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About Spinal Defomity

Scoliosis - Definition

Scoliosis (from Greek: skolíÅ�sis meaning "crooked") is a medical condition in which a person's spine is curved from side to side, shaped like a "s", and may also be rotated. To adults it can be very painful. It is an abnormal lateral curvature of the spine. On an x-ray, the spine of an individual with a typical scoliosis may look more like an "S" or a "C" than a straight line.

Pediatric

  • Congenital (vertebral anomalies present at birth)
  • Malformation of spinal segments
  • Idiopathic
  • Infantile (<3 years of age)
  • Juvenile (3-10 years)
  • Adolescent (>10 years)

Adult

  • Idiopathic:former adolescent, now skeletally mature
  • Degenerative:usually >age 40

Terminology

The condition can be categorized based on convexity, or curvature of the spinal column, with relation to the central axis:

Dextroscoliosis is a scoliosis with the convexity on the right side.

Levoscoliosis is a scoliosis with the convexity on the left side.

Rotoscoliosis (may be used in conjunction with dextroscoliosis and levoscoliosis) refers to scoliosis on which the rotation of the vertebrae is particularly pronounced, or is used simply to draw attention to the fact that scoliosis is a complex 3 dimensional problem.

Cause

In the case of the most common form of scoliosis, adolescent idiopathic scoliosis, there is no clear causal agent. Various causes have been implicated, but none has consensus among scientists as the cause of scoliosis. Scoliosis is more often diagnosed in patients with cerebral palsy or spina bifida, although this form of scoliosis is different from that seen in children without these conditions. In some cases, scoliosis exists at birth due to a congenital vertebral anomaly. Occasionally, development of scoliosis during adolescence is due to an underlying anomaly such as a tethered spinal cord, but most often the cause is unknown or idiopathic.

Prevalence

Scoliotic curves greater than 10° affect 2-3% of the population. The prevalence of curves less than 20° is about equal in males and females. Curves greater than 20° affect about one in 2500 people. Curves convex to the right are more common than those to the left, and single or "C" curves are slightly more common than double or "S" curve patterns. Males are more likely to have infantile or juvenile scoliosis, but there is a high female predominance of adolescent scoliosis.

  • Frequency and prognosis (within the general population)
     â—�  < 10º occurs in 5.0%
     â—�  < 20º occurs in 0.5%
     â—�  < 30º occurs in 0.2%
     â—�  < 40º occurs in 0.1%
  • Most patients with scoliosis have small curves.
  • The greater the degree of curve, the more likely the progressio.

 

Symptoms

Pain is often common in adulthood, especially if the scoliosis is left untreated. Scoliosis surgery can stabilize a curvature and prevent worsening therefore improving one's quality of life. Pain can occur because the muscles try to conform to the way the spine is curving often resulting in muscle spasms. The symptoms of scoliosis can include:

  • Uneven musculature on one side of the spine
  • A rib "hump" and/or a prominent shoulder blade, caused by rotation of the ribcage in thoracic scoliosis
  • Uneven hip, rib cage, and shoulder levels
  • Asymmetric size or location of breast in females
  • Unequal distance between arms and body
  • Slow nerve action (in some cases)
  • Different heights of the shoulders

Associated Conditions

Scoliosis is sometimes associated with other conditions such as Ehler-Danlos Syndrome (hyperflexibility, 'floppy baby' syndrome, and other variants of the condition), Charcot-Marie-Tooth, kyphosis, cerebral palsy, spinal muscular atrophy, familial dysautonomia, CHARGE syndrome, Friedreich's ataxia, proteus syndrome, Spina bifida, Marfan's syndrome, neurofibromatosis, connective tissue disorders, congenital diaphragmatic hernia, and craniospinal axis disorders (e.g., syringomyelia, mitral valve prolapse, Arnold-Chiari malformation).

Investigation

Patients who initially present with scoliosis are examined to determine if there is an underlying cause of the deformity. The patient is asked to bend forward and bend 90 degrees at the waist (Adam's Bend Test).

  • Feet slightly apart
  • Palms together
  • Arms outstretched with straight elbows
  • Head out
  • Bend forward at waist
  • Place hands between legs at knee level

If a hump is noted, then scoliosis is a possibility and the patient should be sent for an x-ray to confirm the diagnosis. The patient's gait is assessed, and there is an exam for signs of other abnormalities.

It is usual when scoliosis is suspected to arrange for weight-bearing full-spine AP/coronal (frontback view) and lateral/sagittal (side view) xrays to be taken, to assess both the scoliosis curves and also the kyphosis and lordosis, as these can also be affected in individuals with scoliosis. Full-length standing spine X-rays are the standard method for evaluating the severity and progression of the scoliosis, and whether it is congenital or idiopathic in nature. In growing individuals, serial radiographs are obtained at 3-12 month intervals to follow curve progression.

The standard method for assessing the curvature quantitatively is measurement of the Cobb angle, which is the angle between two lines, drawn perpendicular to the upper endplate of the uppermost vertebrae involved and the lower endplate of the lowest vertebrae involved. For patients who have two curves, Cobb angles are followed for both curves.

Prognosis

The prognosis of scoliosis depends on the likelihood of progression. The general rules of progression are that larger curves carry a higher risk of progression than smaller curves, and that thoracic and double primary curves carry a higher risk of progression than single lumbar or thoracolumbar curves. In addition, patients who have not yet reached skeletal maturity have a higher likelihood of progression.

Management

The traditional medical management of scoliosis is complex and is determined by the severity of the curvature, skeletal maturity, which together help predict the likelihood of progression. The conventional options are, in order:

  • Observation
    • Curves <25° with follow-up radiographs at regular intervals. (usually 6 months)
  • Bracing
    • Curves that range from 25°-40° with flexibility
    • Curves from 40°-50°
    • Smaller curves 20°-25° that demonstrate rapid progression
  • Surgical intervention
    • Inflexible curves that exceed 40°
    • Any curve that exceeds 50°

Braces

Bracing is the usual treatment choice for adolescents who have a spinal curve between 25 to 40 degrees -- particularly if their bones are still maturing and if they have at least two years of growth remaining. The purpose of bracing is to halt progression of the curve. It may provide a temporary correction, but usually the curve will assume its original magnitude when bracing is eliminated.

Surgery

Surgery is usually indicated for curves that have a high likelihood of progression, curves that cause a significant amount of pain with some regularity, curves that would be cosmetically unacceptable as an adult, curves in patients with spina bifida and cerebral palsy that interfere with sitting and care, and curves that affect physiological functions such as breathing. Surgery for scoliosis is usually done by a surgeon who specializes in spine surgery. For various reasons it is usually impossible to completely straighten a scoliotic spine, but in most cases very good corrections are achieved.

Curve stiffness

  • “Stiff” (usually the major curve)
  • Determined with bending films (x-rays taken while the patient is bending to each side)
  • Stiffness of a curve will influence surgical strategy
  • The stiffness of a curve will influence surgical strategy because a stiff curve resists correction