Scoliosis
So, there are two questions which I want us all to have the answers after reading this chapter:
- What is scoliosis?
- How are abnormal spinal curvatures identified in adolescents?
This is an important topic that is often missed by primary care physicians either due to lack of awareness or due to lack of knowledge regarding the different tests that could help with diagnosis. Therefore, many different cases are often discovered coincidently, sometimes by the parents themselves, often when it is too late.
As I have already mentioned, this chapter is of great importance because early diagnosis and prevention of spinal deformities could be very helpful. I suggest that anybody who is a parent to an adolescent, read this chapter and possibly even try some of the tests I will discuss on him/her.
What are the two types of abnormal spinal curvatures in children?
Often, people will tell you that they’ve noticed that your child doesn’t walk “straight”. Their shoulders could be asymmetrical and their back could be curved forward. The thought that this could be scoliosis of the spine or a weakness of the shoulder girdle crosses the mind and the concern that their back will curve as they grow older arises.
Firstly, one must differentiate between two different situations, depending on how flexible the curvature is: Is your child suffering from a flexible curve, one that can be altered by requesting that he/she stand up straight, or is it a rigid curve of the spine, i.e one that cannot be altered by the child during the physical examination?
The second factor that is to be assessed is with regards to the direction of the curve: is it a bend forward (kyphosis) or is part of the trunk curved towards one of the sides (scoliosis)?
The flexible cases – “My child doesn’t walk straight”
Whether your child bends forward (the more common cases “my child does not walk straight”), or to the side – this is usually due to abnormal postural habits.
This is not true scoliosis but is related to abnormal posture. The curved stature is very disturbing, especially for parents… the child, on the other hand, usually doesn’t understand what the problem is and why he is being asked to stand up straight. The medical reason for asking he do so would be that consistently walking with this curvature position could lead to muscular back pain due to a permanent contraction of muscles in that particular position. Also, this could possibly turn into a structural problem in the long run, and at that point the child would not be able to straighten his back even if they wanted to do so.
In flexible ‘side’ curvatures, there is one more common underlying factor that needs to be looked for – leg-length inequality. In such cases, bending towards one side of the pelvis could cause the spine to curve towards the side of the shorter leg.
Treatment of flexible curvatures of the spine encompasses two aspects: core muscle (back and abdomen) strengthening and increasing awareness towards proper posture. This could be done with the help of physiotherapy exercises first, and independent exercising, at home, afterwards. Daily exercise is also a good way to improve self-awareness. Simply core-muscle strengthening and strengthening of the shoulder-girdle muscles, do not promise a straight posture in the future. Continuous practice is the best way to improve awareness.
A common question we get asked by parents is with regards to the need for bracing, in order to maintain a proper posture. We strongly advise against the use of brace intervention: instead of the bracing maintaining a straight posture, the passive support that it provides leads to weakening of the back muscles and dependency on the device. Posture could worsen after their use is stopped.
Spinal side curvatures that are due to leg-length inequality are managed by elevation of the shorter leg with the use of orthosis for stabilisation of the pelvis and compensating for the asymmetry. The length of the legs is to be followed in such cases, and the management altered accordingly. If the difference is larger than 2 centimeters, surgical intervention is considered.
Rigid situations – these are structural spinal curvatures such as scoliosis and kyphosis
Socliosis (curvature to the side)
This is the most common spinal curvature, to which I will dedicate most of this chapter to. It is the one that occurs mainly during adolescence (the severe type being 7 times more likely to occur in girls than boys). The most common structural curvature is named “idiopathic scoliosis” (idiopathic meaning from an unknown cause), and represents 80% of all the structural curvatures. This is not a congenital abnormality but one that occurs during development and growth after 10 years of age. It could be mild and concealed during its first stages but becomes more severe and prominent during adolescence. The cause of scoliosis is unknown. There is a significant genetic component to the cause and a positive family history could aid in risk stratification and the estimation of how severely it could develop. The progression in the degree of the scoliosis is due to a worsening curvature in the structure of vertebrae themselves, that becomes more prominent as they grow. The most common type of structural curvature is seen in the thoracic spine (the upper part of the vertebral column that is made up of 12 vertebrae, as opposed to the pelvic spine, consisting of the 5 lowest vertebrae). In scoliosis, the spine will usually curve to the right, i.e the curvy end will point towards the right side.
The shape of the scoliotic curvature does not only consist of vertebral bodies curving to the right or left side but there is also a prominent component of horizontal deviation of the vertebra itself.
This same deviation is what causes the curvature of the chest cavity that is easily visible on physical examination: on bending forwards one can see the asymmetry at the level of the rib cage on both sides of the spine – when looking from the back (Adams forward-bending test, see the image and explanation below).
Often, the side curvature precedes the deviation, and so screening and early diagnosis tests are done by early identification of the side curvature. Another component of scoliosis is an exaggerated straightening of the vertebral column in the front to back aspect.
What are the findings in scoliosis?
There are several findings on physical examination that support the presence of scoliosis, these include:
- Asymmetry of shoulder height
- Asymmetric scapular or shoulder position
- Asymmetry of hands to body distance
- Orientation of the pelvis towards one side of the body
What is Adams forward-bending test?
In the past, this test used to be used as a simple screening test, carried out by the school nurse, but all parents can perform it at home.
How is it carried out? The parent sits behind their child, with his eyes at the level of the child’s bending back. The child is then asked to bend forward with their legs pressed tightly against each other and their knees kept straight, in an attempt to produce a straight angle at the level of the hips. If there is a curvature, a protrusion or asymmetry will be visible at the spinal area (see the first picture).
What is the problem in scoliosis and how can we solve it?
As I previously mentioned, this is a structural, developmental problem. As the child grows, there is a risk of progression of the curvature, which usually lasts until the child stops growing. When growth has stopped, the progressions ceases as well and the deviation stabilizes.
The problem with treating the curvature is that once is has occurred, there is no conservative (non-surgical) way of reversing the damage that has already occurred. Different conservative methods have been tried throughout history, unfortunately though, they have not proved to be efficient in correcting structural curvatures. It is indeed true that in most cases, especially in the early stages, there is a secondary flexible component to the rigid curvature, and by working on this flexible component one can certainly strengthen and slightly improve posture. Unfortunately, this does not prevent the progression of the scoliosis nor does it correct it. The old method of bracing is the only efficient method known today, and the use of this method may prevent progression in about 80% of patients.
Bracing is a type of ‘belt’ that hugs the upper part of the body and is made of rigid plastic, custom-designed and individualized for the patient.
There are several types of bracing techniques that are created by orthotists in orthopedic centers that specialize in spinal curvatures. The orthotists’ skill in preparing this brace is of utmost importance. The brace is to be worn for most of the day. It is advised that the child wears it for around 22 hours per day – which means it can only be taken off for short periods at a time, for activities such as bathing and physical exercise, etc. Therefore, management of spinal curvatures with the use of bracing is a tough decision and it is important to understand how it works and when it should be used.
The degree of deviation is measured with the help of an X-ray, taken while the patient is standing, and includes the entire spine and pelvis. The deviation is measured from the side of the vertebra, starting with the first curved vertebral body and up until the last one. The decision for management with the help of bracing is based on the degree of curvature and its potential to progress. Any deviation over 20 degrees is one that should be treated using a brace – as long as the child is still growing. The curvature’s potential for progression thus depends on the age of the patient, their developmental status and their bone age. The younger the patient, the greater the chance that the curvature will worsen as the patient grows. That is why a 16-year-old, for example, with a 30- degree curvature is not suitable for management with bracing as their growth has most probably ended by this time and there is no concern for worsening of the curvature. Since deciding on bracing can be difficult, some suggest following up on the severity of curvature and recommending bracing if the degree of curvature seems to progress.
What is the surgical treatment for scolisos?
The surgical treatment for idiopathic scoliosis is spared for the most severe cases – mainly with curves that are over 45-degrees or those that continue to progress despite conservative measures. The reason that surgical treatment is advised for curves that are over 50-degrees is because they could potentially progress after the child’s growth has ceased. Progression after growth cessation is very gradual (an increase in approximately one degree per year) but the deviation in the long run is significant and can lead to respiratory abnormalities in the future.
Some important points to mention regading scoliosis
Remember, in most cases the problem is mainly cosmetic. The medical concerns arise at significant curves that are above 70 degrees or those atypical curvatures that arise in early childhood, before 10 years of age.
In most cases, no problems arise in the long run and there are no issues with physical activity, pregnancies, etc.
There is evidence of increased frequency of back pain in patients who suffer from idiopathic scoliosis as they get older, but the evidence isn’t clear it. This is indeed one of the problems we see with idiopathic scoliosis – when it first occurs it is does not present with back pain and so diagnosis is often delayed. The main problem with scoliosis is emotional and related to how one perceives themselves.
It is important to mention that hesitating with the start treatment can lead to progression of curvature as treatment is delayed. If there is an indication to begin treatment – it is advised to do so as early as possible to prevent irreversible damage that occurs during accelerated growth periods.
Another important note is with regards to the method of measurement and the follow up of the spinal curvatures. There is no better alternative to scanning the spine with the help of an X-ray. The degree of curvature is measured on an X-ray image and cannot be done with images produced using ultrasound, MRI or others that have been tried throughout history.
The concern for radiation from X-ray scans is justifiable as these patients certainly do undergo many repeated scans. Most centers that manage patients with spinal deformities carry X-ray machines with reduced radiation, that are intended for curvature imaging. It is therefore fair to request to perform these images using X-ray machines that are custom for scanning the vertebral column.
What is Kyphosis (deviation with a forward-curve)?
Kyphosis is less common than scoliosis.
It is caused by vertebral bodies structured in the shape of a peg, with an angle in the frontal part of the vertebral body that produces a forward curve to the spine. Kyphosis is equally common in females and males.
On physical examination there is a sharp curve in the vertebral columns towards the front, which can be seen from the side. Structural kyphosis, unlike postural kyphosis, does not align when an attempt is made to stand up straight or when stretching backwards. Similar to the side curvature, structural kyphosis is managed mainly with the help of a combination of exercises for strengthening the postural muscles of the vertebral column and braces, that support the vertebral column and direct its growth in a straight manner.
A few words to end. There are several topics in pediatrics in which parents play a significant role in identifying and helping with early diagnosis. Spinal curvature is one of them.
I advise all parents who have adolescents to take note of the findings mentioned in this chapter for early diagnosis of abnormal spinal curvatures and to even trying to perform the Adams test on their son/daughter.
If you notice any abnormal findings in your child – see an orthopedist for an examination and consult.
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