Scoliosis

Scoliosis - A Patient Primer

Overview

Basics 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 orthopedic 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.

Symptoms & Diagnosis

Prognosis

Scoliosis is not a life-threatening condition. However, as with many orthopedic 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 orthopedist.

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 Orthopedics (www.aaos.org) and SpineUniverse (www.spineuniverse.com) can be helpful.

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 orthopedic 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 orthopedic 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.