Scoliosis

Scoliosis is abnormal side-to-side curvature of the spine. The spinal curve may develop as a single curve (shaped like the letter C) or as two curves (shaped like the letter S). In children and teens, scoliosis often does not have any noticeable symptoms and may not be noticeable until it has progressed significantly. The two most common forms are degenerative scoliosis and idiopathic scoliosis (adolescent). Three orthopedically approved options exist for combating scoliosis: observation, bracing, or surgery.

Most often this deformity has no known cause, in which case it is called idiopathic scoliosis. While the cause is unknown, idiopathic scoliosis does tend to run in families. The specific genes involved have not all been identified yet, and there could be factors beyond genetics as well. Some people mistakenly think that carrying heavy book bags or sleeping on the side could cause scoliosis, but that is not the case. About 3% of the population is estimated to have idiopathic scoliosis.

Early Stages Rarely Have Signs or Symptoms

Any sideways — or lateral — spinal curvature of at least 10 degrees, as measured on an X-ray of the spine, is considered scoliosis. However, that small curve size would not show signs or symptoms.

As the curve progresses to 20 degrees or beyond, there is an increased chance that the person or an observer, such as a parent or teacher, might notice abnormalities such as clothes hanging unevenly or the body tilting to one side.

The idiopathic scoliosis in and of itself is generally not thought to cause significant pain, especially in adolescents and young adults. However, a scoliosis curve can cause trunk imbalances and other issues that increase the likelihood for muscle spasms and other issues, which can in turn lead to pain.

When Idiopathic Scoliosis Needs Treatment
Treatment options for idiopathic scoliosis could include:
  • Observation. Typically, a doctor will advise observation for a scoliosis curve that has not yet reached 25 degrees. Every 4 to 6 months, the doctor will take another X-ray of the spine to see if the scoliosis is progressing or not.
  • Bracing. If the scoliosis has progressed past 20 or 25 degrees, a back brace could be prescribed to be worn until the adolescent has reached full skeletal maturity. The goal of bracing is to prevent the curve from getting worse and to avoid surgery.
  • Surgery. If the curve continues to progress despite bracing, surgery could be considered. The most common surgical option for scoliosis today is a posterior spinal fusion, which can offer better corrections with fewer fusion levels (preserving more back mobility) than what was done in years past.

Approximately 90% of people identified with idiopathic scoliosis have curves that never progress enough to require bracing or surgery.

Symptoms of Moderate or Severe Scoliosis

Only about 10% of people with idiopathic scoliosis have a curve that progresses beyond mild and needs treatment. If that progression happens, the deformity becomes more obvious to other people and more likely to cause noticeable symptoms.

Some of the more common symptoms present in moderate or severe scoliosis could include:
  • Changes with walking. When the spine abnormally twists and bends sideways enough, it can cause the hips to be out of alignment, which changes a person’s gait or how they walk. The extra compensating that a person does to maintain balance for the uneven hips and legs can cause the muscles to tire sooner. A person might also notice that one hand brushes against a hip while walking but the other does not.
  • Reduced range of motion. The deformity from spinal twisting can increase rigidity, which reduces the spine’s flexibility for bending.
  • Trouble breathing. If the spine rotates enough, the rib cage can twist and tighten the space available for the lungs. Bone might push against the lungs and make breathing more difficult.
  • Cardiovascular problems. Similarly, if the rib cage twists enough, reduced spacing for the heart can hamper its ability to pump blood.
  • Pain. If curvature becomes severe enough, back muscles could become more prone to painful spasms. Local inflammation may develop around the strained muscles, which can also lead to pain. It is possible for the intervertebral discs and facet joints to start to degenerate due to higher loads.
  • Lower self-esteem. This symptom is commonly overlooked or minimized by outside observers, but it can be a significant factor for people who have a noticeable spinal deformity. Especially for adolescents who want to fit in with their friends, it can be stressful and depressing to look different, have clothes fit unevenly, or wear a noticeable back brace that may be uncomfortable or limit activity.

It is possible but highly unlikely for scoliosis to ever progress to the point of causing death. Typically, a person would have access to a surgical solution before that type of deformity could set in.

Possible Back Pain Symptoms

Many people who have idiopathic scoliosis report pain they feel is caused by the curve itself. There is conflicting research on that point, but the current trends in literature seem to point to more back pain reported in scoliosis patients compared to the general population. If scoliosis starts to cause a noticeable deformity or is at high risk of doing so, a doctor might prescribe a brace to prevent the curve from getting any worse. Typically, a brace is worn until the adolescent has reached full skeletal maturity.

Risk Factors for Scoliosis to Progress
In general, the following factors increase a person’s risk for a scoliosis curve to worsen:
  • Large lateral curve. In general, the larger the curve’s Cobb angle, the more likely it will progress. For example, if two adolescents with scoliosis have the same amount of skeletal growth remaining but one has a 20-degree curve and the other already has a 30-degree curve, the person with the larger curve is likely to experience more curve progression in the future.
  • Significant skeletal growth remaining. If scoliosis has been identified and the adolescent has some skeletal growth left, there is potential for the spine’s lateral curve(s) to grow and worsen. The more skeletal growth remaining, the greater the risk for curve progression.
  • Female sex. While boys and girls are about as likely to have mild scoliosis, girls are more than 7 times as likely to have their spinal curves progress to moderate or severe scoliosis and require treatment.
  • Curve in thoracic spine. A scoliosis curve located in the upper back is more likely to progress than a curve located lower in the back.

Once the risk factors for idiopathic scoliosis progression are assessed, treatment decisions can be made.

When Bracing Fails

Sometimes an idiopathic scoliosis curve continues to progress despite bracing. If this happens and the curve progresses past 40 or 50 degrees, surgery may be considered.

If scoliosis continues to get worse and bracing is either not feasible or not working for the patient, surgery may be considered.

3 Goals of Scoliosis Surgery
Scoliosis surgery typically has the following goals:
  1. Stop the curve’s progression. When scoliosis requires surgery, it is usually because the deformity is continuing to worsen. Therefore, scoliosis surgery should at the very least prevent the curve from getting any worse.
  2. Reduce the deformity. Depending on how much flexibility is still in the spine, scoliosis surgery can often de-rotate the abnormal spinal twisting in addition to correcting the lateral curve by about 50% to 70%. These changes can help the person stand up straighter and reduce the rib hump in the back.
  3. Maintain trunk balance. For any changes made to the spine’s positioning, the surgeon will also take into account overall trunk balance by trying to maintain as much of the spine’s natural front/back (lordosis/kyphosis) curvature while also keeping the hips and legs as even as possible.

In addition, any adjustment of the spine must also consider the possible effect on the spinal cord. The health of the spinal cord must be monitored throughout the surgery.

Degenerative Scoliosis

Degenerative scoliosis, also known as adult onset scoliosis, describes a side-to-side curvature of the spine caused by degeneration of the facet joints and intervertebral discs which are the moving parts of the spine. This degeneration and resulting spinal asymmetry can occur slowly over time as a person ages. This is a completely different cause of scoliosis from the standard adolescent onset scoliosis.

If degenerative scoliosis becomes symptomatic, pain can range from a dull back ache to excruciating sensations that shoot down the leg, commonly referred to as sciatica, and make walking difficult or impossible.

How Degenerative Scoliosis Develops

When healthy, facet joints are like hinges that help the spine bend smoothly, and intervertebral discs are like cushions that absorb shock between vertebral bones. Everyone experiences natural degeneration of these joints and discs due to aging—the same processes that cause osteoarthritis and degenerative disc disease—but for some people these degenerative processes are accelerated and/or cause more symptoms.

If degeneration is more pronounced on one side of the spine, degenerative scoliosis can result. The degenerative scoliosis curve, which is often located in the low back (lumbar spine), forms a slight "C" shape as the spine abnormally curves on one side or the other. Any sideways spinal curve of at least 10 degrees, as measured by the Cobb angle on spinal radiographs (X-rays), is considered scoliosis.

Pain From Degenerative Scoliosis
Painful symptoms of degenerative scoliosis are similar to lumbar osteoarthritis and/or lumbar degenerative disc disease because they are all part of the same degenerative process. Degenerative scoliosis can trigger the following types of discomfort:
  • Dull ache or stiffness in the mid to low back
  • Shock-like back pain that can radiate down the buttock and into the leg
  • Pins-and-needles tingling and/or numbness that can radiate down the buttock and into the leg
  • Sharp leg pain that develops while walking but subsides with rest It should be noted that spinal joint inflammation or nerve impingement is the main source of degenerative scoliosis pain, not the abnormal sideways curvature of the spine.
When Adult Scoliosis Means Degenerative Scoliosis
Sometimes there is confusion over the term “adult scoliosis” because it is commonly used to refer to the following two types of scoliosis:
  • Degenerative scoliosis. This type of scoliosis usually starts after age 50 as the spine continues to naturally degenerate, or wear out, due to aging. Technically, this is also known as adult onset scoliosis, but many people just shorten that and say adult scoliosis.
  • Idiopathic scoliosis. This type of scoliosis, which has no known cause, typically begins during adolescence, which is why it is often called adolescent idiopathic scoliosis or just adolescent scoliosis. While the condition can start during adolescence, it might not be caught or addressed until the curve becomes problematic for the person, which sometimes happens later in adulthood. Even though a case could technically be idiopathic scoliosis, it might be referred to as adult scoliosis if the person getting treatment is an adult.

The term adult scoliosis technically refers to any scoliosis in a skeletally mature patient. While knowing exactly what someone means when they say adult scoliosis is usually unimportant in casual conversation, understanding the patient’s exact type of adult scoliosis is critical for determining an effective treatment plan.

When Degenerative Scoliosis Is Serious

If degenerative scoliosis causes the spinal cord or a nerve root to become impinged, either through stenosis (narrowing of the spinal canal) or severe bending of the spine, nerve function could be jeopardized. Initially, this is often felt as a sharp or shock-like pain in the back that can radiate down the buttock and/or into the leg, or as tingling or numbness that can radiate down into the leg. This is commonly referred to as sciatica or sciatic pain. The medical term for this type of radiating pain is radiculopathy. While unlikely, it is possible for degenerative scoliosis to cause permanent leg weakness or problems with bladder/bowel control.

At Restore Medical Partners, we will complete a thorough review of your history and ask patients to describe the location, severity and type of pain, in addition to the history of the pain: when the patient started to feel it, and any activities or positions that make the pain better or worse. We will review your MRI or order imaging if you do not have imaging completed on your first visit. Then, we will explain to you what is causing your low back pain. Our goal is to prevent major surgery and use minor interventional techniques to relieve your pain and get you back to doing the things you enjoy. For pain radiating down the leg or into the buttock, we may recommend an epidural steroid injection. For axial or midline thoracic or lumbar pain we may recommend radio frequency ablation to treat the advanced arthritis of the facet joint that is commonly caused by scoliosis. Some patients may require a combination of techniques to completely resolve your pain symptoms.

REFERENCES:

http://www.spine-health.com/conditions/scoliosis

 
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