Kid's Health

Scoliosis is a form of spine deformity where a lateral or side spine curves. The spine may curve to the left or right.

The term "idiopathic" means that the cause of this form of scoliosis is still unknown although there are many theories as to what may be causing this deformity. It is probable that idiopathic scoliosis is caused by multiple factors. We refer to this condition as “adolescent” because it is present in 2 to 4 percent of children between 10 and 16 years of age.

What are the possible causes of adolescent idiopathic scoliosis?

There are many theories as to its origin, and some of the most probable are:

1. Genetics - No one really knows which gene is causing this deformity but it is proven that this spine deformity runs in certain families. This definitely in favor of the genetic theory.

2. Sub-Clinical Poliomyelitis - This means that before the deformity actually occured, there’s been a sub-clinical inflammation of the spinal cord. Generally, this type of inflammation is causing no notable symptoms and therefore it is very hard or even impossible to detect.

3. Rapid Growth and Hormones - These curves really progress rapidly. High levels of growth hormones are found in all patients, especially girls, which implicates possible hormonal causes.

4. Structural Changes - It has been proven that patients with adolescent idiopathic scoliosis have bone-disc deformities as well as several muscular deformities of the muscles located around the spine. But it still hasn’t been proven what these biomechanical changes are – a cause or a consequence of scoliosis.

5. Nutrition - There is a strong correlation between poor nutrition and the changes in skeletal development which could lead to scoliosis.

6. Body’s equilibrium - Obviously, if a child has balance, posture or body symmetry issues, this could affect the shape or position of the spine.

What are the most common symptoms of adolescent idiopathic scoliosis?

There is a big problem with this spine condition diagnosing since, in most cases, the child will not notice any problems. Furthermore, there may be no apparent symptoms at all.

This may lead to several much more serious problems because this form of scoliosis is often not discovered until the curves have progressed significantly, thus  it becomes much more difficult to treat. There is yet another thing that makes it hard to make a definitive diagnosis - the curves are not visible until the person bends over.

Still, there are some symptoms that could definitely make a person think about this spine deformity rather then something else. First, there could be some form of asymmetry in the shoulders - one may be higher than the other. Then, when the person bends over- a big back hump that sticks up could be seen. This is also potentially an important diagnostic sign. Some patients have one hand that hangs much longer then the other because of the upper body asymmetry.

How to make a definite diagnosis?

It is very important to make a diagnosis on time because late diagnosis can make the treatment much more complicated. A physician will measure the child’s curve progression. This can be done by serial radiographs, measuring the rib humps or changes in height.

Another thing one should pay attention to is whether the scoliosis produces pain or not. If the nerves in the root canal are damaged, a bowel or bladder dysfunction may be present and evidenced.

There are also some special tests used for much more detailed evaluation and detection of spine curvature degree. These special diagnostic tests are:

1. X-rays - Several X-ray images are made from various angles which visualize the spine completely and the angle of the curve can be measured in degrees.
2. Magnetic Resonance Imaging SCAN - MRI creates computer-generated 3D images and, best of all, does not use radiation at all! It’s a much more precise and sensitive technique than the common X-ray imaging. The whole procedure takes about 30-60 minutes and it is completely painless.
Prognosis of adolescent idiopathic scoliosis?
One the definitive diagnosis has been established, the physician’s primary concern should be whether or note there are underlying causes of scoliosis, and even more importantly - will the curve progress in the future!

There are, in fact, three major concerns:

1. The patient’s gender - Scoliosis in girls tends to progress more often

2. Curve growth potential - The level of growth potential is measured by Risser (0 to 5) grades. Grade 0 means that there are no ossification (degree of bony fusion) and grade 5 means complete bony fusion

Curve (degree)

Growth potential (Risser grade)

Risk

10 to 19   

Limited (2 to 4)   

Low

10 to 19

High (0 to 1)   

Moderate

20 to 29   

Limited (2 to 4)

Low/moderate

20 to 29   

High (0 to 1)

High

>29

Limited (2 to 4)

High

>29

High (0 to 1)   

Very high

*chart source American Academy of Family Physicians (AAFP)

3. Curve degree at the time of diagnosis – This angle is measured by Cobb angle.

The Cobb angle is the angle formed by an imaginary line drawn from the bottom to the top of scoliotic curve and a line drawn along the bottom of the “normal” inferior part of spine.

There are some rules about these deformities that every doctor should keep in mind. - Lumbar curves are “steadier” then the thoracic ones, which are more likely to progress.

- The younger the patient is when the curve appears, the greater the chances for the curve to progress rapidly later in life.
What is the treatment of scoliosis?
There are several possible treatments of scoliosis and choosing the right one depends upon the patient’s age, curve severity, deformity location and cause, etc.

Monitoring

The most common treatment of the spine deformities that are less than 15-20 degrees is simple monitoring. Patient should have regular X-rays examinations done about twice a year during rapid growth years, and after that about once a year.

Physical therapy and exercise

Physical therapy and exercise hold a very important place in the successful treatment of adolescent idiopathic scoliosis. The goal of physical therapy is to maximize the range of motion and strength and improve back posture. The exercises should be planned really carefully and rehabilitating program must be made for every patient individually.

Bracing

If the curve angle is between 25 and 40 degrees then bracing is probably the best treatment option. Patient should wear the brace daily and the physician should prescribe exactly for how many hours. These braces are commonly used when the scoliosis is in progression because they can prevent the curve from getting worse.

There are several types of these braces and one of the most common is the Milwaukee brace, which can correct any kind of spinal curve. Another commonly used type is the Boston brace – a simple plastic jacket that pressures the ribs and back. However, it has been established that some curves do not respond to bracing.

Electro-spinal stimulation

This is a form of muscles electro- relaxation. It is relatively painless and can cause great improvement in movement abilities of the patient.

Surgical Treatment

If the angle of the curve is greater than 45 degrees, then the only effective treatment would be surgery. Curves this big can represent significant threats to a patient’s health state because they cause continual pain, breathing difficulties, and significant disfigurement. Even 100 degree curves are known to occur,  but they are quite rare and in most cases life-threatening.

Surgery performed on scoliosis patients is called spinal fusion with instrumentation. There are three possible approaches: anterior, posterior and combined approach and the choice is up to a surgeon.
Anterior approach means that the initial incision is made in the chest and during the procedure a so-called intervertebral discs are being removed because they are responsible for the curve. Instead of them, a metal rod is placed along the vertebrae to keep the spine steady.

Posterior approach is being done through a back incision. During this procedure some bone grafting is performed to fuse the curved vertebras.

A combined approach is probably the best and, in most cases, it includes two separate procedures which can even be scheduled separately.

Possible surgery complications

Since this surgery is extremely complicated and the target tissue extremely sensitive (spinal cord and several nerve structures are very close), there are several possible complications.

As with any operation, infection is the most common complication. Milder form of infection appears only on the skin incision but the problem may occur if it spreads deeper and involves the areas around the spinal cord and the vertebras. The surgeons are of course taking every possible precaution to prevent infection but sometimes it is simply unavoidable. The good thing is that these infections occur in less than 1% of spinal surgeries.

Another possible scenario is that the instruments being inserted into the spine simply break. This includes metal screws, plates, and rods. If this happens, a second procedure is needed to remove and replace the broken parts.

Because of target field sensitivity, nerve damage is also a possible complication. Nerve damage causes paralysis in certain areas of the body depending on which nerve gets damaged. Sometimes, even if the operation went well, there is still a persistent pain after it. In such cases a detailed evaluation is needed and pain killers might be administered for a time.