Pain in adolescent idiopathic scoliosis

As a registrar, I was taught that scoliosis in adolescents was not a painful condition. The textbooks of the time largely echoed this sentiment. But that isn't the whole story.

To be called a scoliosis there must be at least 10° of angulation of curve evident in the coronal plane on a plain radiograph along with evidence of rotation of vertebral bodies. This is often only noticed clinically, usually by the family, when the curve is already well past this threshold. A curve of 10° is barely perceptible clinically and is often a radiological finding only on a chest x-ray taken for other reasons. The usual identification of these curves relatively late in their development, or at least not in their very early stages, is testimony to the fact that very often adolescent idiopathic scoliosis is indeed often not a painful condition. There are commonly no complaints of symptoms from the teenager alerting families and their medical practitioners to the issue and so it goes undetected.

With closer questioning however, teenagers in this group often do complain of vague minor aches and pains, sometimes night pain, sometimes exercise or activity related discomfort and other back pains which are often described by both parents and medical practitioners alike as "growing pains". Quite often, if a patient does complain of pain it is a consequence of associated conditions of the scoliosis rather than the scoliosis itself. L5 pars defects usually of the lytic variety are a common association in teenagers with AIS for example. Again, this common abnormality amongst the general population may be the source of various degrees of pain or be entirely asymptomatic. Other common complaints include neck and shoulder pain as a consequence of the mechanics of the sometimes short sharp angulation of the fractional curve above a significant thoracic scoliosis for instance.

In adolescents who do complain of spine pain and also have a scoliosis, it is important not to simply attribute the pain to the scoliosis and it is important to investigate the patient to exclude the rare but important other common sources of significant pain in teenagers such as osteoid osteoma, infection or developmental anomalies. Along with all patients that complain of neurological symptoms, in patients with scoliosis complaining of pain an MRI of the whole spine is a highly sensitive radiological investigation without exposing the patient to ionising radiation which is appropriate to order in this group. 

Many times, multiple plain radiographs and/or CT scans are ordered with significant radiation exposure over time. It should always be remembered that breast cancer rates are higher in scoliotic females than non-scoliotic girls most likely simply as a consequence of their exposure to plain radiography over time. Usually, a specialist will use radiography to monitor the progression of a curve and wherever possible will use the now well-established EOS radiographic system that captures both a lateral and a PA film at the same time with roughly 15% of the typical plain radiography radiation dose. These systems are available now in every state capital city in Australia and in an increasing number of regional centres.

Pain of course is a complex phenomenon however and an entirely subjective experience and elevated pain scores are typically seen in all ages in those patients with a history of anxiety issues or depression and adolescents are no different and so it is in scoliosis. On occasion, expressions of spine pain may be one of the central symptoms heralding the onset of a mental health problem in a teenager.

Spine pain of all causes can be difficult to treat. Whilst it is common for the small group of scoliosis patients that need to progress to surgery post operatively to demonstrate complete resolution of all spine pain, that is by no means universally the case. In the larger nonoperative group, education about the condition is a central part of developing self efficacy of symptom management, the judicious use of simple analgesics and occasional anti-inflammatory medicine can be useful and short term focused physiotherapy delivered by practitioners with a subspecialty interest has been shown to be useful. As with all forms of chronic spine pain at all ages, it is very important not to escalate patients into chronic analgesic use and in particular chronic opiate use as this very commonly leads to substantial additional morbidity over time. Use of simple neuro modulation medication such as amitriptyline can also be useful in a very small percentage.

Like most spine patients however, the keys to highly effective self-management over the years are education, weight management and exercise. There is an excellent dose response curve for each of them!