Many of us remember the elementary school screenings for scoliosis. We may not have understood it at the time, but these early detection scans were the first step in diagnosing scoliosis and developing a treatment plan. This visual assessment of the symmetry of our shoulders, shoulder blades, and hips during adolescence was used to detect potential problems. But what causes scoliosis and how is it officially diagnosed once a screening uncovers a risk?
Scoliosis is a condition where the vertebral column of the spine curves to the side, typically appearing as an S or C shape. A positive diagnosis of scoliosis occurs when a curvature of more than 10 degrees is observed on an x-ray or radiograph. Curves are considered significant when greater than 25 degrees and those in excess of 45 degrees are considered severe. Scoliosis can cause the appearance of asymmetrical features such as a difference in the shoulder and hip height. A patient’s arms may visibly appear to hang to different lengths, ribs may appear more or less prominent, and the head may appear off-center at rest. Practitioners may note a difference in height between sides of the back when a patient bends forward during a physical exam.
The Causes of Scoliosis
Scoliosis affects 2-3% of Americans. Boys and girls have an equal chance of developing a mild curvature but girls tend to experience a higher risk of the curve becoming more significant and requiring treatment. The cause of scoliosis is unknown (idiopathic) in as many as 80% of the cases identified and these patients often live without pain or neuromuscular issues.
Although less common, specific disease states may induce a curvature of the spine that matches a diagnosis of scoliosis. Degenerative disc disease, arthritis, osteoporosis, and various genetic conditions may predispose people to spinal curvature. Trauma or infection may create these conditions as well. In these atypical cases of scoliosis, patients are likely to have back and leg pain.
Neuromuscular scoliosis is associated with an underlying neuromuscular disease such as cerebral palsy, spina bifida, or muscular dystrophy. In these instances, neuromuscular issues result in inconsistencies within core balance muscles that are needed to maintain and promote vertebral alignment and posture. This imbalance distorts the spinal column’s forces, and further curvature develops over time and with growth. In these cases, the greater the initial curvature, the greater the risk of further curvature.
Scoliosis is often identified in early childhood through visual screenings in school or by a pediatrician or primary care doctor. Early detection of scoliosis is important. Children with mild curves are monitored by their physician so that if it worsens, treatment can begin to stop it. With congenital scoliosis, the curve develops due to abnormally shaped vertebrae, present at birth. Diagnosis may be made during infancy if deformities are noted during physical examination. If the abnormal vertebrae is not identified in infancy, the scoliosis may worsen during childhood growth resulting in more visible signs of asymmetry.
Radiographs and x-rays are used to identify the degree of idiopathic curvatures and monitor for worsening. CT and MRI scans can provide advanced three-dimensional imaging of atypical and congenital curvature and its underlying forces. A CT Scan uses a combination of x-rays and computer technology to create a three-dimensional image for your spine specialist to evaluate. Magnetic Resonance Imaging (MRI) measures peripheral and central nerves and ligament tissue within and around the spinal cord and related structures.
Any surgical planning is likely to involve an MRI to give the surgeon a better understanding of the patient’s spinal structure. This information can help plan for various approaches and expectations during surgical interventions.
Bone Density Scans (known as DEXA) are also commonly used to assess for states of osteoporosis which can be a risk factor in curvature progression.
Who Is Affected?
In children, idiopathic scoliosis comprises most of the cases observed during adolescence. Curvature is monitored for worsening as children grow and depending on severity, may be treated with bracing and/or surgery. This spine curvature coincides with rapid growth during puberty and may cause visual asymmetry but often without symptoms. Diagnosis is usually made during a visit to the pediatrician or primary care provider. With congenital scoliosis, the curvature is caused by an underlying abnormality. In these cases, further evaluation and monitoring is required to identify the root cause.
In adults, a diagnosis of scoliosis is different because they have reached skeletal maturity and so growth is no longer a factor. Adult scoliosis can be categorized as cases where a patient was treated surgically as a child, cases where a patient was not diagnosed with scoliosis as a child, and cases of degenerative scoliosis. Degenerative scoliosis is age related and is basically the result of activity or wear and tear on the spine. In older patients, it is typically associated with osteoporosis.
How We Approach the Treatment of Scoliosis
Periodic monitoring is required to check for curvature progression during adolescent growth phases and as symptoms develop. Minor worsening may be treated using a brace. More serious worsening of a curve may require surgery.
For adults and seniors, additional factors such as trauma, infection, degenerative disc disease, and osteoporosis may contribute to more advanced scoliosis. This can happen spontaneously, even if no symptoms exist for years or decades and result in more aggressive treatment plans including surgery.
There is no specific predictor of progression in curvature or symptoms relative to it. Regular exams and subsequent diagnostic testing can track changes and help monitor for signs and neuromuscular problems. As curvatures increase, or if dramatic growth is anticipated (as in infancy or at the onset of adolescence), bracing often becomes the first intervention beyond monitoring.
The brace is designed to prevent improper spinal column movement as bone and musculature grow. Bracing would not be appropriate for patients with closed growth plates (adults) or in the case of extreme curvature.
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How a Brace Works
A scoliosis brace is designed to slow or stop the progression of a spinal curvature. A brace is appropriate when the curvature is identified early and bones are still developing. A brace is not a treatment option for an adult since it will not help once bone growth is complete.
There are two types of braces: rigid and dynamic. A rigid brace puts pressure on your spine in key places to prevent the curvature from worsening. It will not straighten a curved spine but it will slow or stop additional curving. A dynamic brace slows curvature by training your body to maintain its correct posture. Both brace types may slow the progression of spinal curve enough to avoid surgery.
Surgery to Treat Scoliosis
It becomes a virtual certainty that spine curvatures will worsen at 50 degrees or more, regardless of continued growth. Breathing may become compromised at 80 degrees of curvature, so surgery becomes more likely, whether symptomatic or not.
Surgical intervention is usually the last option for non-acute conditions of the spine but is common enough that there are well-established criteria to evaluate and plan. Various spinal fusion techniques have been used to treat curvatures over the years. With this treatment, the curved vertebrae are realigned and fused together to heal into a single bone. Posterior (from the back) spinal fusion is most common.
The Risks of Scoliosis Surgery
A surgical event involves the inherent risks of anesthesia and injury to spinal structure, nerves, and ligaments and includes the rare cases of temporary or permanent paralysis. Infection is also a concern with any surgery and is proportionate to the extent and duration of the procedure. Corrective spine deformity procedures tend to be relatively lengthy and technically complex. Florida Medical Clinic is proud to employ leaders in the field that mitigate many of these concerns.
Moving around and deep breathing after surgery helps to reduce lung issues that can result in pneumonia. This also reduces the risk of developing deep vein thrombosis, or DVT. Typical complication rates in spinal fusion, ranging from infection to implant failure, are 2% or less.
Exercise, occupational therapy, and strengthening may be necessary for several weeks and up to a year. A patient’s dedication to following their post-op instructions is key to optimal recovery. The fusion does not take place during the surgery. Instead, rods, screws and bone grafts sets the spine and fusion takes place gradually over 6-12 months. Once spinal fusion is confirmed, regular physical activity, including sports, may be resumed with the understanding that there may be risks associated. Younger patients who are still in a growth phase may require closer follow-up as they resume activity. Typically, asymptomatic patients who are beyond growth phases generally do not require constant post-fusion monitoring or imaging.
The Bottom Line
The challenges associated with with scoliosis depend upon an individual’s age and the severity of the curve. Many people live with a moderate curve to their spine and suffer no consequences. But for those with more severe curves, scoliosis can cause physical impairment. It can even have mental health implications when deformities are more prominent. With a choice of non-surgical, minimally invasive and surgical options, scoliosis can be managed.
For this reason, patients with scoliosis should be under the care of a qualified and experienced orthopedic doctor specializing in spine health. It is essential to follow up regularly with your physician and adhere to your treatment plan closely to reduce the risk of progression of scoliosis and maximize nonsurgical therapies.
Meet Dr. Charles “Chuck” Nalley with Florida Medical Clinic, Orthopedics
Your spine is at the center of your overall well-being. Ensuring spine health is critical because it controls your body’s vital functions.
Charles Nalley, MD is a board certified Orthopedic Surgeon, specializing in degenerative spine conditions, scoliosis, spinal cord stimulation and operative & non-operative spine treatments.
To learn more about Dr. Nalley’s approach to spine health, request an appointment.
Official Team Physician of the Tampa Bay Lightning since 2002
Disclaimer: This post is not a substitute for medical advice, diagnosis, or treatment from a licensed medical professional.