Scoliosis - A Patient Primer.
Edited By: Generic Spine Content, Theodore A. Wagner, M.D.
Last updated Wednesday, February 09, 2005
AboutBasics of scoliosis Scoliosis is defined as a curvature of the spine in the frontal and/or
coronal plane. In other words, the spine is abnormally curved when
viewed from the front of the patient, and when viewed from above. The
normal spinal column has no curvature when viewed from to front, but
does have a curvature when viewed from the side (sagittal plane). Think
of your spine when standing- your neck curves backwards slightly, your
upper back is slightly rounded, and you have a slight swayback in your
lower spine. When the spine becomes curved in the frontal plane as it
does with scoliosis, some of the sagittal plane curve is usually lost.Immediate medical attention It is very unusual for a person with scoliosis to require immediate
medical attention. Patients who have difficulty with walking,
spasticity (severe muscle spasms) in their legs, progressive weakness
in their legs and loss of control of urine or stool should seek urgent
medical attention. These symptoms may indicate problems in and around
the spinal cord, which can be associated with some forms of scoliosis,
especially in children.Facts and myths Scoliosis is assumed to be quite common in the teenage population, but
in actuality less than 1% of children have scoliosis that requires
attention from an orthopaedic surgeon. In fact, there is a push towards
doing away with the standard school screening for scoliosis, as
screening has not been shown to improve the management of scoliosis.Prognosis Scoliosis is not a life-threatening condition. However, as with many
orthopaedic conditions, in severe cases it can affect quality of life.
It can cause pain and produce a noticeable deformity of the spine that
can cause problems with self-image and confidence. In extreme cases it
can affect lung function and the function of abdominal organs.Pain Most cases of scoliosis do not cause pain or discomfort. However, in
severe cases, arthritis and intervertebral disc degeneration can
develop, which can be painful. In addition, there are conditions such
as tumors or spinal cord lesions that can cause scoliosis. Scoliosis
associated with these conditions is more likely to cause back pain.Curability There is no cure for scoliosis- surgery for this condition only attempts to correct and/or stabilize the curvature.Fertility and pregnancy Scoliosis itself, whether treated operatively or nonoperatively, should
not affect a patient’s ability to get pregnant, nor should it affect a
patient’s ability to carry a pregnancy to term. There are rare genetic
conditions that can cause problems with fertility that can be
associated with scoliosis. Women often have back pain during their
pregnancy, but there is no evidence that the incidence of back pain is
increased in pregnant women with scoliosis.Independence In severe cases, a patient with scoliosis may lose their independence.
This loss is usually due to a spinal deformity which causes enough
imbalance (leaning towards the left or the right or forward) which
requires the patient to use assistive devices (cane or walker) while
walking and performing activities of daily living. The number of
patients that become this debilitated is small. For patients with
neuromuscular scoliosis (cerebral palsy, spina bifida, spinal cord
injury), a spinal deformity can result in a loss of the independence
that is already in danger.Mobility The majority of scoliosis does not limit a patient’s ability to move
about and participate in all activities, including sports. In severe
cases, the curves can become quite stiff, and can limit bending from
side to side as well as forward and back. Adolescent patients that are
treated with bracing are usually able to perform all of their daily
activites with the brace on, although removal of the brace for sports
is usually recommended. Patients who have had surgery for scoliosis
will have portions of their spine “fused”. The goal of a fusion is to
eliminate motion between two vertebrae so that the curve does not get
larger. After a fusion, a patient does have limited mobility,
especially when the lumbar spine is fused. The lumbar spine is more
mobile than the thoracic spine, and so lumbar fusion limits mobility
more than thoracic fusion.Relationships The main issue for most patients with scoliosis is one of self-esteem
and self-image. Poor self-image can adversely affect relationships,
social support, and family interactions. Unfortunately, there is no
hard data on whether or not surgical intervention improves self-image
and self-esteem. Although the majority of scoliosis is not terribly
disfiguring, this is the age of “extreme makeovers”, and the primary
reason that patients (both adults and adolescents) seek medical
treatment is their appearance.Incidence The majority of scoliosis is termed idiopathic, which means that the
medical community does not know what causes it. The majority of
scoliosis in adolescents is idiopathic. There are congenital causes of
scoliosis which often cause patients to have large curves at a very
young age due to malformed vertebrae. These scolioses can be associated
with spinal cord abnormalities as well as heart and kidney problems.
Neuromuscular scoliosis occurs in patients who have abnormal nerve
and/or spinal cord function such as in cerebral palsy, spina bifida, or
spinal cord injury. Adult scoliosis can be from an adolescent
scoliosis, or it can be what is termed a degenerative scoliosis. This
condition is caused by an asymmetric wearing of the intervertebral
discs and the joints between the vertebrae.Acquisition The majority of scoliosis is called idiopathic, which means that the
medical community does not know what causes it. There have been recent
studies that suggest that there is a genetic component to adolescent
idiopathic scoliosis. Neuromuscular scoliosis occurs as a result of
abnormalities in nerve function which control the trunk musculature,
such as spina bifida and cerebral palsy. Patients with spinal cord
injury can also develop scoliosis because of abnormal nerve function.
New onset adult scoliosis is usually caused by degeneration of the
discs and joints in between the vertebral bodies, and can be
exacerbated by osteoporosis. Sometimes, a scoliosis can develop after a
spine fracture or infection due to asymmetry caused by the injury or
the treatment of the injury. Scoliosis also can develop after spinal
surgery, which is called post-laminectomy scoliosis.Genetics There is current ongoing research that is attempting to localize a
“scoliosis gene”. Although there have been some associations made, at
this time there is no definite gene that is associated with any type of
scoliosis.Communicability Scoliosis is not contagious.Lifestyle risk factors Scoliosis itself (idiopathic, congenital, post-traumatic, degenerative)
is not affected by diet, metabolism, or lifestyle. There have been some
studies suggesting that physical therapy can change the natural history
of scoliosis in adolescents, but this is not the widely accepted view
of the medical community. There is some evidence that osteoporosis can
cause progression of a scoliosis in the older adult. A patient’s
symptoms can be affected by diet, metabolism and lifestyle. Patients
that are active, maintain a normal body weight, and ingest the normal
daily requirements of all nutrients, including calcium, may experience
less discomfort and pain.Injury & trauma risk factors Scoliosis can arise after a spinal fracture or a spinal infection, due
to asymmetric collapse of a portion of the spine, asymmetric healing,
and asymmetric injury.Prevention There is currently no way to prevent idiopathic scoliosis. The risk of
congential scoliosis can theoretically be minimized with proper
prenatal care, as can the risk of neuromuscular scoliosis. The risk of
degenerative scoliosis can be minimized by minimizing the risk of
osteoporosis (increasing calcium intake, avoiding (or quitting)
smoking, avoiding heavy alcohol use, exercising, taking estrogen,
avoiding falls and injuries).Anatomy Scoliosis affects the vertebral bodies within the spinal column. In
idiopathic cases, the spine rotates about its long axis, resembling a
spiral staircase, and with time the vertebral bodies can become
misshapen and the intervertebal discs can become degenerated.Initial symptoms The early signs of scoliosis are subtle. In adolescents, parents will
often notice an asymmetry of the patient’s back, or perhaps different
should heights. Adults often notice a decrease in height, or that their
clothes fit differently, or their chest becomes prominent on one side.Symptoms Adolescents rarely have symptoms of pain or discomfort. Back pain in
children and adolescents can be a sign of something more ominous than
scoliosis, such as infection or tumor, and should be investigated.
Young children with scoliosis can have spinal cord involvement, which
may manifest itself as difficulty walking, stumbling, and spasms.
Patients with neuromuscular scoliosis may develop progressive loss of
balance while standing and sitting; they can also have progressive
difficulty with walking. Adults can experience back pain, fatigue,
sciatica, decreased walking tolerance, loss of height and leaning
forward or to one side.Progression Mild scoliosis may be asymptomatic- adolescents will usually present
with a cosmetic deformity only, but as a curve worsens they may
experience back pain or fatigue, often activity related. Patients with
neuromuscular scoliosis may develop progressive difficulty with
walking, and may have problems maintaining and upright posture either
sitting or standing. As adult scoliosis worsens, patients can suffer
from increasing pain and fatigue, which can lead to increasing
difficulty with activities of daily living.Causes The majority of scoliosis is called idiopathic, which means that the
medical community does not know what causes it. There have been recent
studies that suggest that there is a genetic component to adolescent
idiopathic scoliosis. Congenital scoliosis is a result of abnormal
formation of the spinal column. Neuromuscular scoliosis results from
abnormal nerve function which causes abnormal muscle activity around
the spinal column. New onset adult scoliosis is usually caused by
degeneration of the discs and joints in between the vertebral bodies,
and can be exacerbated by osteoporosis. Sometimes, a scoliosis can
develop after a spine fracture or infection due to asymmetry caused by
the injury or the treatment of the injury. Scoliosis also can develop
after spinal surgery, which is called post-laminectomy scoliosis.Effects By a rotation about the long axis of the spine, abnormal curvatures
develop in the spinal column. The spine becomes curved in the frontal
plane (looking at the patient face on)- in patients without scoliosis
the spine is straight in this plane. In the sagittal plane (looking at
the patient from the side) patients without scoliosis normally have a
thoracic kyphosis (hump) and a lumbar lordosis (swayback). In the
scoliotic patient these curves flatten out.Diagnosis If scoliosis is suspected, a simple Xray in the frontal plane should be
enough to make a diagnosis. For completeness, long (from base of neck
to pelvis) front and side view xrays with the patient standing are
needed for an adequate evaluation. The majority of adolescent and adult
patients do not require an MRI. In the young child however, congenital
deformities may be present within the bony spinal elements as well as
the spinal cord, and an MRI is often ordered.Effects Radiographs impose radiation upon a patient, and excessive use can lead
to malignancy. Patients who do not have any metal within their bodies
should have no difficulties with an MRI, which does not use radiation.Health care team In the adolescent and the young child, school screening by a nurse has
diagnosed many a scoliosis, although this screening is not as
widespread as it once was. A pediatrician should always examine a
patient’s back at a routine physical. Adults often make their own
diagnosis, but Xrays can of course be taken by any primary care
provider, who can then also make a referral to an orthopaedist.Finding a doctor Surgeons specializing in scoliosis usually tend to be located in
cities, and close to if not at academic medical centers. For physicians
in a particular area, websites such as the American Academy of
Orthopaedics (www.aaos.org) and SpineUniverse (www.spineuniverse.com) can be helpful. In addition, the Scoliosis Association (www.scoliosis-assoc.org) is a volunteer, non-medical group providing support and information to patients with scoliosis.Treatment The goal of scoliosis treatment is to stabilize the curve (stop it
from getting bigger) and to keep the patient balanced (keep the head
over the pelvis so that the patient can stand straight). In adults, the
goals also include relief or limitation of back pain, as well as
preservation of neurologic function, both of the spinal cord and of the
individual nerve roots. In very large curves (which often occur in the
neuromuscular patient), preservation of lung function can be a goal.
For the patient with neuromuscular scoliosis, preservation of walking
ability and/or balance while sitting are also goals.
In children and adolescents, mild scoliosis is often followed
expectantly- that is, no surgery or braces, just routine follow-up with
Xrays. For curves of a certain size, braces are often recommended in
this population, although this recommendation depends on a great number
of factors, including the type of scoliosis and the age and skeletal
maturity of the patient.
For the child with a progressive scoliosis, surgery is usually
recommended to preserve neurologic function. Neuromuscular patients
with scoliosis are often treated with spinal fusion because their
curves tend to be very stiff and progressive in nature, leading to
great difficulty with balance, which can cause problems for caretakers.
For the adolescent scoliosis that does not stabilize with bracing,
surgery in the form of spinal fusion is often recommended, depending on
the age of the patient, the size of the curve, and the skeletal
maturity of the patient. Adult patients are somewhat more complex, in
that they often have nerve compression in the lumbar spine in addition
to a curve, which calls for a decompression (removal of the compression
on the nerves) followed by a fusion to attempt to straighten and
stabilize the spine. The goal of surgery is usually not to straighten
the curve completely, as this cannot usually be done without injuring
the spinal cord. Rather, the goal is to balance the spine and prevent
the curve from getting worse. Self-management The most important thing the patient can do is to stay as active as
possible, maintain a healthy weight, and minimize the risk of
osteoporosis. These recommendations apply regardless of the type of
scoliosis. However, it is widely accepted that congenital scoliosis
will need to be treated surgically. For the remainder of patients,
maintaining strong trunk musculature and keeping the limb musculature
long and limber go a long way towards minimizing the symptoms of
scoliosis. There is no data to show that muscle strengthening and
stretching will alter the natural history of scoliosis, although there
is some evidence that elderly patients with osteoporosis will tend to
have more rapidly progressive curves than those without osteoporosis.Health care team Usually an orthopaedic surgeon specializing in spinal surgery and/or
pediatrics is the physician of choice for scoliosis patients.
Physiatrists (rehabilitation doctors) and physical therapists can
follow scoliosis patients and manage them non-operatively. Surgery is
performed by an orthopaedic surgeon specializing in spine surgery.Pain and fatigue The majority of children and adolescents with scoliosis do not
experience pain and fatigue. Staying as active as possible and taking
acetaminophen and non-steroidal anti-inflammatories (NSAID’s) such as
ibuprofen are usually all that are required.
For adults with scoliosis the mainstay of treatment is therapy for a
strong core musculature and keeping the lower extremity musculature
strong and limber. Acetaminophen and NSAID’s are recommended as needed.
Narcotic medications are strongly discouraged as the pain and
discomfort from adult scoliosis is chronic in nature and patients can
become narcotic dependent.
Braces can be used in adult scoliosis for flare-ups, but usually
long term brace use deconditions core musculature, which only makes
patients more symptomatic. Diet Poor diet itself is not a cause of scoliosis, but maintaining a healthy
diet can diminish the symptoms of scoliosis. Osteoporosis can cause
progression of scoliosis, so Viatmin D and sunshine are recommended
prior to menopause, as is weight-bearing activities to maximize bone
mass. Obesity can cause patients to have increased back pain and
discomfort, as the discs in the back function as shock absorbers which
can get overloaded with too much weight. Maintaining a normal body
weight certainly will minimize the pain and discomfort caused by
scoliosis.Exercise and therapy Staying active and maintaining a healthy weight are of paramount
importance in managing the pain and discomfort of scoliosis.
Strengthening of the core musculature (abdominals, paraspinals) can
alleviate scoliosis pain. Stretching of the lower extremity musculature
can be quite beneficial as well, as hamstrings can become tight as the
lumbar swayback is lost. In addition, sometimes the nerve roots
supplying the lower extremity muscles can be compressed, resulting in
lower extremity spasms. Paraspinal spasms can also be problematic for
scoliosis patients; stretching of these can be helpful as well. For
patients with kyphosis (excessive thoracic hump) in addition to
scoliosis, pectoral (chest musculature) stretching can be helpful.Medications Acetaminophen and NSAID’s are recommended as needed. Narcotic
medications are strongly discouraged as the pain and discomfort from
adult scoliosis is chronic in nature and patients can become narcotic
dependent.Surgery Surgery can help treat scoliosis, in large curves that have not
responded to non-operative treatment and continued to progress. Surgery
involves fusion of the portions of the spine that are curved. Fusion
refers to taking away the joints that are between the bones and packing
them with bone so that they heal together and become one long bony
column. The goal of surgery is usually not to straighten the curve
completely, as this cannot usually be done without injuring the spinal
cord. Rather, the goal is to balance the spine and prevent the curve
from getting worse.Joint aspiration Injections can be used to treat the symptoms of spinal stenosis- areas
where arthritis and ligament is pressing on nerve roots. The goal with
these injections is to alleviate leg pain and sciatic type symptoms.
Some physicians use trigger point injections of local anesthetic with
anti-inflammatory medication in the office to manage muscle pain and
spasm. There are no injections used to manage scoliosis per se.Surgery for scoliosis at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-4288 (outside the Seattle area: 800-440-3280) to make an appointment.
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