When viewed from the side, the spine features natural curves that form an “S”-like shape. The cervical (neck) spine curves slightly forward; the thoracic (middle back) spine curves backward; and the lumbar (lower back) spine curves forward again. Viewed from the back or front, however, the spine should remain straight. When the spine twists and develops side-to-side curves, the condition is called scoliosis. Scoliosis can occur in either the thoracic or lumbar spine, or both. Orthopedists measure the severity of scoliosis in degrees of curvature, ranging from as little as 10 degrees to extreme cases of more than 100 degrees.
In childhood, scoliosis seldom causes any pain. However, young patients may notice a problem in the way their back looks–a symptom often first noticed during a routine physical exam or during school screening. Indications of possible scoliosis, which become more pronounced and noticeable when bending over, include:
- One shoulder or hip that appears higher than the other
- One shoulder blade that appears higher and sticks farther out than the other
- One arm that hangs longer than the other because of a tilt in the upper body
- A “rib hump,” a hump on the back that sticks up when the spine bends forward, which forms because the ribs on one side tilt more than those on the other side.
As the condition progresses, back pain can eventually develop. The deformity caused by scoliosis may put pressure on certain nerves and possibly on the spinal cord, which can lead to weakness, numbness, and pain in the lower extremities. In rare and severe cases, the chest may become deformed due to scoliosis, a deformity that may affect the lungs and heart, leading to breathing problems, fatigue, and even heart failure.
Sciatica most often results from general wear and tear or sudden pressure on the discs that cushion the vertebrae of the lower spine. A herniated disc may press directly on the nerve roots that lead into the sciatic nerve. The damaged disc can also leak fluid, which may inflame and irritate the nerve. Other less common causes of sciatica include: Degenerative Disc Disease, Lumbar Spinal Stenosis, Isthmic Spondylolisthesis, Sacro-iliitis, Lumbar Facet Joint Syndrome, Piriformis Syndrome and Iliolumbar Syndrome. In rare cases, it can also be caused by infection or tumor.
Doctors divide scoliosis into four categories based on the age at which the condition is diagnosed:
- Infantile scoliosis is diagnosed before age 3
- Juvenile scoliosis is diagnosed from age 3 to 10
- Adolescent scoliosis is iagnosed between ages 10 and 15
- Adult scoliosis is diagnosed after the spine has stopped growing
When scoliosis appears in infants, observation is usually the best treatment because most of the cases are relatively minor and almost 90% of them resolve themselves without any treatment. However, it is still important for your baby’s pediatrician to monitor the curve, because if it progresses, surgery may be necessary.
Juvenile and Adolescent Scoliosis
Most cases of scoliosis are first discovered and treated in childhood or adolescence, when rapid growth tends to accelerate the progression of spinal curves. If the condition affects an otherwise healthy child and no specific cause can be identified, it is called “idiopathic scoliosis.” Idiopathic scoliosis represents 80 to 85% of all forms of scoliosis. By far the most common form of spinal deformity, idiopathic scoliosis affects about 3% of the general population.
Scoliosis that is first diagnosed in adulthood may actually represent a progression of juvenile or adolescent scoliosis that went untreated or unrecognized during childhood. But scoliosis can also first develop during adulthood. The causes of adult-onset scoliosis, unlike those of most juvenile or adolescent scoliosis, can often be identified. Degenerative adult scoliosis occurs when a combination of age and deterioration of the spine leads to the development of a scoliotic curve. Degenerative scoliosis usually appears after the age of 40. In older patients, particularly women, it is often related to osteoporosis, which weakens the bone, leading to deterioration. As the deteriorating spine “sags,” a scoliotic curve can slowly develop.
The remaining types of scoliosis are rare and can be categorized as: Congenital Curve, Paralytic Curve, Myopathic Deformity, and Secondary Scoliosis.
Your doctor will ask a variety of questions about your family history, dates of onset and progression, the presence of pain, bowel or bladder dysfunction, motor function, and whether you have had previous surgery. Your doctor will also perform a physical exam and will order X-rays to measure the degree of curvature. Your doctor may also order other tests to examine specific aspects of the spine. The most common tests are: an MRI to look at the nerves and spinal cord, a CT scan to get a better picture of the vertebral bones, and special nerve tests to determine if the scoliosis has irritated or pinched any nerves.
Your doctor will recommend a specific treatment based on your age at the onset of scoliosis, the degree of curvature, and the presence of other symptoms. For curves of less than 40 degrees, conservative treatment often suffices to halt progression. Curves greater than 40 degrees, however, may require surgery.
Conservative treatments may include medication, bracing, physical therapy and exercise. Bracing, often considered as a treatment option for medium range curves, applies only in cases of juvenile or adolescent scoliosis, when the spine is still growing. Scoliosis often affects more than one area of the spine, and a brace can be used to support all the curved areas that need to be protected from progression. Though the brace can help a curve from getting worse, adolescents often feel self-conscious about having to wear a brace, so it may take some time for the patient (and caregiver) to get used to it.
Conservative treatment for adults begins with the treatment of osteoporosis, if any is present. Treatment of osteoporosis may also slow the progression of scoliosis. Current recommendations include an increase in calcium and vitamin D intake, hormone replacement therapy, and weight-bearing exercises. Exercise may help to relieve pain but will not affect the natural history of the curve.
After the completion of skeletal maturity, smaller curves tend not to progress, seldom cause significant back pain, and therefore do not require surgery. With medium and large curves, however, adult progression and the presence of secondary symptoms become more likely, making surgery a treatment option to consider. Those who would benefit most from surgery include patients with severe pain, difficulty breathing, or progressive deformity.
Surgery for scoliosis almost always involves spinal fusion with instrumentation. Nearly all scoliosis surgery employs some type of rods to help straighten the spine. The physician may use a posterior approach, which involves entering the spine through the back, an anterior approach, which is performed from the front or side, or a combined approach. The decision to have surgery is a joint decision arrived at by the patient, patient’s family and the physician. Surgery for scoliosis is never an emergency and sufficient time is always available to make everyone comfortable with the decision.