Scoliosis

Definition

Scoliosis is defined as an abnormal side-to-side or front-to-back curvature of the spine.

Description

When viewed from the rear, the spine usually appears perfectly straight. Scoliosis is a lateral (side-to-side) curve in the spine, usually combined with a rotation of the vertebrae. The lateral curvature of scoliosis should not be confused with the normal set of front-to-back spinal curves visible from the side. While a small degree of lateral curvature does not cause any medical problems, larger curves can cause postural imbalance and lead to muscle fatigue and pain . More severe scoliosis can interfere with breathing and lead to arthritis of the spine (spondylosis).

Approximately 10% of all adolescents have some degree of scoliosis, though fewer than 1% have curves that require medical attention beyond monitoring. Scoliosis is found in both boys and girls, but a girl's spinal curve is much more likely to progress than a boy's. Girls require scoliosis treatment about five times as often. The reason for these differences is not known.

Causes & symptoms

Four out of five cases of scoliosis are idiopathic, meaning that the cause is unknown. Idiopathic scoliosis tends to run in families; genetic screening has identified several different patterns of genetic transmission as of late 2001. In some families, idiopathic scoliosis is transmitted in an autosomal dominant pattern, while in others the mode of inheritance is X-linked. Children with idiopathic scoliosis appear to be otherwise entirely healthy, and have not had any bone or joint disease early in life. Scoliosis is not caused by poor posture, diet, or carrying a heavy book-bag exclusively on one shoulder.

Idiopathic scoliosis is further classified according to age of onset:

• Infantile. Curvature appears before age three. This type is quite rare in the United States, but is more common in Europe.
• Juvenile. Curvature appears between ages three and 10. This type may be equivalent to the adolescent type, except for the age of onset.
• Adolescent. Curvature appears between ages of 10 and 13, near the beginning of puberty. This is the most common type of idiopathic scoliosis.
• Adult. Curvature begins after physical maturation is completed.

Causes are known for three other types of scoliosis:

• Congenital scoliosis is due to congenital birth defects in the spine, often associated with other organ defects.
• Neuromuscular scoliosis is due to loss of control of the nerves or muscles that support the spine. The most common causes of this type of scoliosis are cerebral palsy and muscular dystrophy.
• Degenerative scoliosis may be caused by degeneration of the discs that separate the vertebrae or arthritis in the joints that link them.

Scoliosis causes a noticeable asymmetry in the torso when viewed from the front or back. The first sign of scoliosis is often seen when a child is wearing a bathing suit or underwear. A child may appear to be standing with one shoulder higher than the other, or to have a tilt in the waistline. One shoulder blade may appear more prominent than the other due to rotation. In girls, one breast may appear higher than the other, or larger if rotation pushes that side forward.

Curve progression is greatest near the adolescent growth spurt. Scoliosis that begins early is more likely to progress significantly than scoliosis that begins later in puberty.

More than 30 states have screening programs in schools for adolescent scoliosis, usually conducted by trained school nurses or physical education teachers.

Diagnosis

Diagnosis for scoliosis is typically continued by an orthopedist. A complete medical history is taken, including questions abouta a family history of scoliosis. The physical examination includes determination of pubertal development in adolescents, a neurological examination (which may reveal a neuromuscular cause), and measurements of trunk asymmetry. Examination of the trunk is done while the patient is standing, bending over, and lying down. The forward bending test is sometimes referred to as the Adams test. It involves both visual inspection and use of a simple mechanical device called a scoliometer.

If a curve is detected, one or more x rays will usually be taken to define the curve or curves more precisely. An x ray is used to document spinal maturity, any pelvic tilt or hip asymmetry, and the location, extent, and degree of curvature. The curve is defined in terms of its beginning and ending points, its direction, and by an angle measure known as the Cobb angle. The Cobb angle is found by projecting lines parallel to the vertebrae tops at the extremes of the curve, projecting perpendiculars from these lines, and measuring the angle of intersection. To properly track the progress of scoliosis, it is important to project from the same points of the spine each time.

Occasionally, magnetic resonance imaging (MRI) is used, primarily to look more closely at the condition of the spinal cord and nerve roots extending from it if neurological problems are suspected.

Treatment

Although important for general health and strength, exercise has not been shown to prevent or slow the progression of scoliosis. It may help to relieve pain from scoliosis by helping to maintain range of motion. Good nutrition is also important for general health, but no specific dietary regimen has been shown to control scoliosis development. In particular, dietary calcium levels do not influence scoliosis progression.

Chiropractic treatment may relieve pain but cannot halt scoliosis development, and should not be a substitute for conventional treatment of progressive scoliosis. Acupuncture and acupressure may also help reduce pain and discomfort, but they cannot halt scoliosis development either.

Other movement therapies (yoga, t'ai chi, qigong , and dance) improve flexibility and are useful when used with such movement education therapies as Feldenkrais , the Rosen method , the Alexander technique , and Pilates .

Allopathic treatment

Treatment decisions for scoliosis are based on the degree of curvature, the likelihood of significant progression, and the presence of pain, if any.

Curves less than 20° are not usually treated, except by regular follow-up for children who are still growing. Watchful waiting is usually all that is required in adolescents with curves of 20–30°, or adults with curves up to 40° or slightly more, as long as there is no pain.

For children or adolescents whose curves progress to 30°, and who have a year or more of growth left, bracing may be required. Bracing cannot correct curvature but may be effective in halting or slowing progression. Bracing is rarely used in adults, except where pain is significant and surgery is not an option, as in some elderly patients.

Two general styles of braces are used for daytime wear. The Milwaukee brace consists of metal uprights attached to pads at the hips, rib cage, and neck. The under-arm brace uses rigid plastic to encircle the lower rib cage, abdomen, and hips. Both of these brace types hold the spine in a vertical position. Because it can be worn out of sight beneath clothing, the underarm brace is better tolerated and often leads to better compliance. A third style, the Charleston bending brace, is used at night to bend the spine in the opposite direction. Braces are often prescribed to be worn for 22–23 hours per day, though some clinicians allow or encourage removal of the brace for exercise.

Bracing may be appropriate for scoliosis due to some types of neuromuscular disease, including spinal muscular atrophy, before growth is finished. Duchenne muscular dystrophy is not treated by bracing, since surgery is likely to be required and later surgery is complicated by loss of respiratory capacity.

Surgery for idiopathic scoliosis is usually recommended if:

• The curve has progressed despite bracing.
• The curve is greater than 40–50° before growth has stopped in an adolescent.
• The curve is greater than 50° and continues to increase in an adult.
• There is significant pain.

Orthopedic surgery for neuromuscular scoliosis is often done earlier. The goals of surgery are to correct the deformity as much as possible, to prevent further deformity, and to eliminate pain as much as possible. Surgery can usually correct 40–50% of the curve, sometimes as much as 80%. Surgery cannot always completely remove pain.

The surgical procedure for scoliosis is called spinal fusion, because the goal is to straighten the spine as much as possible, and then to fuse the vertebrae together to prevent further curvature. To achieve fusion, the involved vertebra are first exposed, and then scraped to promote regrowth. Bone chips are usually used to splint together the vertebrae to increase the likelihood of fusion. To maintain the proper spinal posture before fusion occurs, metal rods are inserted alongside the spine and attached to the vertebrae by hooks, screws, or wires. Fusion of the spine makes it rigid and resistant to further curvature. The metal rods are no longer needed once fusion is complete but are rarely removed unless their presence leads to complications.

Spinal fusion leaves the involved portion of the spine permanently stiff and inflexible. While this stiffness leads to some loss of normal motion, most functional activities are not strongly affected, unless the very lowest portion of the spine (the lumbar region) is fused. Normal mobility, exercise, and even contact sports are usually all possible after spinal fusion. Full recovery takes approximately six months.

Expected results

The prognosis for a person with scoliosis depends on many factors, including the age at which scoliosis begins and the treatment received. More importantly, mostly unknown individual factors affect the likelihood of progression and the severity of the curve. Most cases of mild adolescent idiopathic scoliosis need no treatment and do not progress. Untreated severe scoliosis often leads to spondylosis and may impair breathing.

Prevention

There is no known way to prevent the development of scoliosis. Progression of scoliosis may be prevented through bracing or surgery.

Resources

BOOKS

Neuwirth, Michael, and Kevin Osborn. The Scoliosis Handbook. New York: Henry Holt & Co., 1996.

PERIODICALS

Justice, C.M., N. H. Miller, B. Marosy, et al. "Genetic Heterogeneity Comprising Both X-Linked and Autosomal Dominant Forms of Inheritance in Families with Familial Idiopathic Scoliosis." American Journal of Human Genetics 69 (October 2001): 384.

Splete, Heidi. "Catch Curves Like Scoliosis in Time for Bracing (Watch Your Patients' Backs)." Pediatric News 35 (November 2001): 42–43.

ORGANIZATIONS

National Scoliosis Foundation. 5 Cabot Place Stoughton, MA 02072. (800) 673-6922. [email protected]. <http://www.scoliosis.org>.

The Scoliosis Association. PO Box 811705 Boca Raton, FL 33481-1705. (407) 368-8518. [email protected]. <http://www.scoliosis-assoc.org>.

Scoliosis Research Society. 611 East Wells Street Milwaukee, WI 53202. (414) 289-9107. [email protected]. <http://www.srs.org>.

Paula Ford-Martin

Rebecca J. Frey, PhD

Scoliosis

Definition

Scoliosis is a side-to-side (lateral) curvature of the spine of 10 degrees or greater.

Description

When viewed from the rear, the spine usually appears to form a straight vertical line. Scoliosis is a lateral (side-to-side) curve in the spine, usually combined with a rotation of the vertebrae. The lateral curvature of scoliosis should not be confused with the normal set of front-to-back spinal curves visible from the side. While a small degree of lateral curvature does not cause any medical problems, larger curves can cause postural imbalance and lead to muscle fatigue and pain . More severe scoliosis can interfere with breathing and lead to arthritis of the spine (spondylosis).

Four out of five cases of scoliosis are idiopathic, meaning their cause is unknown. Children with idiopathic scoliosis appear to be otherwise entirely healthy, and have not had any bone or joint disease early in life. Scoliosis is not caused by poor posture, diet, or carrying a heavy bookbag exclusively on one shoulder.

Idiopathic scoliosis is further classified according to age of onset:

• Infantile. Curvature appears before age three. This type is quite rare in the United States, but is more common in Europe.
• Juvenile. Curvature appears between ages three and 10. This type may be equivalent to the adolescent type, except for the age of onset.
• Adolescent. Curvature appears between ages of 10 and 13, near the beginning of puberty . This is the most common type of idiopathic scoliosis.
• Adult. Curvature begins after physical maturation is completed.

Causes are known for three other types of scoliosis:

• Congenital scoliosis is due to congenital birth defects in the spine, often associated with other structural defects.
• Neuromuscular scoliosis is due to loss of control of the nerves or muscles which support the spine. The most common causes of this type of scoliosis are cerebral palsy and muscular dystrophy .
• Degenerative scoliosis may be caused by degeneration of the discs which separate the vertebrae or arthritis in the joints that link them.

Genetic profile

Idiopathic scoliosis has long been observed to run in families. Twin and family studies have consistently indicated a genetic contribution to the condition. However, no consistent pattern of transmission has been observed in familial cases. As of 2001, no genes have been identified which specifically cause or predispose individuals to the idiopathic form of scoliosis.

There are several genetic syndromes which involve a predisposition to scoliosis. Several studies have investigated whether or not the genes which cause these syndromes may also be responsible for idiopathic scoliosis. Using this candidate gene approach, the genes responsible for Marfan syndrome (fibrillin), Stickler syndrome, and some forms of osteogenesis imperfecta (collagen types I and II) have been shown not to correlate with idiopathic scoliosis.

Attempts to map a gene or genes for scoliosis have not shown consistent linkages to any particular chromosome region.

Most researchers have concluded that scoliosis is a complex trait. As such, there are likely to be multiple genetic, environmental, and potentially additional factors that contribute to the etiology of the condition. Complex traits are difficult to study due to the difficulty in identifying and isolating multiple factors.

Demographics

The incidence of scoliosis in the general population is approximately 2–3%. Among adolescents, however, 10% have some degree of scoliosis, though fewer than 1% have curves that require treatment.

Scoliosis is found in both males and females, but a female's spinal curve is much more likely to progress than a male's. Females require scoliosis treatment about five times as often as males. The reason for these differences is not known with certainty but they may relate to increased levels of estrogen and other hormones in females.

Causes and symptoms

Scoliosis causes a noticeable asymmetry in the torso when viewed from the front or back. The first sign of scoliosis is often seen when a child is wearing a bathing suit or underwear. A child may appear to be standing with one shoulder higher than the other, or to have a tilt in the waistline. One shoulder blade may appear more prominent than the other due to rotation. In girls, one breast may appear higher than the other, or larger if rotation pushes that side forward.

Curve progression is greatest near the adolescent growth spurt. Scoliosis that begins early in life is more likely to progress significantly than scoliosis that begins later in puberty.

More than 30 states have screening programs in schools for adolescent scoliosis. These are usually conducted by physicians, school nurses or trained physical education teachers.

Diagnosis

Scoliosis is initially noticed during a screening program or during a routine physical examination conducted by a pediatrician or family physician. Confirmatory diagnosis of scoliosis is often conducted by an orthopedic surgeon. A complete medical history is taken, including questions about family history of scoliosis. The physical examination includes determination of pubertal development in adolescents, a neurological exam (which may reveal a neuromuscular cause), and measurements of trunk asymmetry. Examination of the trunk is done while the person is standing, bending over, and lying down, and involves both visual inspection and use of a simple mechanical device called a scoliometer.

If a curve is detected, one or more x rays will usually be taken to define more precisely the curve or curves. An x ray is used to document spinal maturity, any pelvic tilt or hip asymmetry, and the location, extent, and degree of curvature. The curve is defined in terms of where it begins and ends, in which direction it bends, and by an angular measure known as the Cobb angle. The Cobb angle is found by projecting lines parallel to the vertebrae tops at the extremes of the curve; projecting perpendiculars from these lines; and measuring their angle of intersection. To properly track the progress of scoliosis, it is important to project from the same points of the spine each time.

Occasionally, magnetic resonance imaging (MRI) is used, primarily to look more closely at the condition of the spinal cord and nerve roots extending from it if neurological problems are suspected.

Treatment

Treatment decisions for scoliosis are based on the degree of curvature, the likelihood of significant progression, and the presence of pain, if any.

Curves less than 20 degrees are not usually treated, except by regular follow-up for children who are still growing. Watchful waiting is usually all that is required in adolescents with curves of 20–25 degrees, or adults with curves up to 40 degrees or slightly more, as long as there is no pain.

For children or adolescents whose curves progress to 25 degrees, and who have a year or more of growth left, bracing may be required. Bracing cannot correct curvature, but may be effective in halting or slowing its progression. Bracing is rarely used in adults, except where pain is significant and surgery is not an option, as in some elderly patients.

There are two different categories of braces, those designed for nearly 24 hour per day use and those designed for night use. The full-time brace styles are designed to hold the spine in a vertical position, while the night use braces are designed to bend the spine in the direction opposite the curve.

The Milwaukee brace is a full-time brace which consists of metal uprights attached to pads at the hips, rib cage, and neck. Other types of full-time braces, such as the Boston brace, involve underarm rigid plastic molding to encircle the lower rib cage, abdomen, and hips. Because they can be worn out of sight beneath clothing, underarm braces are better tolerated and often lead to better compliance. The Boston brace is currently the most commonly used. Full-time braces are often prescribed to be worn for 22–23 hours per day, though some clinicians believe that recommending brace use of 16 hours leads to better compliance and results.

Night-use braces bend an individual's scoliosis into a correct angle, and are prescribed for eight hours of use during sleep. Some investigators have found that night-use braces are not as effective as the day-use types.

Bracing may be appropriate for scoliosis due to some types of neuromuscular disease, including spinal muscular atrophy, before growth is finished. Duchenne muscular dystrophy is not treated by bracing, since surgery is likely to be required, and since later surgery is complicated by loss of respiratory capacity.

Surgery for idiopathic scoliosis is usually recommended if:

• The curve has progressed despite bracing.
• The curve is greater than 40–50 degrees before growth has stopped in an adolescent.
• The curve is greater than 50 degrees and continues to increase in an adult.
• There is significant pain.

Orthopedic surgery for neuromuscular scoliosis is often done early in life. The goals of surgery are to correct the deformity as much as possible, to prevent further deformity, and to eliminate pain as much as possible. Surgery can usually correct 40–50% of the curve, and sometimes as much as 80%. Surgery cannot always completely remove pain.

The surgical procedure for scoliosis is called spinal fusion, because the goal is to straighten the spine as much as possible, and then to fuse the vertebrae together to prevent further curvature. To achieve fusion, the involved vertebra are first exposed, and then scraped to promote re-growth. Bone chips are usually used to splint together the vertebrae to increase the likelihood of fusion. To maintain the proper spinal posture before fusion occurs, metal rods are inserted alongside the spine, and are attached to the vertebrae by hooks, screws, or wires. Fusion of the spine makes it rigid and resistant to further curvature. The metal rods are no longer needed once fusion is complete, but are rarely removed unless their presence leads to complications.

Spinal fusion leaves the involved portion of the spine permanently stiff and inflexible. While this leads to some loss of normal motion, most functional activities are not strongly affected, unless the very lowest portion of the spine (the lumbar region) is fused. Normal mobility, exercise , and even contact sports are usually all possible after spinal fusion. Full recovery takes approximately six months.

Prognosis

The prognosis for a person with scoliosis depends on many factors, including the age at which scoliosis begins and the treatment received. Most cases of mild adolescent idiopathic scoliosis need no treatment, do not progress, and do not cause pain or functional limitations. Untreated severe scoliosis often leads to spondylosis, and may impair breathing.

Health care team roles

A pediatrician or family physician usually makes an initial diagnosis of scoliosis. Orthopedic surgeons may provide surgical treatment. Physical therapists may provide therapeutic exercises for a person with scoliosis.

Prevention

There is no known way to prevent any of the forms of scoliosis.

KEY TERMS

Cobb angle —A measure of the curvature of scoliosis, determined by measurements made on x rays.

Scoliometer —A tool for measuring trunk asymmetry; it includes a bubble level and angle measure.

Spondylosis —Arthritis of the spine.

Resources

BOOKS

Canale, S. Terry, Kay Daugherty, and Linda Jones. Campbell's Operative Orthopaedics. 9th ed. St. Louis: Mosby, 1998.

Eisenpreis, B. Coping with Scoliosis. New York: Rosen Publishing Group, 1999.

Neuwirth, Michael, and Kevin Osborn. Scoliosis Sourcebook. 2nd ed. Lincolnwood, IL: NTC/Contemporary Publishing, 2001.

Thompson, George H., and Peter V. Scoles. "Idiopathic scoliosis." In Nelson Textbook of Pediatrics. 16th ed. Ed. by Richard E. Behrman et al. Philadelphia: Saunders, 2000, 2083-2084.

Thompson, George H., and Peter V. Scoles "Congenital scoliosis." In Nelson Textbook of Pediatrics. 16th ed. Ed. by Richard E. Behrman et al. Philadelphia: Saunders, 2000, 2084-2085.

Thompson, George H., and Peter V. Scoles. "Neuromuscular scoliosis, syndromes, and compensatory scoliosis." In Nelson Textbook of Pediatrics. 16th ed. Ed. by Richard E. Behrman et al. Philadelphia: Saunders, 2000, 2085-2086.

Thompson, George H., and Peter V. Scoles. "Kyphosis." In Nelson Textbook of Pediatrics. 16th ed. Ed. by Richard E. Behrman et al. Philadelphia: Saunders, 2000, 2086-2087.

PERIODICALS

Betz, R. R., and H. Shufflebarger. "Anterior versus posterior instrumentation for the correction of thoracic idiopathic scoliosis." Spine 26, no. 9 (2001): 1095-1100.

Gross, G. W., and W. G. Mackenzie. "Scoliosis in Children: Surgical Management and Postoperative Radiographic Appearances." Seminars in Musculoskeletal Radiology> 3, no. 3 (1999): 267-288.

Jason Lowry, K, J. Tobias, D. Kittle, T. Burd, and R. W. Gaines. "Postoperative pain control using epidural catheters after anterior spinal fusion for adolescent scoliosis." Spine 26, no. 11 (2001): 1290-1293.

Padua, R., S. Padua, L. Aulisa, E. Ceccarelli, L. Padua, E. Romanini, G. Zanoli, and A. Campi. "Patient outcomes after Harrington instrumentation for idiopathic scoliosis: a 15- to 28-year evaluation." Spine 26, no 11 (2001): 1268-1273.

Redla, S., T. Sikdar, and A. Saifuddin. "Magnetic resonance imaging of scoliosis." Clinical Radiology 56, no 5(2001): 360-371.

Trivedi, J. M., and J. D. Thomson. "Results of Charleston bracing in skeletally immature patients with idiopathic scoliosis." Journal of Pediatric Orthopedics 21, no 3(2001): 277-280.

ORGANIZATIONS

American Academy of Orthopedic Surgeons. 6300 North River Road, Rosemont, IL 60018-4262. (847) 823-7186 or (800) 346-2267. Fax: (847) 823-8125. <http://www.aaos.org/>.

American Academy of Physical Medicine and Rehabilitation. One IBM Plaza, Suite 2500, Chicago, IL 60611-3604.(312) 464-9700. Fax: (312) 464-0227. <http://www.aapmr.org/consumers/public/amputations.htm>. [email protected].

American Thoracic Society. 1740 Broadway, New York, NY 10019. (212) 315-8700. Fax: (212) 315-6498. <http://www.thoracic.org/>.

National Scoliosis Foundation. 5 Cabot Place, Stoughton, MA 02072. (800) 673-6922, or (781) 341-6333. Fax: (781) 341-8333. <http://www.scoliosis.org/>. [email protected].

OTHER

American Academy of Family Physicians. <http://familydoctor.org/handouts/107.html>.

American Academy of Orthopedic Surgeons. <http://orthoinfo.aaos.org/brochure/thr_report.cfm?Thread_ID=14&topcategory=Spine>.

National Institute of Arthritis and Musculoskeletal and Skin Diseases. <http://www.nih.gov/niams/healthinfo/scochild.htm>.

Nemours Foundation. <http://kidshealth.org/teen/health_problems/diseases/scoliosis.html>.

Scoliosis Association, Inc. <http://www.scoliosis-assoc.org>

Scoliosis Research Society. <http://www.srs.org>.

University of Iowa Hospitals. <http://www.vh.org/Providers/Textbooks/AIS/AIS.html>.

L. Fleming Fallon, Jr., MD, DrPH

Scoliosis

Definition

Scoliosis is a side-to-side (lateral) curvature of the spine of 10 degrees or greater.

Description

When viewed from the rear, the spine usually appears to form a straight vertical line. Scoliosis is a lateral (side-to-side) curve in the spine, usually combined with a rotation of the vertebrae. The lateral curvature of scoliosis should not be confused with the normal set of front-to-back spinal curves visible from the side. While a small degree of lateral curvature does not cause any medical problems, larger curves can cause postural imbalance and lead to muscle fatigue and pain. More severe scoliosis can interfere with breathing and lead to arthritis of the spine (spondylosis).

Four out of five cases of scoliosis are idiopathic, meaning their cause is unknown. Children with idiopathic scoliosis appear to be otherwise entirely healthy, and have not had any bone or joint disease early in life. Scoliosis is not caused by poor posture, diet, or carrying a heavy bookbag exclusively on one shoulder.

Idiopathic scoliosis is further classified according to age of onset:

• Infantile. Curvature appears before age three. This type is quite rare in the United States, but is more common in Europe.
• Juvenile. Curvature appears between ages three and 10. This type may be equivalent to the adolescent type, except for the age of onset.
• Adolescent. Curvature appears between ages of 10 and 13, near the beginning of puberty. This is the most common type of idiopathic scoliosis.
• Adult. Curvature begins after physical maturation is completed.

Causes are known for three other types of scoliosis:

• Congenital scoliosis is due to congenital birth defects in the spine, often associated with other structural defects.
• Neuromuscular scoliosis is due to loss of control of the nerves or muscles which support the spine. The most common causes of this type of scoliosis are cerebral palsy and muscular dystrophy.

• Degenerative scoliosis may be caused by degeneration of the discs which separate the vertebrae or arthritis in the joints that link them.

Genetic profile

Idiopathic scoliosis has long been observed to run in families. Twin and family studies have consistently indicated a genetic contribution to the condition. However, no consistent pattern of transmission has been observed in familial cases. No genes have been identified which specifically cause or predispose individuals to the idiopathic form of scoliosis.

There are several genetic syndromes which involve a predisposition to scoliosis. Several studies have investigated whether or not the genes which cause these syndromes may also be responsible for idiopathic scoliosis. Using this candidate gene approach, the genes responsible for Marfan syndrome (fibrillin), Stickler syndrome, and some forms of osteogenesis imperfecta (collagen types I and II) have been shown not to correlate with idiopathic scoliosis.

Attempts to map a gene or genes for scoliosis have not shown consistent linkages to any particular chromosome region.

Most researchers have concluded that scoliosis is a complex trait. As such, there are likely to be multiple genetic, environmental, and potentially additional factors that contribute to the etiology of the condition. Complex traits are difficult to study due to the difficulty in identifying and isolating multiple factors.

Demographics

The incidence of scoliosis in the general population is approximately 2-3%. Among adolescents, however, 10% have some degree of scoliosis, though fewer than 1% have curves that require treatment.

Scoliosis is found in both males and females, but a female's spinal curve is much more likely to progress than a male's. Females require scoliosis treatment about five times as often as males. The reason for these differences is not known with certainty but they may relate to increased levels of estrogen and other hormones in females.

Causes and symptoms

Scoliosis causes a noticeable asymmetry in the torso when viewed from the front or back. The first sign of scoliosis is often seen when a child is wearing a bathing suit or underwear. A child may appear to be standing with one shoulder higher than the other, or to have a tilt in the waistline. One shoulder blade may appear more prominent than the other due to rotation. In girls, one breast may appear higher than the other, or larger if rotation pushes that side forward.

Curve progression is greatest near the adolescent growth spurt. Scoliosis that begins early in life is more likely to progress significantly than scoliosis that begins later in puberty.

More than 30 states have screening programs in schools for adolescent scoliosis. These are usually conducted by physicians, school nurses or trained physical education teachers.

Diagnosis

Scoliosis is initially noticed during a screening program or during a routine physical examination conducted by a pediatrician or family physician. Confirmatory diagnosis of scoliosis is often conducted by an orthopedic surgeon. A complete medical history is taken, including questions about family history of scoliosis. The physical examination includes determination of pubertal development in adolescents, a neurological exam (which may reveal a neuromuscular cause), and measurements of trunk asymmetry. Examination of the trunk is done while the person is standing, bending over, and lying down, and involves both visual inspection and use of a simple mechanical device called a scoliometer.

If a curve is detected, one or more x rays will usually be taken to define more precisely the curve or curves. An x ray is used to document spinal maturity, any pelvic tilt or hip asymmetry, and the location, extent, and degree of curvature. The curve is defined in terms of where it begins and ends, in which direction it bends, and by an angular measure known as the Cobb angle. The Cobb angle is found by projecting lines parallel to the vertebrae tops at the extremes of the curve; projecting perpendiculars from these lines; and measuring their angle of intersection. To properly track the progress of scoliosis, it is important to project from the same points of the spine each time.

Occasionally, magnetic resonance imaging (MRI) is used, primarily to look more closely at the condition of the spinal cord and nerve roots extending from it if neurological problems are suspected.

Treatment

Treatment decisions for scoliosis are based on the degree of curvature, the likelihood of significant progression, and the presence of pain, if any.

Curves less than 20 degrees are not usually treated, except by regular follow-up for children who are still growing. Watchful waiting is usually all that is required in adolescents with curves of 20-25 degrees, or adults with curves up to 40 degrees or slightly more, as long as there is no pain.

For children or adolescents whose curves progress to 25 degrees, and who have a year or more of growth left, bracing may be required. Bracing cannot correct curvature, but may be effective in halting or slowing its progression. Bracing is rarely used in adults, except where pain is significant and surgery is not an option, as in some elderly patients.

There are two different categories of braces, those designed for nearly 24 hour per day use and those designed for night use. The full-time brace styles are designed to hold the spine in a vertical position, while the night use braces are designed to bend the spine in the direction opposite the curve.

The Milwaukee brace is a full-time brace which consists of metal uprights attached to pads at the hips, rib cage, and neck. Other types of full-time braces, such as the Boston brace, involve underarm rigid plastic molding to encircle the lower rib cage, abdomen, and hips. Because they can be worn out of sight beneath clothing, underarm braces are better tolerated and often lead to better compliance. The Boston brace is currently the most commonly used. Full-time braces are often prescribed to be worn for 22-23 hours per day, though some clinicians believe that recommending brace use of 16 hours leads to better compliance and results.

Night-use braces bend an individual's scoliosis into a correct angle, and are prescribed for eight hours of use during sleep. Some investigators have found that night-use braces are not as effective as the day-use types.

Bracing may be appropriate for scoliosis due to some types of neuromuscular disease, including spinal muscular atrophy, before growth is finished. Duchenne muscular dystrophy is not treated by bracing, since surgery is likely to be required, and since later surgery is complicated by loss of respiratory capacity.

Surgery for idiopathic scoliosis is usually recommended if:

• The curve has progressed despite bracing.
• The curve is greater than 40-50 degrees before growth has stopped in an adolescent.
• The curve is greater than 50 degrees and continues to increase in an adult.
• There is significant pain.

Orthopedic surgery for neuromuscular scoliosis is often done early in life. The goals of surgery are to correct the deformity as much as possible, to prevent further deformity, and to eliminate pain as much as possible. Surgery can usually correct 40-50% of the curve, and sometimes as much as 80%. Surgery cannot always completely remove pain.

The surgical procedure for scoliosis is called spinal fusion, because the goal is to straighten the spine as much as possible, and then to fuse the vertebrae together to prevent further curvature. To achieve fusion, the involved vertebra are first exposed, and then scraped to promote re-growth. Bone chips are usually used to splint together the vertebrae to increase the likelihood of fusion. To maintain the proper spinal posture before fusion occurs, metal rods are inserted alongside the spine, and are attached to the vertebrae by hooks, screws, or wires. Fusion of the spine makes it rigid and resistant to further curvature. The metal rods are no longer needed once fusion is complete, but are rarely removed unless their presence leads to complications.

Spinal fusion leaves the involved portion of the spine permanently stiff and inflexible. While this leads to some loss of normal motion, most functional activities are not strongly affected, unless the very lowest portion of the spine (the lumbar region) is fused. Normal mobility, exercise, and even contact sports are usually all possible after spinal fusion. Full recovery takes approximately six months.

Prognosis

The prognosis for a person with scoliosis depends on many factors, including the age at which scoliosis begins and the treatment received. Most cases of mild adolescent idiopathic scoliosis need no treatment, do not progress, and do not cause pain or functional limitations. Untreated severe scoliosis often leads to spondylosis, and may impair breathing.

Health care team roles

A pediatrician or family physician usually makes an initial diagnosis of scoliosis. Orthopedic surgeons may provide surgical treatment. Physical therapists may provide therapeutic exercises for a person with scoliosis.

Prevention

There is no known way to prevent any of the forms of scoliosis.

KEY TERMS

Cobb angle— A measure of the curvature of scoliosis, determined by measurements made on x rays.

Scoliometer— A tool for measuring trunk asymmetry; it includes a bubble level and angle measure.

Spondylosis— Arthritis of the spine.

Resources

BOOKS

Canale, S. Terry, Kay Daugherty, and Linda Jones. Campbell's Operative Orthopaedics, 9th ed. St. Louis: Mosby, 1998.

Eisenpreis, B. Coping with Scoliosis. New York: Rosen Publishing Group, 1999.

Neuwirth, Michael and Kevin Osborn. Scoliosis Sourcebook, 2nd ed. Lincolnwood, IL: NTC/Contemporary Publishing, 2001.

Thompson, George H and Peter V. Scoles. "Idiopathic scoliosis." In Nelson Textbook of Pediatrics, 16th ed. Ed. by Richard E. Behrman et al., Philadelphia: Saunders, 2000, 2083-2084.

Thompson, George H and Peter V. Scoles "Congenital scoliosis." In Nelson Textbook of Pediatrics, 16th ed. Ed. by Richard E. Behrman et al., Philadelphia: Saunders, 2000, 2084-2085.

Thompson, George H and Peter V. Scoles. "Neuromuscular scoliosis, syndromes, and compensatory scoliosis." In Nelson Textbook of Pediatrics, 16th ed. Ed. by Richard E. Behrman et al., Philadelphia: Saunders, 2000, 2085-2086.

Thompson, George H and Peter V. Scoles. "Kyphosis." In Nelson Textbook of Pediatrics, 16th ed., Ed. by Richard E. Behrman et al., Philadelphia: Saunders, 2000, 2086-2087.

PERIODICALS

Betz, R. R., and H. Shufflebarger. "Anterior versus posterior instrumentation for the correction of thoracic idiopathic scoliosis." Spine 26, no. 9 (2001): 1095-1100.

Gross, G. W., and W. G. Mackenzie. "Scoliosis in Children: Surgical Management and Postoperative Radiographic Appearances." Seminars in Musculoskeletal Radiology 3, no. 3 (1999): 267-288.

Jason Lowry, K, J. Tobias, D. Kittle, T. Burd, and R. W. Gaines. "Postoperative pain control using epidural catheters after anterior spinal fusion for adolescent scoliosis." Spine 26, no. 11 (2001): 1290-1293.

Padua, R., S. Padua, L. Aulisa, E. Ceccarelli, L. Padua, E. Romanini, G. Zanoli, and A. Campi. "Patient outcomes after Harrington instrumentation for idiopathic scoliosis: a 15- to 28-year evaluation." Spine 26, no 11 (2001): 1268-1273.

Redla, S., T. Sikdar, and A. Saifuddin. "Magnetic resonance imaging of scoliosis." Clinical Radiology 56, no 5 (2001): 360-371.

Trivedi, J. M., and J. D. Thomson. "Results of Charleston bracing in skeletally immature patients with idiopathic scoliosis." Journal of Pediatric Orthopedics 21, no 3 (2001): 277-280.

ORGANIZATIONS

American Academy of Orthopedic Surgeons. 6300 North River Road, Rosemont, IL 60018-4262. (847) 823-7186 or (800) 346-2267. Fax: (847) 823-8125. 〈http://www.aaos.org/〉.

American Academy of Physical Medicine and Rehabilitation. One IBM Plaza, Suite 2500, Chicago, IL 60611-3604. (312) 464-9700. Fax: (312) 464-0227. 〈http://www.aapmr.org/consumers/public/amputations.htm〉. [email protected].

American Thoracic Society. 1740 Broadway, New York, NY 10019. (212) 315-8700. Fax: (212) 315-6498. 〈http://www.thoracic.org/〉.

National Scoliosis Foundation. 5 Cabot Place, Stoughton, MA 02072. (800) 673-6922, or (781) 341-6333. Fax: (781) 341-8333. 〈http://www.scoliosis.org/〉. [email protected].

OTHER

American Academy of Family Physicians. 〈http://familydoctor.org/handouts/107.html〉.

American Academy of Orthopedic Surgeons. 〈http://orthoinfo.aaos.org/brochure/thr_report.cfm?Thread_ID=14&topcategory=Spine〉.

National Institute of Arthritis and Musculoskeletal and Skin Diseases. 〈http://www.nih.gov/niams/healthinfo/scochild.htm〉.

Nemours Foundation. 〈http://kidshealth.org/teen/health_problems/diseases/scoliosis.html〉.

Scoliosis Association, Inc. 〈http://www.scoliosisassoc.org〉

Scoliosis Research Society. 〈http://www.srs.org〉.

University of Iowa Hospitals. 〈http://www.vh.org/Providers/Textbooks/AIS/AIS.html〉.

Scoliosis

Definition

Scoliosis is a side-to-side curvature of the spine.

Description

When viewed from the rear, the spine usually appears perfectly straight. Scoliosis is a lateral (side-to-side) curve in the spine, usually combined with a rotation of the vertebrae. (The lateral curvature of scoliosis should not be confused with the normal set of front-to-back spinal curves visible from the side.) While a small degree of lateral curvature does not cause any medical problems, larger curves can cause postural imbalance and lead to muscle fatigue and pain . More severe scoliosis can interfere with breathing and lead to arthritis of the spine (spondylosis).

Demographics

Approximately 10 percent of all adolescents have some degree of scoliosis, although fewer than 1 percent have curves that require medical attention beyond monitoring. Scoliosis is found in both boys and girls, but a girl's spinal curve is much more likely to progress than a boy's. Girls require scoliosis treatment about five times more often than boys. The reason for these differences as of 2004 was not known.

Causes and symptoms

Four out of five cases of scoliosis are idiopathic, meaning the cause is unknown. While idiopathic scoliosis tends to run in families, no specific genes responsible for the condition have been identified. Children with idiopathic scoliosis appear to be otherwise entirely healthy and have not had any bone or joint disease early in life. Scoliosis is not caused by poor posture, diet, or carrying a heavy book bag on one shoulder.

Idiopathic scoliosis is further classified according to age of onset:

• Infantile: Curvature appears before age three. This type is quite rare in the United States but is more common in Europe.
• Juvenile: Curvature appears between ages three and ten. This type may be equivalent to the adolescent type, except for the age of onset.
• Adolescent: Curvature usually appears between ages of ten and 13, near the beginning of puberty . This is the most common type of idiopathic scoliosis.
• Adult: Curvature begins after physical maturation is completed.

Causes are known for three other types of scoliosis:

• Congenital scoliosis is due to abnormal formation of the bones of the spine and is often associated with other organ defects.
• Neuromuscular scoliosis is due to loss of control of the nerves or muscles that support the spine. The most common causes of this type of scoliosis are cerebral palsy and muscular dystrophy .
• Degenerative scoliosis may be caused by breaking down of the discs that separate the vertebrae or by arthritis in the joints that link them.

Scoliosis causes a noticeable asymmetry in the torso when viewed from the front or back. The first sign of scoliosis is often seen when a child is wearing a bathing suit or underwear. A child may appear to be standing with one shoulder higher than the other or to have a tilt in the waistline. One shoulder blade may appear more prominent than the other due to rotation. In girls, one breast may appear higher than the other or larger if rotation pushes one side forward.

Curve progression is greatest near the adolescent growth spurt. Scoliosis that begins early is more likely to progress significantly than scoliosis that begins later in puberty.

When to call the doctor

If the parent notices that a child's posture is abnormal, if when the child stands one hip appears to be higher than the other, if one shoulder blade appears to be sticking out, or the child appears to lean regularly to one side, the doctor should be notified. If the child is screened at school and the screener reports a suspicion of scoliosis, a doctor should be seen to follow up on this suspicion.

Diagnosis

Diagnosis for scoliosis is done by an orthopedist. A complete medical history is taken, including questions about family history of scoliosis. The physical examination includes determination of pubertal development in adolescents, a neurological exam (which may reveal a neuromuscular cause), and measurements of trunk asymmetry. Examination of the trunk is done while the patient is standing, bending over, and lying down and involves both visual inspection and use of a simple mechanical device called a scoliometer.

If a curve is detected, one or more x rays will usually be taken to define the curve or curves more precisely. An x ray is also used to document spinal maturity, any pelvic tilt or hip asymmetry, and the location, extent, and degree of curvature. The curve is defined in terms of where it begins and ends, in which direction it bends, and by an angle measure known as the Cobb angle. The Cobb angle is found by taking an x ray of the spine. Lines are then projected out parallel to the vertebrae at the top and bottom of the curve. Then perpendicular lines are projected from these lines and the angle at which the lines intersect is measured. These angles are referred to when the angle of the curvature is discussed. To properly track the progress of scoliosis, it is important to project from the same points of the spine each time a measurement is made; otherwise, there is a risk of getting misleading measurements.

Occasionally, magnetic resonance imaging (MRI) is used as a diagnostic tool, primarily to look more closely at the condition of the spinal cord and nerve roots extending from it if neurological problems are suspected.

Treatment

Treatment decisions for scoliosis are based on the degree of curvature, the likelihood of significant progression, and the presence of pain, if any.

Curves less than 20 degrees are not usually treated, except by regular follow-up for children who are still growing. Watchful waiting is usually all that is required in adolescents with curves of 20 to 30 degrees as long as there is no pain.

For children or adolescents whose curves progress to 30 degrees and who have a year or more of growth left, bracing may be required. Bracing cannot correct curvature but may be effective in halting or slowing progression.

Two styles of braces are used for daytime wear. The Milwaukee brace consists of metal uprights attached to pads at the hips, rib cage, and neck. The other kind of brace is the underarm brace, which uses rigid plastic to encircle the lower rib cage, abdomen, and hips. Both these brace types hold the spine in a vertical position. Because it can be worn out of sight beneath clothing, the underarm brace is better tolerated and often leads to better compliance. A third style, the Charleston bending brace, is used at night to bend the spine in the opposite direction. Braces are often prescribed to be worn for 22 to 23 hours per day, though some clinicians allow or encourage removal of the brace for exercise .

Bracing may be appropriate for scoliosis due to some types of neuromuscular disease, including spinal muscular atrophy , before growth is finished. Duchenne muscular dystrophy is not treated by bracing. Surgery is likely to be required.

Surgery is usually the option of last resort in cases of scoliosis. Surgery for idiopathic scoliosis is usually recommended if one of the following conditions is present:

• The curve has progressed despite bracing.
• The curve is greater than 40 to 50 degrees before growth has stopped in an adolescent.
• There is significant pain.

Orthopedic surgery for neuromuscular scoliosis is often done earlier. The goals of surgery are to correct the deformity as much as possible, to prevent further deformity, and to eliminate pain as much as possible. Surgery can usually correct 40 to 50 percent of the curve, and sometimes as much as 80 percent. Surgery cannot always completely remove pain.

The surgical procedure for scoliosis is called spinal fusion, because the goal is to straighten the spine as much as possible and then to fuse the vertebrae together to prevent further curvature. To achieve fusion, the involved vertebra are first exposed and then scraped to promote regrowth. Bone chips are usually used to splint together the vertebrae to increase the likelihood of fusion. To maintain the proper spinal posture before fusion occurs, metal rods are inserted alongside the spine and are attached to the vertebrae by hooks, screws, or wires. Fusion of the spine makes it rigid and resistant to further curvature. The metal rods are no longer needed once fusion is complete but are rarely removed unless their presence leads to complications.

Spinal fusion leaves the involved portion of the spine permanently stiff and inflexible. While this leads to some loss of normal motion, most functional activities are not strongly affected, unless the very lowest portion of the spine (the lumbar region) is fused. Normal mobility, exercise, and even contact sports are usually all possible after spinal fusion. Full recovery takes approximately six months. Physical therapy is part of standard treatment as well.

Alternative treatment

Numerous alternative therapies have been touted to provide relief and help for individuals with scoliosis, but none has been proven beneficial in clinical trials. These include massage and electrical stimulation. In addition, alternatives such as rolfing or chiropractic manipulation of soft tissue to improve alignment may provide improved flexibility, stronger muscles, and pain relief but cannot prevent or correct the curvature of the spine or its progression.

Although important for general health and strength, exercise has not been shown to prevent or slow the development of scoliosis. It may help relieve pain from scoliosis by helping to maintain range of motion. Aquatic exercise, in particular, can increase flexibility and improve posture, balance, coordination, and range of motion. Because it decreases joint compression, it can lessen the pain caused by scoliosis or surgery.

Good nutrition is also important for general health, but no specific dietary regimen has been shown to control scoliosis development. In particular, dietary calcium levels do not influence scoliosis progression.

Chiropractic treatment may relieve pain, but it cannot halt scoliosis development and should not be a substitute for conventional treatment of progressing scoliosis. Acupuncture and acupressure may also help reduce pain and discomfort, but these treatments cannot halt scoliosis development either.

Prognosis

The prognosis for a child with scoliosis depends on many factors, including the age at which scoliosis begins and the treatment received. More importantly, mostly unknown individual factors affect the likelihood of progression and the severity of the curve. Most cases of mild adolescent idiopathic scoliosis need no treatment and do not progress. Untreated severe scoliosis often leads to spondylosis and may impair breathing. Degenerative arthritis of the spine, sciatica, and severe physical deformities can also result if severe scoliosis is left untreated. Finally, scoliosis can also poorly affect the individual's self-esteem and cause serious emotional problems.

Prevention

There is no known way to prevent the development of scoliosis. Progression of scoliosis may be prevented through bracing or surgery. More than 30 states have screening programs in schools for adolescent scoliosis, usually conducted by trained school nurses or physical education teachers. These programs can help to catch scoliosis early, so that treatment can begin and progression can often be halted or slowed.

Parental concerns

Children with scoliosis often have a negative self-image associated with irregular posture or having to wear a brace. This problem is being combated with new braces that can be worn under the clothing and are more discreet than traditional braces. Scoliosis can be life threatening if it is not treated and progresses to a point at which breathing is impaired. This is very rare, however. Scoliosis should be watched carefully by a physician for signs of worsening, but it usually does not progress to the point at which treatment is needed.

Resources

BOOKS

Hooper, Nancy J. Stopping Scoliosis: The Whole Family Guide to Diagnosis and Treatment. East Rutherford, NJ: Penguin Group, 2002.

Lenke, Lawrence, et al. Modern Anterior Scoliosis Surgery. St. Louis, MO: Quality Medical Publishing, 2002.

Newton, Peter O. Adolescent Idiopathic Scoliosis. Rosemont, IL: Academy of Orthopaedic Surgeons, 2004.

Schommer, Nancy. Stopping Scoliosis: The Complete Guide to Diagnosis and Treatment, 2nd ed. New York: Avery, 2002.

Silverstein, Alvin. Scoliosis. Minneapolis, MN: Sagebrush Education Resources, 2003.

Spray, Michelle L., et al. Growing Up with Scoliosis: A Young Girl's Story. Stratford, CT: Book Shelf Inc., 2002.

PERIODICALS

Sullivan, Michele G. "Surgical Stapling Can Halt Curve of Scoliosis: Orthotics Can Be Helpful." Family Practice News 33 (December 15, 2003): 35.

Wachter, Kerry. "Prognosis for Scoliosis Better than Once Thought." Family Practice News 33 (July 1, 2003): 59.

Weomstoem. Stuart, et al. "Health and Function of Patients with Untreated Idiopathic Scoliosis: a 50-Year Natural History Study." The Journal of the American Medical Association 289 (February 5, 2003): 559.

ORGANIZATIONS

National Scoliosis Foundation. 5 Cabot Place, Stoughton, MA 02072. Web site: <www.scoliosis.org>.

Scoliosis Research Society. 55 East Wells St. Suite 1100. Milwaukee, WI 53202–3823. Web site: <www.srs.org>.

Tish Davidson, A.M. Liz Meszaros

KEY TERMS

Cobb angle —A measure of the curvature of scoliosis, determined by measurements made on x rays.

Rolfing —A holistic system of bodywork that uses deep manipulation of the body's soft tissue to realign and rebalance the body's myofacial (connective) structure. It is used to improve posture, relieve chronic pain, and reduce stress.

Scoliosis

Definition

Scoliosis is a side-to-side curvature of the spine.

Description

When viewed from the rear, the spine usually appears perfectly straight. Scoliosis is a lateral (side-to-side) curve in the spine, usually combined with a rotation of the vertebrae. (The lateral curvature of scoliosis should not be confused with the normal set of front-to-back spinal curves visible from the side.) While a small degree of lateral curvature does not cause any medical problems, larger curves can cause postural imbalance and lead to muscle fatigue and pain. More severe scoliosis can interfere with breathing and lead to arthritis of the spine (spondylosis).

Approximately 10% of all adolescents have some degree of scoliosis, though fewer than 1% have curves which require medical attention beyond monitoring. Scoliosis is found in both boys and girls, but a girl's spinal curve is much more likely to progress than a boy's. Girls require scoliosis treatment about five times as often. The reason for these differences is not known.

Causes and symptoms

Four out of five cases of scoliosis are idiopathic, meaning the cause is unknown. While idiopathic scoliosis tends to run in families, no responsible genes had been identified as of 1997. Children with idiopathic scoliosis appear to be otherwise entirely healthy, and have not had any bone or joint disease early in life. Scoliosis is not caused by poor posture, diet, or carrying a heavy bookbag exclusively on one shoulder.

Idiopathic scoliosis is further classified according to age of onset:

• Infantile. Curvature appears before age three. This type is quite rare in the United States, but is more common in Europe.
• Juvenile. Curvature appears between ages 3 and 10. This type may be equivalent to the adolescent type, except for the age of onset.
• Adolescent. Curvature appears between ages of 10 and 13, near the beginning of puberty. This is the most common type of idiopathic scoliosis.
• Adult. Curvature begins after physical maturation is completed.

Causes are known for three other types of scoliosis:

• Congenital scoliosis is due to congenital abnormal formation of the bones of the spine, and is often associated with other organ defects.
• Neuromuscular scoliosis is due to loss of control of the nerves or muscles which support the spine. The most common causes of this type of scoliosis are cerebral palsy and muscular dystrophy.
• Degenerative scoliosis may be caused by degeneration of the discs which separate the vertebrae or arthritis in the joints that link them.

Scoliosis causes a noticeable asymmetry in the torso when viewed from the front or back. The first sign of scoliosis is often seen when a child is wearing a bathing suit or underwear. A child may appear to be standing with one shoulder higher than the other, or to have a tilt in the waistline. One shoulder blade may appear more prominent than the other due to rotation. In girls, one breast may appear higher than the other, or larger if rotation pushes that side forward.

Curve progression is greatest near the adolescent growth spurt. Scoliosis that begins early on is more likely to progress significantly than scoliosis that begins later in puberty.

More than 30 states have screening programs in schools for adolescent scoliosis, usually conducted by trained school nurses or gym teachers.

Diagnosis

Diagnosis for scoliosis is done by an orthopedist. A complete medical history is taken, including questions about family history of scoliosis. The physical examination includes determination of pubertal development in adolescents, a neurological exam (which may reveal a neuromuscular cause), and measurements of trunk asymmetry. Examination of the trunk is done while the patient is standing, bending over, and lying down, and involves both visual inspection and use of a simple mechanical device called a scoliometer.

If a curve is detected, one or more x rays will usually be taken to define the curve or curves more precisely. An x ray is used to document spinal maturity, any pelvic tilt or hip asymmetry, and the location, extent, and degree of curvature. The curve is defined in terms of where it begins and ends, in which direction it bends, and by an angle measure known as the Cobb angle. The Cobb angle is found by projecting lines parallel to the vertebrae tops at the extremes of the curve; projecting perpendiculars from these lines; and measuring the angle of intersection. To properly track the progress of scoliosis, it is important to project from the same points of the spine each time.

Occasionally, magnetic resonance imaging (MRI) is used, primarily to look more closely at the condition of the spinal cord and nerve roots extending from it if neurological problems are suspected.

Treatment

Treatment decisions for scoliosis are based on the degree of curvature, the likelihood of significant progression, and the presence of pain, if any.

Curves less than 20 degrees are not usually treated, except by regular follow-up for children who are still growing. Watchful waiting is usually all that is required in adolescents with curves of 20-30 degrees, or adults with curves up to 40 degrees or slightly more, as long as there is no pain.

For children or adolescents whose curves progress to 30 degrees, and who have a year or more of growth left, bracing may be required. Bracing cannot correct curvature, but may be effective in halting or slowing progression. Bracing is rarely used in adults, except where pain is significant and surgery is not an option, as in some elderly patients.

Two general styles of braces are used for daytime wear. The Milwaukee brace consists of metal uprights attached to pads at the hips, rib cage, and neck. The underarm brace uses rigid plastic to encircle the lower rib cage, abdomen, and hips. Both these brace types hold the spine in a vertical position. Because it can be worn out of sight beneath clothing, the underarm brace is better tolerated and often leads to better compliance. A third style, the Charleston bending brace, is used at night to bend the spine in the opposite direction. Braces are often prescribed to be worn for 22-23 hours per day, though some clinicians allow or encourage removal of the brace for exercise.

Bracing may be appropriate for scoliosis due to some types of neuromuscular disease, including spinal muscular atrophy, before growth is finished. Duchenne muscular dystrophy is not treated by bracing, since surgery is likely to be required, and since later surgery is complicated by loss of respiratory capacity.

Surgery for idiopathic scoliosis is usually recommended if:

• the curve has progressed despite bracing
• the curve is greater than 40-50 degrees before growth has stopped in an adolescent
• the curve is greater than 50 degrees and continues to increase in an adult
• there is significant pain

Orthopedic surgery for neuromuscular scoliosis is often done earlier. The goals of surgery are to correct the deformity as much as possible, to prevent further deformity, and to eliminate pain as much as possible. Surgery can usually correct 40-50% of the curve, and sometimes as much as 80%. Surgery cannot always completely remove pain.

The surgical procedure for scoliosis is called spinal fusion, because the goal is to straighten the spine as much as possible, and then to fuse the vertebrae together to prevent further curvature. To achieve fusion, the involved vertebra are first exposed, and then scraped to promote regrowth. Bone chips are usually used to splint together the vertebrae to increase the likelihood of fusion. To maintain the proper spinal posture before fusion occurs, metal rods are inserted alongside the spine, and are attached to the vertebrae by hooks, screws, or wires. Fusion of the spine makes it rigid and resistant to further curvature. The metal rods are no longer needed once fusion is complete, but are rarely removed unless their presence leads to complications.

Spinal fusion leaves the involved portion of the spine permanently stiff and inflexible. While this leads to some loss of normal motion, most functional activities are not strongly affected, unless the very lowest portion of the spine (the lumbar region) is fused. Normal mobility, exercise, and even contact sports are usually all possible after spinal fusion. Full recovery takes approximately six months.

Alternative treatment

Numerous alternative therapies have been touted to provide relief and help for individuals with scoliosis, but none have been proven beneficial in clinical trials. These include massage, physical therapy, and electrical stimulation. In addition, alternatives such as physical therapy, rolfing, or chiropractice manipulation may provide improved flexibility, stronger muscles, and pain relief, but cannot prevent or correct the curvature of the spine or its natural progression.

Although important for general health and strength, exercise has not been shown to prevent or slow the development of scoliosis. It may help relieve pain from scoliosis by helping to maintain range of motion. Aquatic exercise, in particular, can increase flexibility and improve posture, balance, coordination, and range of motion. Because it decreases joint compression, it can lessen the pain caused by scoliosis or surgery.

Good nutrition is also important for general health, but no specific dietary regimen has been shown to control scoliosis development. In particular, dietary calcium levels do not influence scoliosis progression.

Chiropractic treatment may relieve pain, but it cannot halt scoliosis development, and should not be a substitute for conventional treatment of progressing scoliosis. Acupuncture and acupressure may also help reduce pain and discomfort, but they cannot halt scoliosis development either.

Prognosis

The prognosis for a person with scoliosis depends on many factors, including the age at which scoliosis begins and the treatment received. More importantly, mostly unknown individual factors affect the likelihood of progression and the severity of the curve. Most cases of mild adolescent idiopathic scoliosis need no treatment and do not progress. Untreated severe scoliosis often leads to spondylosis, and may impair breathing. Degenerative arthritis of the spine, sciatica, and severe physical deformities can also result if severe scoliosis is left untreated. Finally, scoliosis can also poorly affect the individual's self-esteem and cause serious emotional problems.

Prevention

There is no known way to prevent the development of scoliosis. Progression of scoliosis may be prevented through bracing or surgery.

Exercise and physical fitness are of paramount importance for all individuals affected with scoliosis. They not only work to maintain flexibility and health, but decrease the likelihood of osteoporosis, which in these individuals, can be extremely debilitating.

Resources

BOOKS

Lyons, Brooke, et al. Scoliosis: Ascending the Curve. New York: M. Evans & Co., 1999.

PERIODICALS

Bridwell, KH, et al., editors. "Parents' and Patients' Preferences and Concerns in Idiopathic Adolescent Scoliosis: A Cross-Sectional Preoperative Analysis." Spine 25, no. 18 (September 2000): 2392-9.

ORGANIZATIONS

American Physical Therapy Assocation. Scoliosis, P.O. Box 37257, Washington, DC 20013.

Center for Spinal Disorders, PC. 8515 Pearl Street, Suite 350, Thornton, CO 80229. (303) 287-2800; fax: (303) 287-7357. 〈http://www.cntrforspinaldisorders.com〉.

National Scoliosis Foundation. 72 Mount Auburn St., Watertown, MA 02172. (617) 926-0397.

The Scoliosis Association. PO Box 811705, Boca Raton, FL 33481-0669. (407) 368-8518.

OTHER

"Chiropractic Treatment of Scoliosis." Scoliosis World.

KEY TERMS

Cobb angle— A measure of the curvature of scoliosis, determined by measurements made on x rays.

Rolfing— A system of soft tissue manipulation and movement education to realign and reorient the body.

Scoliometer— A tool for measuring trunk asymmetry; it includes a bubble level and angle measure.

Spondylosis— Arthritis of the spine.