On Call: Scoliosis

What is scoliosis?
Scoliosis is defined as a lateral (side to side) curvature of the spine. This lateral curvature is usually associated with rotation as well. Scoliosis can occur with a variety of conditions, and often progresses during periods of rapid growth (such as the adolescent growth spurt).

Types of scoliosis
Neuromuscular scoliosis occurs in patients with neurologic or musculoskeletal problems such as cerebral palsy, spina bifida or muscular dystrophy. It is the result of muscle imbalance and resulting lack of trunk control.

Congenital scoliosis is a result of abnormalities in the shape of the spinal vertebrae that one is born with. Congenital scoliosis is usually diagnosed before adolescence.

Idiopathic scoliosis is the most common type and occurs when there is no specific cause for the curvature. Idiopathic scoliosis is categorized based on the patient’s age at presentation: infantile=less than 3 years, juvenile=4 to 9 years and adolescent=10 years or older.

How is scoliosis diagnosed?
Examination of the spine for scoliosis is performed at routine physical exams. The first step is simple inspection. Though minor curves may not be immediately obvious, subtle differences in the height of the shoulders, shoulder blades or hips might be noticed on closer inspection. The forward bend test is performed by observing the patient from the back while he or she bends forward at the waist, with feet together, knees straight ahead and arms hanging free. In a patient with scoliosis, a thoracic (middle back) or lumbar (lower back) prominence on one side will be evident. The forward bend test actually demonstrates the rotational component of scoliosis, since the prominence is the result of the ribcage rotating along with the spine. If an asymmetry is noted, X-rays can help with assessment of the degree of curvature. On X-ray, the angle of the curvature is called the Cobb angle. A Cobb angle of greater than 10 percent is consistent with a diagnosis of scoliosis.

What is the risk of a curvature progressing?
The risk for progression is important in determining the need for treatment; however, it is very difficult to accurately predict which curves will progress. Multiple factors are useful in predicting the risk: sex, magnitude of the curve, curve pattern and skeletal maturity at the time of diagnosis.
Sex – risk for progression is increased markedly in girls compared to boys.

Curve magnitude – curves with initial Cobb angle of 20 to 29º are most likely to increase.
Curve pattern – thoracic curves have a three-fold increased risk of progression compared to curves at other locations.
Skeletal maturity – patients who are more advanced through puberty, that is, have less growing left to do, are less likely to progress. Patients younger than 12 years have a much greater risk for progression than older patients. Girls who have had their first menstrual period are unlikely to have further progression.

Scoliosis Treatment
Patients with a Cobb angle of greater than 20 percent should be referred to an orthopedic surgeon; however, only 10 percent of adolescents with idiopathic scoliosis will require treatment. Options for treatment include observation, bracing, and surgery, and the best option for a particular patient is chosen based upon the best estimate of their risk for progression. The goal of treatment is a Cobb angle of less than 40 percent at skeletal maturity.

A patient’s primary care provider may be comfortable monitoring scoliosis prior to referral to an orthopedic doctor. The curvature will be monitored by physical exam and X-ray, and if progression of greater than 5 percent occurs, referral will be made.

The orthopedic surgeon may recommend further observation, bracing or surgery. Bracing does not correct curvature that is present at the time of diagnosis, but does prevent curve progression, and thus may reduce the need for surgery. Because the objective of bracing is prevention of curve progression, bracing is only indicated for patients who are still growing. Bracing is more effective the longer the brace is worn, so it is generally recommended that the brace be worn 23 hours a day, and the brace should be worn until the end of a teen’s growth.
Surgery may prevent progression as well as correcting existing curvature. This is usually accomplished through fusion of the spinal vertebrae. Surgery is highly successful in the treatment of scoliosis.

If you have any concerns that your child may have scoliosis,call for an appointment for a thorough examination with your primary care provider.

Kristen Rager, MD MPH