Scoliosis
What is scoliosis?
Scoliosis is a defined as a side to side deviation or curvature of the spine when viewing the body from the front or back. Generally the cause in most cases is unknown. Severe curve progression has an increased incidence in the female population. Some known causes include congenital malformation of the spinal column, neuromuscular scoliosis caused by cerebral palsy or spina bifida, genetic anomalies, and other conditions.
|
|
|
|
|
Congenital scoliosis, |
Correction of congenital scoliosis |
Typically, other than the above mentioned congenital scoliosis and neuromuscular scoliosis, most scoliosis is called idiopathic scoliosis. This is further divided into infantile, ages birth to 3 years, juvenile, ages 3 to 9 years, and adolescent, ages 10 to 18 years. Curves appearing earlier in life may be more likely to progress as there is more time and growth potential prior to skeletal maturity, which may slow curve progression. Later in life, degeneration may occur in the spine due to age or unusual stresses on the spine, and previously mild and undiagnosed scoliosis may progress and become symptomatic. This is referred to as degenerative scoliosis.
Curvature may be mild to severe, and treatment is varied depending on severity and response to conservative means. Generally a mild curve of less than 10 degrees is considered spinal asymmetry not scoliosis. Curves larger than 10 degrees are often watched for progression by X-ray measurement over time. If the patient is skeletally immature as determined by the pelvic growth plate on X-ray, bracing may be helpful in controlling progression. Not all cases are candidates for bracing as this depends on the type and severity of curve. Bracing is not always considered until curves reach 20-25 degrees or show rapid progression in skeletally immature individuals.
Scoliosis Evaluation and Treatment
Typically scoliosis is found during a routine pediatric evaluation or in a school screening. Sometimes it is picked up by family or friends at the pool. When found, it generally is referred to an orthopedic or spine surgeon. General physical evaluation, looking at the individual's spinal alignment both in the frontal and side planes will help ascertain the severity of the curve. Also evaluated are the alignment of shoulders, scapulae, hips, and pelvis. The forward flexion test familiar to most people from school screenings is invaluable in ascertaining the significance of the spinal rotation.
The mainstay in evaluating scoliosis is the standing 36-inch X-ray in the front and side view. A standing X-ray is critical because gravity will show the scoliosis at its worst, whereas a supine or lying down film may lessen the severity of the curve. Also, full-length views are important to determine spinal balance, or where the head appears in space in relationship to the pelvis. The goal of treatment, whether it is conservative or surgical, is to maximize the alignment of the head over the pelvis.
Generally, low-degrees curves are watched and re-evaluated every 6-12 months depending on the potential for growth and progression of scoliosis. If growth and progression are both ongoing, bracing may be recommended with a TLSO or thoracolumbar sacral orthosis, a hard plastic clamshell type brace, which may help limit progression of the curve. Sometimes these braces are worn 24 hours a day or just at night, depending on the condition and surgeon preference. If bracing does not slow or stop curve progression and curve magnitude is approaching the 40 to 50 degree range, surgery may be recommended. There is no absolute number of degrees that require surgery; rather, it is more a function of growth potential, skeletal maturity, and rate of progression.
In the mature spine, a progression of 2 or 3 degrees a year may not sound like a large progression, but if you have a 40 degree curve with a 2 degree per year progression, in 15 years you have a 70 degree curve, which is a significant problem. Therefore, sometimes follow up X-rays may be needed into adult life to make sure there is no progression of the scoliosis. Once this is determined, the patient is generally released from follow up with instructions to return if loss of height or change in shape occur or new onset pain begins that may indicate a change in the scoliosis.
Generally scoliosis is not a problem for individuals throughout their lives, and patients are encouraged to remain active and maintain a weight close to ideal body weight to avoid extra stress on the spine. Women generally have no trouble bearing children but sometimes do have back pain with the additional stress of carrying 30 to 40 pounds of extra weight during pregnancy. Continued back pain after child birth should be evaluated for potential progression of the scoliosis.
Surgical treatment of scoliosis
Surgical procedures used to treat scoliosis at Emory include:
