Scoliosis is an abnormal sideways curvature of the spine that is usually painless but can result in chronic back pain if left untreated. Severe cases in young children can cause deformities, impair development and be life threatening.

In most people, the spine appears straight when viewed from behind. However, patients with scoliosis have one or more side-to-side spinal curvatures. Scoliosis is diagnosed when a patient has a spinal curvature greater than 10 degrees.

Scoliosis is most often found in patients between 10 and 14 years old, although it can also affect infants. In infancy, boys are at higher risk for scoliosis than girls, but girls are at much higher risk for developing scoliosis after age 3.

Most cases of scoliosis, especially those among adolescents, have an unknown origin. Certain birth defects and neuromuscular diseases also cause spinal problems that may result in scoliosis.

Scoliosis is an abnormal sideways curvature of the spine that is typically found in children and adolescents. In most cases, scoliosis is painless. However, it can become gradually more severe if left untreated. In young children, severe cases can cause deformities, impair development and be life threatening.

In most people, the spine appears straight when viewed from behind, with the lower back bending slightly inward and the upper back bowing a little outward. However, scoliosis patients have one or more side-to-side spinal curvatures that can appear in the shape of an “s” or a “c.” Though this curve is not always visible, it can be seen from behind in many patients. This is especially true in severe cases.

Scoliosis, which comes from the Greek word for “crooked,” is usually diagnosed when a patient has a spinal curvature greater than 10 degrees. It is most often found in patients between 10 and 14 years old, although it can be present in infancy. Infant boys are at higher risk for scoliosis than girls, but girls are at much higher risk for developing scoliosis after age 3.

The cause of about 80 percent to 85 percent of all scoliosis cases is unknown (idiopathic), according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases. The most common form of scoliosis is known as adolescent idiopathic scoliosis, which occurs when a patient is older than 10 years of age. Idiopathic scoliosis can also occur in children younger than age 10, but is very rare.

Scoliosis is also a common complication of other diseases such as muscular dystrophy and cerebral palsy. Scoliosis is less common in adults, but may occur as a result of neuromuscular diseases or degenerative diseases such as osteoporosis.

In most cases, scoliosis is painless and develops gradually. It often worsens during growth spurts in children and teens. Scoliosis patients who wear a back brace over an extended period of time can usually prevent further curvature of the spine.

Scoliosis can develop at any age, but most commonly occurs before adulthood in children and adolescents. The American Academy of Orthopaedic Surgeons classifies scoliosis into three types. These types include:

• Idiopathic. Scoliosis of unknown origin. About 80 percent of scoliosis cases are idiopathic. Idiopathic scoliosis is subdivided by age. Infantile (age 3 or younger), juvenile (ages 3 to 10) and adolescent (10 and older). Adolescent idiopathic scoliosis is the most common type.
  
  
• Congenital. Scoliosis that develops as a result of an abnormal formation of vertebrae that is present at birth. The vertebrae may be partially formed, asymmetrical or absent, eventually causing deformity.
  
  
• Neuromuscular. Scoliosis that is a complication of an underlying neuromuscular condition that affects the spinal column. Many of these conditions and diseases are also congenital (present at birth). These conditions include muscular dystrophy, spina bifida, cerebral palsy and neurofibromatosis. The associated scoliosis sometimes develops because the patients cannot walk and spend most of their time in wheelchairs.

The cause of most cases of scoliosis is unknown. Causes of the other types of scoliosis include underlying congenital or neuromuscular conditions. In many cases, progression of a disease eventually affects the spine and scoliosis develops.

Certain factors are known to increase the risk for developing scoliosis, as well as the risk that the disorder will become more severe. These include:

• Sex. Above age 3, girls are more likely to have scoliosis than boys.
  
  
• Age. Younger children with scoliosis are likely to have worsening conditions because they have more time to grow.
  
  
• Congenital condition. Children who are born with scoliosis may experience rapid worsening of the curve.
  
  
• Nature of the curve. Curves with greater angles are more likely to worsen. In addition, curves in the upper spine are more likely to worsen than those in the lower spine.

Environmental factors, such as poor posture or carrying heavy backpacks, are not causes of scoliosis.

Early diagnosis of scoliosis may prevent worsening of the condition. In attempting to diagnose scoliosis, the physician will compile a medical history and perform a physical examination. A medical history and exam that searches for other potential problems are especially important in identifying scoliosis. For example, congenital scoliosis is frequently associated with kidney problems. A physician who diagnoses congenital scoliosis may follow up by examining the kidneys. Conversely, a physician who finds a kidney problem in a young child will check the back for scoliosis. A physician may ask if there were difficulties during a pregnancy or at what age a child learned to walk.

In some cases, the signs of scoliosis are visibly obvious. The spine may be curved to one side or one shoulder blade may be noticeably higher than the other. The physician will also look to see if one side of the rib cage is higher than the other. Congenital scoliosis may be diagnosed in infancy when a vertebral defect is identified. When a neuromuscular disease such as muscular dystrophy or spina bifida is an underlying condition, physicians regularly check for the onset of scoliosis.

One of the first steps used to diagnose scoliosis is the Adams forward bending test. The patient bends forward from the waist with straight legs and the arms extended. The physician checks to see if the back is parallel to the floor, with neither side significantly higher than the other. This test is also used by some public schools that screen students for scoliosis.

When these physical tests indicate a potential problem, patients may have an x-ray of the spine. X-rays show spinal curvature and can also indicate the likelihood of progression in adolescents by whether or not they have finished growing. Other imaging tests, such as computed axial tomography (CAT scan) or magnetic resonance imaging (MRI) may also be used. A physician will consider the characteristics associated with the spinal curvature, including its shape, location on the spine, direction and angle. Physicians who detect mild curvature may not take x-rays, but only recheck the patient in a few months.

If the examination reveals significant curvature of the spine, the patient will be referred to an orthopedist, a physician who specializes in the diagnosis and treatment of conditions related to the skeletal system. An orthopedist uses a measure called a Cobb angle to diagnose the severity of a patient’s spinal curvature. The Cobb angle measures the curvature of the spine in degrees and recommends treatment options based on this reading. Cobb angle measurements are taken with a device called a scoliometer. The results of these measurements will determine the method of treatment used for idiopathic scoliosis:

The angle measurements used to treat other types of scoliosis may vary. Patients with neuromuscular scoliosis caused by muscular dystrophy cannot be treated with braces and may be advised to have surgery when their spinal curvature is less than 30 degrees. Muscular dystrophy patients progressively lose lung function and must have surgery while they still have enough lung capacity for the anesthesia and surgery.

Many cases of scoliosis are mild and require no treatment. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, about three to five out of every 1,000 children develop curves in the spine that are large enough to require treatment.

The primary treatment for scoliosis that requires therapy is the use of a back brace. These are either custom-made or made from a prefabricated mold. They are constructed of a lightweight material that usually is not visible under clothes.

Most patients wear a back brace for 18 to 20 hours each day. However, they likely will wear the brace less and less as their body gets closer to full adult size. Once the body has reached maturity, the patient no longer needs to wear the brace.

Back braces hold the spine in place and keep it from developing a greater curve than already exists. The brace is not designed to straighten the spine, but rather to help keep the spine from curving no more than an additional 5 to 10 degrees.

There are various types of back braces, and patients wear the brace that is appropriate given the severity of their curvature. Types of back braces include:

• Thoracolumbosacral orthosis (TLSO). This is a low-profile brace, which means that it comes up to a level under the arms and is comfortable to wear. It is worn by patients who have a curvature in the lower part of their back. The TLSO is worn under clothes and is also known by various other names, including the New York, Wilmington, Miami or Boston brace.
• Milwaukee brace. This brace has a neck ring. It can be used to correct any curve in the spine.
• Charleston brace. Also a low-profile brace, it bends the spine in an effort to straighten the curve and keep it from worsening. However, the brace puts the wearer’s body in an awkward position and can be worn only when the patient is sleeping.

If the scoliosis causes back pain, a physician may recommend treatments including medications such as analgesics or anti-inflammatories, modalities (physical agents) such as hydrotherapy or thermotherapy, or physical therapy.

In some cases, spinal surgery is required to correct a severe spinal curvature. Surgical options include:

• Posterior spinal fusion and instrumentation. The most common surgical procedure for scoliosis, it involves removing tiny pieces of bone from the patient’s pelvis (hipbone). These are then inserted between two or more vertebrae. Over time, the vertebrae and pieces of bone grow together, which provides stability and prevents further side-to-side curvature of the spine.  In a process known as instrumentation, the surgeon will also use metal rods, hooks and wire to keep the spine straight while the bits of bone fuse together with the vertebrae. This process normally takes about a year. In addition, it can help reduce the spinal curvature by as much as 50 percent.
• Anterior spinal fusion. In some situations, surgery may involve the front of the spine. The surgeon performs the procedure through the chest cavity.

Scoliosis surgery generally takes between three and six hours, and the patient may stay in the hospital for about a week. Within a month, most patients are back in school. Patients can usually return to regular activities within three or four months. After one year, a patient typically can return to contact sports.

Within a year, the bone fusion will be complete, the metal rods that have been placed in the back will not substantially limit movement and the patient should be able to bend and move normally.

For young children born with severe cases of scoliosis that deform the chest and restrict the lungs, one treatment option may be a vertical expandable prosthetic titanium rib (VEPTR). The Food and Drug Administration (FDA) approved this device in 2004 to treat thoracic insufficiency syndrome, a congenital condition in which severe deformities of the spine, ribs and chest hinder lung development and breathing. The syndrome can include severe scoliosis.

VEPTR involves the surgical implantation of an adjustable curved metal rod to ribs near the spine. The goal is to support the chest and allow normal development. A surgeon adjusts or replaces the device periodically as the child grows. Eventually it can be removed. According to the FDA, VEPTR should not be used for conditions other than chest wall instability and cannot be used in certain populations, such as infants younger than 6 months or children who are skeletally mature (about age 16 years for boys, 14 for girls).  

Some patients with scoliosis have used electrical stimulation of muscles or chiropractic manipulation to try to treat scoliosis. However, there is little evidence that these methods work. 

Exercise cannot prevent scoliosis, but it may improve the health and well-being of patients with scoliosis. Parents and patients should consult their child’s physician about the most appropriate exercise regimen.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients (or parents) may wish to ask their doctor the following questions about scoliosis:

1. How severe is my scoliosis?
   
   
2. Can my child’s scoliosis be corrected while he/she is still growing?
   
   
3. What is the likely cause of my scoliosis?
   
   
4. What will happen if I leave it untreated?
   
   
5. Should I wear a back brace? If so, which kind?
   
   
6. How many hours a day should my child wear a brace? What if he/she does not?
   
   
7. How long will I have to wear the back brace?
   
   
8. Will my scoliosis require surgery?
   
   
9. Am I a good candidate for a titanium rib implant to correct my severe scoliosis?
   
   
10. Do I have any restrictions on my activities because of my scoliosis?