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Scoliosis

Definition :
Scoliosis is an abnormal curvature of the spine. Although it usually doesn't cause pain, scoliosis or its treatment can sometimes wound a child's self-esteem. At worst, scoliosis can interfere with the function of organs.

The spine is an elegant structure — from the side it takes the form of an elongated S, the upper back bowing outward and the lower back curving slightly inward. Viewed from behind though, the spine should appear as a straight line from the base of the neck to the tailbone. If your child has scoliosis, the view from behind may reveal one or more abnormal curves. Most cases of scoliosis don't get worse, and periodic checkups may be all that your child needs. Children with more a severe curve that continues to increase, however, may require a brace or surgery.

Scoliosis runs in families, but doctors often don't know the cause. More girls get scoliosis than boys. Of every 1,000 children, three to five develop spinal curves that are severe enough to need treatment. Onset of scoliosis rarely occurs in adults. Sometimes, adult scoliosis is a worsening of a condition that began in childhood, but wasn't diagnosed or treated. In other cases, it may result from a degenerative joint condition in the spine.

Causes:
Doctors don't know what causes the most common type of scoliosis. When a cause can't be identified, the scoliosis is called idiopathic.

Sometimes, an underlying disease that affects the neuromuscular system, a leg-length discrepancy, or a birth defect may cause scoliosis. Scoliosis can also begin in a fetus during fetal development. Congenital scoliosis is a type of birth defect that affects the development of the vertebrae and often occurs with other congenital problems.

Scoliosis runs in families and may involve genetic (hereditary) factors. But researchers haven't identified the gene or genes that may cause scoliosis. Doctors also recognize that spinal cord and brainstem abnormalities play a role in some cases of scoliosis.

Scoliosis isn't caused by poor posture, diet, exercise, or the use of backpacks.

Risk Factor :
The cause of most scoliosis is unknown (idiopathic). Scoliosis is often first noticed just before and during adolescence, during a growth spurt. Growth is the biggest risk factor for worsening of an existing curve.

Although infantile idiopathic scoliosis is more common in boys, the other forms — congenital, juvenile (ages 3 to 10) and adolescent (older than 10) — are more common in girls.

Other than growth, risk factors that make it more likely that a scoliosis curve will get worse include :

  • Sex. Curves in girls are more likely to worsen than curves in boys.
  • Age. The younger the child when scoliosis appears, the greater the chance the curve will worsen.
  • Angle of the curve. The greater the curve angle, the higher the likelihood that it will worsen.
  • Location. Curves in the middle to lower spine are less likely to progress than those in the upper spine.
  • Spinal problems at birth. Children who are born with scoliosis (congenital scoliosis) may have rapid progression of the curve. Congenital scoliosis is thought of as a birth defect in the spine itself.

When to seek medical advice :
The development of scoliosis is usually gradual and almost always painless. A curve can develop without the parent or child knowing it. Early detection is important to start treatment that can prevent the curve from getting worse. For this reason, many schools provide screening for scoliosis.

Unfortunately, scoliosis usually becomes noticeable during the time that children become more self-conscious about their bodies (ages 10 to 16) so parents and others are even less likely to see the problem. Have your child examined if you notice any of the signs of scoliosis.

Although rare, scoliosis has the potential to lead to serious health problems, such as severe back pain, difficulty breathing, physical deformity, and even injury to the lungs and heart. Be sure to have your child see your doctor if you have a family history of scoliosis.

Symptoms:
Signs of scoliosis may include :
  • Uneven shoulders
  • One shoulder blade that appears more prominent than the other
  • Uneven waist
  • One hip higher than the other
  • Leaning to one side

As scoliosis curves get worse, the spine will also rotate or twist, in addition to curving side to side. This causes the ribs on one side of the body to stick out farther than on the other side. Severe scoliosis can cause back pain and difficulty breathing.

Diagnosis:
Your child's doctor may check for scoliosis at routine well-child visits. Many schools also have screening programs for scoliosis. If your child has a positive screen for scoliosis at school, see your doctor to confirm the condition.

Your doctor will ask about your child's personal and family medical history and may take these diagnostic steps :

  • Physical examination. Your doctor examines the spine as well as the shoulders, hips, legs and the rib cage for signs of scoliosis.
  • X-rays. Your doctor may do an initial X-ray to confirm the diagnosis and determine the curve angle. After that, periodic X-rays are done to monitor the curve and help make treatment decisions.

Doctors describe a child's scoliosis based on the shape of the curve, the location of the curve and other factors :

  • Shape. Curves develop side-to-side as a C- or S-shaped curve. The rotation of the spine causes the ribs and muscles near the spine to move out of normal alignment.
  • Location. The curve may occur in the upper back area (thoracic), the lower back area (lumbar) or in both areas (thoracolumbar).
  • Direction. The curve can bend to the left or to the right.
  • Angle. Doctors figure out the angle of the curve using the vertebra at the apex of the curve. A normal spine, viewed from the back, is at 0 degrees — a straight line. A curve that is horizontal, or parallel to the floor, is described as at 90 degrees. Scoliosis is defined as a spinal curvature of greater than 10 degrees. Most doctors can detect even mild curves during a physical exam. Your child's doctor can compare these measurements over time to see if the curve is getting worse.
  • Cause. About 80 percent of scoliosis cases are idiopathic, meaning the cause is unknown.

Complication :
In some cases, scoliosis may cause complications :

  • Lung and heart damage. In severe scoliosis — a curve greater than 70 degrees — the rib cage may press against the lungs and heart, making it more difficult to breathe and harder for the heart to pump. In very severe scoliosis — a curve greater than 100 degrees — damage to the lungs and the heart can occur. Any time breathing is compromised, the risk of lung infections and pneumonia increases.
  • Back problems. Adults who had scoliosis as children are more likely to have chronic back pain than do people in the general population. Also, people with untreated scoliosis may develop arthritis of the spine.
  • Body image. Your child might feel isolated and develop a poor body image from wearing a brace during childhood and teenage years. As a parent, try to keep your child involved in activities that build confidence. Encourage friendships and normalcy whenever possible. Help your child understand the benefits of the brace.

Treatment:
Most children with scoliosis have mild curves — less than 20 degrees — and probably won’t need a brace or surgery. Periodic checkups are needed, though, to be sure the curve doesn’t progress. Kids who are still growing need checkups every three to six months to see if there have been changes in the curvature of their spines.

The decision to treat scoliosis is not always clear. While there are guidelines for mild, moderate and severe curves, there is a range in which you may have a choice among treatments. Treatment decisions depend on your child's age, how much he or she is likely to grow and the degree and pattern of the curve.

Braces
If your child has a curve of 25 to 40 degrees and he or she is still growing, your doctor may recommend using a brace. Wearing a brace won't cure scoliosis, or even improve the curve, but it usually prevents further progression of the curve.

The brace may correct the curve as much as 50 percent during treatment. However, once the brace is discontinued, the spine often reverts back to its pretreatment curve. Once the skeleton is mature, or if the curve is too large, a brace doesn't help.

Children who wear braces can usually participate in most activities and have few restrictions. Kids can take off the brace to participate in sports or other physical activities.

Braces aren't useful for the treatment of congenital scoliosis.

Braces are of two main types :

  • Underarm or low-profile brace. This type of brace is made of modern plastic materials and is contoured to conform to the body. Also called a thoracolumbosacral orthosis (TLSO), this closer-fitting brace is less visible under the clothes as it fits under the arms and around the rib cage, lower back and hips. A custom brace is molded to place corrective forces on the curve. Other types of braces place pads in areas to stabilize the curve.
  • Milwaukee brace. This full-torso brace has a neck ring with rests for the chin and for the back of the head. The brace has a flat bar in the front and two flat bars in the back. A Milwaukee brace may be used for curves in the upper spine. This brace is not commonly used.

Other types of braces are being evaluated — some are worn only at night, others are made of material that is more flexible or use different mechanisms of pressure. However, there is currently no evidence available to support their effectiveness.

A brace isn't effective unless a child wears it as prescribed. A brace will feel uncomfortable and awkward at first. After a couple of weeks, however, wearing a brace begins to feel normal. Your child may need help building a positive attitude about wearing the brace and maintaining a healthy body image.

Surgery
If your child's curve is greater than 40 to 50 degrees, doctors typically recommend surgery. Scoliosis surgery involves techniques to fuse or join the vertebrae along the curve. Surgery is most commonly done through incisions in the back. For very rigid or severe curves, additional surgery may be needed through the front of the body.

"Fusion" means joining two pieces together. In the treatment of scoliosis, fusion involves connecting two or more vertebrae with pieces of bone taken from the pelvis. Eventually, the vertebrae and the pieces of bone fuse together preventing further progression of the curve. Doctors attach metal rods, hooks, screws or wires (instrumentation) to the spine to hold the vertebrae together during the months after surgery while the bones fuse. The instrumentation is left in the body, even after the bones have fused, to avoid another surgery. In addition to supporting the fused area, instrumentation also applies force to the spine to help correct the deformity and may straighten the curve by as much as 50 percent.

A drawback of spinal fusion is that it stops growth in that area of the spine. A child's final height is not drastically affected, however, because most growth occurs in the leg bones and in the unaffected part of the spine.

Scoliosis surgery is one of the longest and most complicated orthopedic surgical procedures performed on children. The operation takes several hours. Hospitalization can last several days, and activities are restricted for several months.

Because of this, the complication rate of scoliosis surgery is high (nearly 10 percent). Complications may include bleeding, infection, pain, nerve damage, arthritis and disk degeneration. Sometimes another surgery is needed if the first one fails to correct the problem.

Other therapies
Other treatments that have been studied for treatment of scoliosis include electrical stimulation of muscles, chiropractic manipulation and exercise. There's no evidence that any of these methods prevent spinal curvature from progressing. Although exercise alone can't stop scoliosis, exercise directed or prescribed by physical medicine professionals may have the benefit of improving overall health and well-being.

 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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