My child has abnormal curvature of the spine (scoliosis). What is this?
Scoliosis is a fixed lateral curvature of the spine of 10 degrees or more. This is a very technical definition, but basically, the spine should be perfectly straight when an x-ray is taken in the frontal or anterior-posterior (AP) plane. Having a small curvature is not a problem, but if the curvature gets larger, problems can occur both cosmetically and physically. These include tilting of the trunk, development of rib humps (deformation of the chest wall), and even problems with function of the heart and lungs at very large curvatures.
Since scoliosis has many different causes, it should really be considered a phenotype, almost like having blue or brown eyes, except that scoliosis isn't normal. Thus, when your doctor tells you that your child has a curvature, they have not really made a diagnosis but only identified that there is a problem with the spine's alignment. They still need to investigate why the spine is curved.
How is scoliosis noticed?
It can be very upsetting when your daughter (or son) is diagnosed with scoliosis. Sometimes it is noticed by the school nurse during a screening examination, and sometimes by your pediatrician. Usually during a screening examination, your child is asked to bend over (an Adam's forward bend test) and the clinician looks at the shape of their back. If it is asymmetric, they may be concerned that the spine is abnormally curved. Sometimes they will use a device called a scoliometer that measures the amount of tilt of the back. A tilt of 7 degrees or more is concerning for a significant curve. If there is concern, the clinician will refer your child for further evaluation to a specialist.
School Screening for Scoliosis
Does your school district screen for scoliosis?
What is the usual cause of scoliosis?
There are many potential causes of scoliosis. However, by far the most common cause of scoliosis is called "idiopathic." This type accounts for about 85% of all curves and is usually identified during the adolescent growth spurt. The term "idiopathic" comes from Greek and means "peculiar to ones self." Obviously, this doesn't mean very much and in fact there is quite a bit known about this type of scoliosis.
Idiopathic scoliosis tends to run in families although it often skips generations. More importantly, if it does run in families it is important to understand the the severity (size of the curve and need for treatment) does not! The physician will examine your child, look at their back, test their reflexes and muscle strength, and look for any abnormalities. They may recommend radiographs (x-rays) to measure the size of the curve.
If the specialist rules out all possible causes and everything else comes back normal, your child will be diagnosed with "idiopathic scoliosis." In fact, more is known about idiopathic then most of the other types. Other causes of scoliosis are listed in the table below.
Some Other Causes of Scoliosis
Other Causes of Scoliosis
Spinal cord tumor
Infection of the vertebral body
Leg length difference
Intraspinal Syrinx (cyst)
Congenital abnormality of the spine
Degenerative (in older people)
So once your child is diagnosed, it is important to consult a scoliosis specialist. This is usually a pediatric orthopaedic surgeon, although some adult spine surgeons also care for patients with scoliosis. Your pediatrician will likely refer you to one. Another way to find a scoliosis surgeon is to look on the Scoliosis Research Society website at SRS.org. This is the largest and most prestigious society in the world dedicated to the diagnosis and treatment of scoliosis.
Most children will simply be observed for progression. If the curve remains small, no treatment will be needed. Some may require a brace to prevent the curve from getting worse. There are different types of braces, but the goal is the same; to prevent the curve from getting worse until growth is complete. And on occasion, surgery may be recommended by your specialist if the curve is too big to hold in a brace and will affect your child's health. It is important to know that there is no published evidence in the medical literature that chiropractic manipulation, physical therapy, acupuncture, or other treatments will alter the natural history of idiopathic scoliosis. Thus, beware of promises that seem too good to be true. Be sure to consult a specialist.
Bracing and Scoliosis
Do you think that bracing helps a growing child to prevent progression of scoliosis?
Bracing and Scoliosis
For many years, scoliosis surgeons used bracing to try to prevent an idiopathic curve from getting worse. The goal of the brace is to stop the curve from getting to about 50 degrees, in the hopes that the child would then not need surgery. While there was ample anecdotal evidence that bracing was successful, until recently, there was no controlled study that proved it.
In 2007, the BrAIST study (bracing in adolescent idiopathic scoliosis trial) was started. Patients were enrolled in 25 sites, either to be braced or observed. By 2013, the study was discontinued because it was so clear that bracing significantly decreased the progression of the scoliosis and thus resulted in many fewer patients requiring surgery.
Bracing really does work!
Surgery and Scoliosis
Sometimes, surgery is needed to prevent progression of scoliosis. Usually the curve has reached about 50 degrees when the surgeon recommends surgery. The reason 50 degrees is the "rule of thumb" is that over 50 degrees, the spine seems to be unstable and there is virtually a 100% chance that the curve will continue to worsen throughout the patient's lifetime, even after skeletal growth has finished.
As the curve progresses (particularly curves in the chest or thoracic area), the shape of the chest changes and the space available for the heart and lungs actually decreases, making them work harder. If the curve becomes really large (over 80 degrees), the heart and lungs may become so compromised that the patient gets out of breath walking up stairs.
If the surgery is in the lower back or lumbar area, it will not affect the shape of the chest but can cause imbalance and low back pain.
If surgery is recommended, there are number of ways of performing the surgery. In general, it involves using screws, hooks, and or cables to attach to the spine and rods to help push the spine into a straighter position. Usually this is done from the back (a posterior spinal fusion) but sometimes is done from the front or side (an anterior spinal fusion). Either way, the area of the spine that is instrumented is permentanly immobilized and "fused" with bone like reinforced concrete.
There are different types of metal that can be used. The most common type of metal used is stainless steel. On occasion the surgeon will choose titianium. Each has its pros and cons, and the decision is up to the treating surgeon.
Surgery is often performed in the teenage years. One reason is that the teenager is healthier then they will every be as an adult, and thus their risk will be minimized and their recovery will be shorter. In addition, it is easier for a child to take time off then it is for an adult who has a job and a family. Your child will gain some height from the surgery by making the spine straighter. They are usually in the hospital about 5-7 days and home from school for about 4-6 weeks. Return to non-contact sports is usually allowed around 6 months, and most contact sports (except tackling sports, gymnastics and skydiving) are allowed by one year after surgery. You should discuss this with the surgeon as their postoperative protocols can vary.
It can be very worrisome if your child undergoes screening at school or by the pediatrician and is noted to have a curve in their back. Understanding the different causes of scoliosis is important, as it will have an effect on the outcome and treatment. For adolescent idiopathic scoliosis, the most common treatment is observation. Bracing has been conclusively shown to alter the natrual history and decrease the chance that a child may need surgery. If necessary, surgery can help straighten the spine and stabilizes the curve, preventing further progression and chest-wall deformties that can affect the heart and lungs.
- Scoliosis Research Society (SRS)
This is the website for the Scoliosis Research Society, a non-profit organization dedicated to education, research, and treatment of spinal deformity.
BrAISt study results
- Study: Bracing Really Works for Scoliosis
American Academy of Orthopaedic Surgeons website discussing the results of the BrAISt study.
The Pediatric Orthopaedic Society of North America
- The Pediatric Orthopaedic Society of North America - POSNA
The major children's orthopaedic society whose members are dedicated to the treatment of children with orthopaedic problems. Additional information on scoliosis can be found here.
The American Academy of Orthopaedic Surgeons
- American Academy of Orthopaedic Surgeons - AAOS
The AAOS is the major orthopaedic organization in the United States. Additional information on scoliosis can be found here.