scoliosis. This is the second most common type of scoliosis, caused by an underlying nerve-muscle disease. Nerve disorders may arise from the brain or spinal cord (i.e., polio, cerebral palsy, meningomyelocele, children with traumatic spinal cord injury and paralysis, etc.) Muscular diseases are present during childhood or later (such as Duchenne's disease).
· Congenital scoliosis. This type of scoliosis is caused by spinal abnormalities that have occurred during development of the child inside the uterus. They are generally progressive because of their onset from birth.
· Syndromic diseases: Scoliosis may occur following numerous genetic diseases. Patients with syndromic illnesses need close observation for the development of scoliosis.
· Neurofibromatosis: This is a disease affecting the bones and soft tissues. Scoliosis often accompanies this condition.
· Rheumatoid diseases
· Diseases affecting the connective tissues, such as Osteogenesis imperfecta, Marfan's syndrome, Ehlers Danlos.
· Spinal fractures
· Spinal infections
· Metabolic diseases, such as Morquio, Gaucher's disease, etc.
As can be seen, there are many diseases only some of which are listed above, that cause scoliosis. The follow-up and treatment of the patients may vary depending on the underlying disease.
What is Early Onset Scoliosis?
Early Onset Scoliosis vs. Adolescent Scoliosis
Scoliosis occurring at an early age especially under age 10 show different characteristics than adolescent scolioses.
Early onset scolioses are often progressive because of a child’s growth potential.
What Causes Early Onset Scoliosis?
Early onset scoliosis may be infantile or juvenile scoliosis, which are types of idiopathic (unknown cause) scoliosis. Congenital scoliosis becomes evident at earlier ages, and has a rapid progression. Early onset scoliosis may also occur in some syndromic patients. Others are scolioses caused by muscle and nerve (neuromuscular) diseases, metabolic diseases (mucopolysaccharidosis, etc.), and connective tissue disorders (osteogenesis imperfecta, etc).
Brace Treatment
In the treatment of scoliosis and kyphosis, bracing is applied to:
· Skeletally immature patients
· Those having a curve mild or moderate curve magnitude
· Patients with documented or expected curve progression
Who benefits from brace treatment?
Brace treatment is recommended for growing children having curves between 20-40 degrees. The success rate is low for curves >40 degrees, therefore, bracing is generally not recommended for adolescents with >40 degree curves.
There are exceptions. In some cases with very young children who have substantial growth potential and have curves up to 60 degrees, bracing can be used. It is important for these children that surgery is postponed as long as possible for the controlled growth of the spine.
Which scoliosis brace is better?
There are many types of “scoliosis braces” or “correction braces” on the market, which may confuse patients. Your doctor will decide the appropriate brace according to the curve location and shape. Braces that are used for similar curves can further differ according to their material and production processes. This also effects the price.
The most important aspect is to use a brace that effectively corrects the curve. The type of the brace does not directly effect the results. Generally, the ones that can be hidden under dresses are more acceptable among children.
In general, the most preferred braces are: thoraco-lumbo-sacral-orthosis (TLSO), Milwaukee, Boston, and Rigo-Weiss-Cheneau-Gensingen. Wilmington and Lyon braces are used as well. For kyphosis, Milwaukee type braces are generally preferred.
Braces are not like prescribed drugs that you can buy from any pharmacy. The brace must be tailored to achieve the best fit and best correction. Therefore, for a brace to be effective, the doctor, orthosis specialist, parents and child should cooperate:
The doctor decides if bracing is necessary and suitable
Parents support the decision
Children accept and comply with the decision
The orthosis specialist uses his or her expertise to fit the brace to the patient
The brace, its pressure points and amount, and the curve correction rate should be radiographically assessed before the child starts using it. The ideal situation is to achieve a 50 percent in-brace correction.
It is difficult and cumbersome to wear a brace, and it requires patience. However, when properly produced and used with high compliance, the results are very satisfactory.
What are the expected results of bracing?
Bracing is used to prevent the progression of the curve. The main reason for bracing is not to completely correct the spinal curvature or decrease the curve magnitude, but to prevent its progression.
The studies show that appropriately prepared and worn braces reduces the need for surgical treatment by 50 percent. As seen on the table, 52 percent of children not using braces will require surgical correction. However, for children using braces, only 28 percent will need surgery.
What are the requirements for a succesfull brace treatment?
Main principles, appropriate patient, appropriate timing, appropriate brace, appropriate usage and regular controls.
Appropriate patient. Mild to moderate scoliosis (20-40 degree curves). Mild-moderate Scheuermann kyphosis (60-75 degrees)
· Appropriate timing. Early diagnosis is important in scoliosis. Braces should be started while the child still has growth potential. (For girls, it is important that the brace is started before menarche.)
· Appropriate brace. The brace should specifically be prepared for the patient. The brace should be controlled before the patient starts using it.
· Appropriate usage. The brace should be worn daily 20-23 hours.
Regular controls with the orthopedic surgeon. To continue scoliosis exercises, sports, dancing and other practices, with the information of the doctor, the brace might be removed for a couple of hours. Swimming can also be recommended in the off-brace hours.
How long the brace should be worn?
As it is seen in the graph, the treatment success is 41 percent when the brace worn <6 hours/day and the curve progression is similar to patients without braces. The treatment success is 90 percent in patients who wear the brace >13 hours/daily.
Brace treatment is proven to be effective, although it is difficult to use. Therefore, it is important that the parents are supportive and the child is complying.
Schroth Method for Scoliosis Rehabilitation
Schroth method is a scoliosis-specific rehabilitation program. It’s a three-dimensional approach that aims to achieve stabilization by activating muscles to maintain the corrected posture. It is tailored for each patient based on the concept of functional segments.
The therapist gives visual, vocal and tactile feedback. Mirrors and bars are generally used. Schroth method also trains the individual to integrate the correction in the activities of daily living such as sitting in accordance with the curvature.
Schroth can be applied on an individual or group therapy basis.
Non-Surgical Treatment in Scoliosis?
Is non-surgical treatment of scoliosis possible?
Non-surgical treatment of scoliosis is possible in various ways. Follow-up is advised for the mild curves, meaning routine controls, examinations, and X-rays of the patients in particular time periods to define whether or not a curve is progressing. Exercise, physical therapy, and bracing can be applied for moderate curves. Permanent curve correction is not expected in bracing, however. Well-applied brace treatment is expected to prevent or decrease curve progression, so that the curves will not exceed the surgical limits.
How is scoliosis corrected? How does it heal?
The only proven way to correct scoliosis is surgery. However, because of the risk of potential complications, not all scoliosis patients are candidates for surgery.
When is scoliosis surgery necessary?
Surgical decision is typically based on the degree of the curvature. The main consideration is whether the curve will progress. Curve progression in skeletally immature patients necessitates surgery to correct the curve and prevent further progression.
The treatment scheme for the skeletally immature patients are as follows;
· 0-20 degrees is observation with follow-up controls
· 20-40 degrees is bracing
· And >40 degrees is surgical treatment
Skeletally mature patients and adults do not have the same risk of curve progression between 0-40 degrees. Hence, the surgical decision for adults is given when the thoracic curves are >45-50 degrees and lumbar curves are >40 degrees.
What are the other factors affecting the surgery desicion?
· The affected part of the spine
· The presence of increased or decreased kyphosis
· Residual potantial for growing
· Patient’s alignment and balance
· The HQRoL scores of the patients
· Pain (Rare in adolescents, more common in adults)
· Personal factors
What is the important of balance and off-balance in scoliosis?
The treatment algorithms for balanced and off-balanced scoliosis can differ. A curve causing serious off-balance might require surgery to maintain balance even below the surgical threshold degree of 40-50 degrees. Balance is important. A balanced gait is necessary for minimal energy expenditure during movement. For instance, an off-balanced person spends more energy to walk 100 meters than a balanced person. An off-balanced person will more quickly and easily become exhausted during the activities of daily living.
What hapens if surgery is not performed to a scoliosis that reaches or passes surgical threshold degrees?
Children or adolescents having a curve degree >40 degrees tend to progress with growth, and may reach to a severity that can cause lung and heart problems, decrease the quality of life, and shorten the lifespan.
Even in skeletally mature individuals, thoracic curves of >50 degrees and lumbar curves of >40 degrees tend to progress with time. This progression rate is not as fast as in the skeletally immature. Spinal degenerative changes will be absent or few in young adults. Likewise, comorbidities such as diabetes, hypertension, cardiovascular diseases, etc., will be less frequent. Therefore, surgical deformity correction for young adults may be more beneficial and easier than later adulthood and for the elderly.
