Scoliosis
Summary/Definition
Scoliosis refers to a condition where the spine curves abnormally to the side. In a normal spine, when viewed from the side, it forms a slight curve front to back, but in scoliosis, the spine bends abnormally to the left or right. This condition mainly occurs during adolescence, particularly during the growth period, and while the exact cause is unclear, genetic factors may play a role.
Scoliosis can arise from various causes, including genetic factors, neuromuscular abnormalities, hormonal imbalances, biochemical abnormalities, developmental abnormalities of the spine, abnormal fetal positioning, and proprioceptive dysfunction. However, a definitive cause has not been proven. It is believed that most cases of scoliosis result from a combination of these factors. In particular, idiopathic scoliosis accounts for 80-85% of all scoliosis cases, meaning cases where no clear cause has been identified. Idiopathic scoliosis is classified based on the age at which it is detected:
- Infantile (discovered before the age of 3)
- Juvenile (discovered between ages 3 and 10)
- Adolescent (discovered between ages 11 and 17, before skeletal maturity is complete)
- Adult (discovered after the age of 18, when skeletal growth has completed).
In addition to idiopathic scoliosis, there are other types, such as:
- Congenital scoliosis, caused by abnormal spinal development during fetal growth,
- Neuromuscular scoliosis, caused by neurological or muscular diseases such as poliomyelitis, cerebral palsy, or muscular dystrophy
- Syndromic scoliosis, associated with syndromes like neurofibromatosis and Marfan syndrome.
During adolescence, non-structural scoliosis often occurs due to poor posture or conditions like disc herniation. If this type of scoliosis is mistaken for structural scoliosis or not treated properly, it may cause problems after growth is completed.
In adults, scoliosis is categorized into two types:
- Persistent scoliosis, which continues from adolescence into adulthood.
- Degenerative scoliosis, which develops in adulthood due to degenerative changes. Degenerative scoliosis involves severe degenerative changes throughout the lumbar spine, and the main issue is not the spinal deformity itself but rather nerve root irritation and symptoms of spinal stenosis caused by these degenerative changes.
Symptoms
In the most common form of idiopathic scoliosis found in adolescents, there is generally no significant impairment of physical function, but visible deformities may be an issue. These deformities can be observed as asymmetry in shoulder height, scapula positioning, the gap between the body and the arms, rib protrusion, asymmetry in breast size, and the curve of the waist. However, if a scoliosis patient experiences severe lower back pain, other underlying conditions should be investigated.
If structural scoliosis is left untreated, it can worsen, leading to more severe deformities. In severe cases, this not only causes cosmetic concerns but can also impact the heart, lungs, and other internal organs, potentially shortening life expectancy.
Degenerative scoliosis, which develops in adulthood, is often accompanied by nerve root irritation symptoms and spinal stenosis, leading to lower back pain, radiating leg pain, difficulty walking, and intermittent claudication. This can significantly affect daily life, necessitating proper diagnosis and treatment.
Diagnostics
Scoliosis is often asymptomatic and may be discovered incidentally during chest X-rays or other imaging tests. For an accurate diagnosis, a thorough family and medical history is taken, followed by a neurological exam and physical examination. X-rays are the primary tool for diagnosing scoliosis, assessing its cause, determining treatment, and evaluating prognosis. Anteroposterior and lateral X-rays are taken to observe changes in the coronal and sagittal planes.
During the physical examination, the patient’s body alignment is first assessed. While the patient stands in a straight posture, the heights of both shoulders, the symmetry of the scapulae, and the heights of the waist and pelvis are measured. A vertical line drawn from the spinous process of the 7th cervical vertebra is checked to see if it aligns between the two gluteal folds, to assess the body’s balance.
One of the simplest physical tests is the forward bend test, where the patient stands with feet together and knees straight, then bends forward at the waist. The examiner observes from behind to check for any rib humps or lumbar humps, which appear in structural scoliosis but not in non-structural scoliosis. In non-structural scoliosis, the curvature disappears when the patient lies down. The forward bend test is easy for caregivers to perform at home as well.
X-rays are essential for evaluating the cause and prognosis of scoliosis. To assess the patient’s growth stage, additional images of the pelvis (anteroposterior) and hand may be taken. If scoliosis is confirmed, side-bending X-rays or traction films may be used to assess the flexibility of the curvature. The progression of scoliosis can be predicted by taking pelvic radiographs and examining the degree of ossification of the iliac crest apophysis, which is done in stages. The patient’s skeletal maturity is also assessed by checking secondary sexual characteristics, such as the Tanner staging system, which divides the development of pubic hair and breasts in females, and pubic hair and penis development in males into five stages. For girls, the onset of menstruation is an important marker, and for boys, the growth spurt typically begins about two years later than in girls.
If scoliosis is suspected, a thorough physical examination and X-rays are performed by an orthopedic specialist. In some cases, an MRI may be ordered to determine the underlying cause. This helps differentiate between structural and non-structural scoliosis, guiding the appropriate treatment plan.
Treatment and course of the disease
The treatment of idiopathic scoliosis is generally divided into three main categories: regular observation, bracing, and surgical treatment.
- Regular Observation: In cases where the curvature angle is less than 20 degrees and the spine is flexible, periodic evaluations including X-rays are conducted every 3 to 6 months to monitor the progression of the curve. During this period, no specific treatment is given, and the condition is closely monitored to observe any changes in the curvature.
- Bracing: For patients with a curvature angle between 20 to 40 degrees and at least two years of skeletal growth remaining, bracing is recommended. The brace must be worn for more than 22 hours a day until growth is complete, with exceptions only for bathing or physical education classes. The purpose of the brace is to allow spinal growth while maintaining the correction of the curve and preventing further progression until growth is completed. In addition to wearing a brace, exercises to strengthen the back and abdominal muscles can enhance the effectiveness of the treatment.
- Surgical Treatment: Surgery is considered when the curvature has significantly progressed, causing severe visible deformities, when conservative treatments are ineffective or fail to maintain correction, when the curve continues to progress in growing children despite the use of a brace, or when there is severe imbalance or pain in the torso. For adolescent scoliosis, surgery is typically required when the curvature angle exceeds 40 degrees, and for adult scoliosis, when it exceeds 50 degrees. The goal of surgery is to straighten the curved spine to maintain balance, relieve back pain, prevent degenerative arthritis, and avoid cardiopulmonary function impairment. The basic principle of the surgery is to correct and stabilize the curved spine using metal instrumentation and then perform a bone graft to achieve solid spinal fusion, preventing recurrence. Surgical methods include anterior fusion, posterior fusion, anterior-posterior fusion, and endoscopic correction techniques. The key goal is not the degree of correction but restoring balance to the torso.
