Understanding Scoliosis

What is scoliosis?

Looking from someone’s front or back, their spine should be straight. The term scoliosis simply refers to a sideways bend of the spine. There are two main types of scoliosis – postural and structural.

Postural – a sideways bend, without the spine also rotating. The person stands with waist or shoulders that appear uneven. When they bend forward, there is no sign of one side of the chest looking higher than the other. Postural curves may come about because someone has pain, has a difference in the lengths of their legs or just slump to one side. Postural curves tend to disappear when you sit. 

Structural – these curves also “spin”. That is, as well as the shoulders or waist looking uneven, there is chest wall asymmetry. There is a prominence on one side of the back when the person bends over. Sometimes, the front will also look different. 

Structural Scoliosis

Structural scoliosis can happen at any age and there are many different causes. 

Babies and toddlers

Curves appearing at this age are rare. They may be caused by the following:

1. Congenital. The spine has not formed properly. Normally, the spine is a column of blocks. Problems with the formation of the column very early in foetal life can lead to bones forming as wedges, or other shapes instead. This can cause the spine to be bent at birth or bend with growth. Sometimes, the bend only becomes obvious when the child becomes a teenager. Treatment is necessary if the curve is getting worse. This normally means surgery. 
2. Neuromuscular. This term usually means that the child has a problem in the brain, spinal cord, nerves or muscles that cause weakness or an inability to control posture. Examples include cerebral palsy and spina bifida. 
3. Idiopathic. This term means “cause unknown.” It usually is noticed in the first months of life. The back looks bent and the ribs prominent on one side. This type of scoliosis is notable because it is the only type that affects more boys than girls, is almost always a curve convex to the left and it usually gets better. Treatment is largely stretching out the curve. Early diagnosis and treatment is essential, as if neglected, the curve may worsen to a point where plaster jackets or surgery is needed. 

All early onset scoliosis should be seen by a medical specialist. 

Children

Curves can develop between the ages of 3 and 10 years, but like those occurring in younger children, they are rare. Most are idiopathic, but congenital and neuromuscular curves can appear at this age too. Another category is “syndromal.” Some syndromes are commonly associated with scoliosis. Often it is related to the underlying condition causing poor strength, coordination or hypermobility. Down’s syndrome, Brittle bone disease, Rett’s syndrome and Marfan’s syndrome are all examples of this. Treatment is usually needed, by bracing or surgery, if the curves get large enough. 

Adolescent Idiopathic Scoliosis

Many of the causes of scoliosis affecting younger children can appear in this age group. However, the commonest cause is Adolescent Idiopathic Scoliosis. 3-4% of girls will develop AIS. It’s much less common in boys – about 0.5%. It runs strongly in families. If a mother has scoliosis, there is a 25% chance of her daughters getting it. There are at least 20 genes associated with the condition, but exactly how they act is unknown. Some are involved with neural development, others have no obvious relationship to the spine or nervous system. And genetics aren’t the whole story; if a girl with scoliosis has an identical twin, then the risk of her having a curve is only 60-70%, not 100%. There are unknown environmental factors at play. Heavy school bags, asymmetric sports (like tennis), playing the violin, etc. do not cause this condition.

It is rare for treatment to be needed. In fact, only 1-2% of people with AIS need treatment. The indications for treatment is almost always appearance – the person’s curve is very obvious, or will become obvious with growth and time. Scoliosis of this type has no significant effect on health, heart, breathing, etc, unless the curve gets very big (>90 degrees).

The spine is not weak, just bent. People can play all their normal sports without restriction. There is also no restriction on employment, but the military tends not to enlist people with anything but mild scoliosis. 

Back pain is common. Most people with AIS experience dull backache around the apex of the curve after activity. It usually doesn’t interfere with sport, and usually gets better with rest. Massage, heat packs, simple pain medications can help. Exercise programs to improve core strength are often also a good idea. There is some evidence the formal scoliosis specific exercises, like the Schroth Method may have some benefit in reducing or arresting curve progression. It is not recommended for this to be the only treatment for a progressive curve.

Treatment for AIS

Bracing

This is an effective way of preventing a curve from worsening. However, research has shown that the following factors are required:

1. A curve between 20 and 40 degrees. Curves smaller than this may not progress and merely need observation. Curves larger than 40 degrees are hard to control in a brace and the benefit is generally minimal.
2. Sufficient growth remaining. At least 18 months of growth is needed for bracing to be useful. There is no indication for bracing an adult with scoliosis – it will do nothing to prevent curve progression.
3. Ability to wear the brace for between 16 and 20 hours per day. This will give the greatest chance of controlling the curve. It is hard work to wear a brace, but compliance is essential. 
4. A braceable curve type. Some curves are too high, or of an unusual shape that makes a brace unable to be effective.
5. A good brace. Custom made braces are necessary to provide the best fit and correction. Trained orthotists are recommended to do this. 

Surgery

This is appropriate for individuals who have a curve that is too big to brace. It is generally curves over about 50 degrees (depending on curve type), but can also be necessary in those with smaller curves that are very obvious. There are different techniques and surgical approaches, depending on the curve pattern and region of the spine. Posterior fusion is the most common type. The spine is exposed by a cut down the centre of the back. The joints between each bone are loosened and anchors (screws, hooks and tapes) are connected to the bones. Contoured rods are then attached to the anchors and the spine drawn slowly to the rods. Once the spine is straightened, bone graft is laid along the area. This causes that area of the spine to fuse solidly. The length of the operation depends on the type of curve, but is usually 4 to 6 hours. People are in hospital for about a week and off school for a few weeks. After 6 months, most can return to all sports and activities without restriction. 

What to do if you think you, or someone you know may have scoliosis?

A good place to start is a website that shows you how to look for structural scoliosis, by using the Forward Bend Test. This is a good one: www.scoliosis_australia.org

If scoliosis is then suspected, it is recommended that you see your GP for confirmation. X-rays will help with the diagnosis. It is important to know that whilst most people don’t need treatment, early diagnosis can be very important for those that might.