Scoliosis

What Causes Scoliosis?

• Scoliosis can result from a number of underlying medical conditions, but in in most cases the cause of scoliosis is unknown which is termed “idiopathic”.
• There is some evidence there is a genetic component to its cause. Research is ongoing. There is no clear pattern, but there has been shown to be an increased incidence in family members of affected individuals. Therefore, if one family member has scoliosis, future generations are at slightly higher risk.
• Small spinal curves in general equally affect boys and girls. However girls are more likely to have curves that progress to the point of requiring some form of treatment.

There are several different types of scoliosis that affect children. The three main types of scoliosis in children include idiopathic, congenital and neuromuscular/syndrome-related scoliosis.

Idopathic Scoliosis

The most common type of scoliosis is “idiopathic”, which means the exact cause is not known. Approximately 80% of patients with scoliosis have this type.

• Progression of scoliosis curves is most rapid during peak skeletal growth , during early infancy and adolescence
• Risk of curve progression includes gender, remaining skeletal growth, curve location and size.

Idiopathic Scoliosis can occur at any age.

• Infantile – occurs from birth to 3 years of age.
  • Infantile idiopathic scoliosis is rare but is mostly found in males
  • Some infant scoliosis curves correct themselves spontaneously without treatment as the child grows but should be monitored
  • Progressive curves may require bracing and/or serial Risser casting.
• Juvenile – occurs in children between the ages of 3-10 years
  • Generally occur during a time of rapid growth
  • Increased incidence of curve progression that will require some form of treatment
• Adolescent - occurs in children from age 10-18 years. This is the most common type of scoliosis
  • Adolescents are the most common group for idiopathic scoliosis. These curves are generally identified during the rapid growth spurt associated with puberty.
  • Incidence in boys vs. girls is equal for small curves but girls are more likely to have progressive larger curves

Congenital Scoliosis

Congenital scoliosis is a curvature of the spine that occurs during fetal development. The curve occurs as a result of abnormally shaped bones in the spine and/or ribs

• Occurs in 1 in 10,000 newborns
• Although present at birth , it is sometimes difficult to see the spine deformity until a child reaches adolescence
• Spinal development occurs during the same time as several other major organ systems such as the bladder, kidneys and heart. Therefore, if a child is found to have abnormal vertebrae, this is usually indication for additional testing.

Neuromuscular/Syndrome-related Scoliosis

Neuromuscular/Syndrome-related Scoliosis is a curving of the spine related to a defect in the nervous or muscular system. This type of scoliosis is associated with a number of syndromes including but not limited to cerebral palsy, spina bifida, muscular dystrophy, spinal cord tumors, neurofibromatosis, paralytic conditions or traumatic spinal cord injuries.

What Are The Signs & Symptoms Of Scoliosis?

Idiopathic scoliosis (the most common type) can be present with little or no outward signs. Children usually are not limited in their activities. Idiopathic scoliosis does not usually cause back pain, leg pain, neurological dysfunction, or respiratory problems. The first sign is usually a subtle difference in appearance of the back that is noticed by a parent, doctor or school nurse.

Physical signs of scoliosis include:

• Uneven shoulders, difference in height or position of shoulder blades
• Uneven waistline
• One hip appears higher than the other
• Appearance of leaning to the side when standing straight
• When bending forward, the sides of the back appear different in height

Treatment

The specific treatment required for your child’s scoliosis will be determined by the physician based on:

• Child’s age, medical history & overall health
• Size of the curve
• Type of scoliosis
• Time remaining until child reaches skeletal maturity

Tools that help estimate your child’s remaining spine growth may include x-rays of the pelvis and/or hands.

• Options for treatment include observation, bracing and surgery.

Observation

If the curve is mild and/or the child is near skeletal maturation this may be appropriate

• Many patients are simply monitored with “watchful waiting”. The doctor will recheck the curve on a regular basis to see that it is not progressing
• Mild curves (less than25°), curves that haven’t shown progression, or adolescents with little or no growth remaining may be monitored for changes using physical examination and x-rays at 4 to 12 month intervals
• Many instances of scoliosis fall into this category

Bracing

The goal of bracing is to limit the curve from getting worse. A special back brace called a thoracolumbar spinal orthosis (TLSO) may be prescribed. Bracing is recommended when there is significant risk for the curve to worsen.

• Moderate curves (25-45°) in a child that is still growing. Bracing may be recommend to help slow the progression of the curve
• There are several different types of braces that can be used. Each brace looks a little different. The type of brace used depends on several factors including the characteristics of the child’s curve.
• Time is allowed out of the brace for participation in sporting activities
• In very immature children with progressive curves, a Risser body cast can be applied in an attempt to improve flexibility until they can convert to brace wear. Again, the objective is to limit the curve progression and once the child has matured, a spinal fusion may be indicated.

Surgery

One surgical procedure is called a “Spinal fusion”. This surgery involves stabilizing the scoliotic portion of the spine with hardware that may include rods, hooks and/or screws. The goal of surgery is to obtain fusion of the bone to prevent further progression of the curve. An added benefit is often cosmetic improvement.

This surgery may be recommended if:

• Curves greater than 45° and the child is still growing
• The curve exceeds 50° even if the child is skeletally mature. Curves of this magnitude are at increased risk for continued progression
• Curves that significantly worsen during the course of x-ray monitoring

In general, after scoliosis surgery it is possible to return to most sporting activities within 6 months to one year.

If left untreated, curves greater than 50° are at increased risk for worsening and can potentially lead to long term health problems involving the heart and/or lungs. Additionally, the cosmetic aspects of scoliosis become concerning to many patients and families

Other surgical procedures for younger children may consist of implanting ‘growing rods’. The term ‘growing rod’ loosely means instrumentation without fusion. This procedure is used in young patients with rapidly progressive curves despite aggressive brace therapy. A limited fusion is performed at the top and bottom of the affected spine with hooks to hold a more subcutaneous rod in place. Subsequent distraction (minor surgical procedure to lengthen the rod) is performed every six to 12 months during the child’s growth phase. Eventually, these children will have a spinal fusion and may be braced in addition during growth.

VEPTR

A Vertical Expandable Prosthetic Titanium Rib is a Synthes™ device indicated for treatment of thoracic insufficiency syndrome (TIS) in skeletally immature patients. This is defined as the inability of the thorax to support normal organ growth. Young patients with scoliosis with or without rib abnormalities or congenitally malformed vertebrae fall into this category. Again, this is only a temporary measure that enables the thoracic cavity and spine to grow until a spinal fusion can be performed. Nationwide Children’s Hospital is the first hospital in Ohio to receive access to the VEPTR device. Less than 10 surgeons in Ohio have accessibility to the VEPTR device and need to be approved by the Institutional Review Board.

Notes For Parents:

• Scoliosis cannot be prevented. There is nothing you did or didn’t do to cause scoliosis
• There is no form of therapy, stretching or exercise that has been proven to improve or stop scoliosis
• Treatment options for management are individualized for each child.
• Routine examinations with x-rays are required to monitor the curve as your child grows
• Most cases of adolescent idiopathic scoliosis less than 20 degrees require no treatment outside of observation
• Incidence of back pain is not proven to be any higher in patients with scoliosis than in the general population
• Scoliosis should not limit activities and children can maintain living a normal active lifestyle with family, school and sporting activities.

Helpful Online Resources:

• American Academy of Orthopedic Surgeons
• Pediatric Orthopedic Society of North America
• Scoliosis Research Society

Famous People with Scoliosis:

• James Blake - Tennis player
• Usain Bolt - Olympic Gold medalist
• Stacy Lewis - Golfer
• Kelly Pesticco - Miss Wales
• Rebecca Romijn - Model and Actress
• Janet Evans - Olympic swimmer
• And many, many others!