Scoliosis
Encyclopedia
Scoliosis is a medical condition in which a person's spine
is curved from side to side. Although it is a complex three-dimensional deformity, on an X-ray, viewed from the rear, the spine of an individual with scoliosis may look more like an "S" or a "C" than a straight line. Scoliosis is typically classified as either congenital (caused by vertebral anomalies present at birth), idiopathic
(cause unknown, subclassified as infantile, juvenile, adolescent, or adult, according to when onset occurred), or neuromuscular (having developed as a secondary symptom of another condition, such as spina bifida
, cerebral palsy
, spinal muscular atrophy
, or physical trauma
).
The signs of scoliosis can include:
, cerebral palsy
, spinal muscular atrophy
, muscular dystrophy
, familial dysautonomia
, CHARGE syndrome
, Friedreich's ataxia
, Fragile X syndrome
, proteus syndrome
, spina bifida
, Marfan's syndrome, neurofibromatosis
, connective tissue disorders, congenital diaphragmatic hernia
, hemihypertrophy
, and craniospinal axis disorders (e.g., syringomyelia
, mitral valve prolapse
, Arnold–Chiari malformation), and Amniotic Band Syndrome
(ABS).
Scoliosis associated with known syndromes such as Marfan's or Prader–Willi is often sub-classified as "syndromic scoliosis."
, approximately 15% are congenital and approximately 10% are secondary to a neuromuscular disease
.
Idiopathic scoliosis is a condition which lasts a lifetime, but it does not increase the risk of mortality.
In adolescent idiopathic scoliosis, there is no clear causal agent and it is generally believed to be multifactorial, although genetics are believed to play a role. Various causes have been implicated, but none of them have consensus among scientists as the cause of scoliosis, though the role of genetic factors in the development of this condition is widely accepted. Still, at least one gene, notably CHD7
, has been associated with the idiopathic form of scoliosis.
In some cases, scoliosis exists at birth due to a congenital vertebral anomaly
. Another cause in the past was when the father had ether in his blood stream when the baby was conceived. This would happen if the man was a busy anaesthetist using ether daily in hosptal operating rooms. It no longer happens because ether is not used for anaesthetic any more.
Scoliosis secondary to neuromuscular disease may develop during adolescence
, such as with tethered spinal cord syndrome
. Scoliosis often presents itself, or worsens, during the adolescence growth spurt and is more often diagnosed in females versus males.
During the exam, the patient is asked to remove his or her shirt and bend forward. This is known as the Adams Forward Bend Test and is often performed on school students. If a prominence is noted, then scoliosis is a possibility and the patient should be sent for an X-ray to confirm the diagnosis.
As an alternative, a scoliometer may be used to diagnose the condition.
The patient's gait is assessed
, and there is an exam for signs of other abnormalities (e.g., spina bifida
as evidenced by a dimple
, hairy patch, lipoma
, or hemangioma
).
A thorough neurological examination
is also performed.
It is usual, when scoliosis is suspected, to arrange for weight-bearing full-spine AP/coronal (front-back view) and lateral/sagittal (side view) X-rays to be taken. This is to assess the scoliosis curves and the kyphosis
and lordosis
, as these can also be affected in individuals with scoliosis. Full-length standing spine X-ray
s 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, and, in some instances, MRI investigation is warranted to look at the spinal cord.
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 with two curves, Cobb angles are followed for both curves. In some patients, lateral-bending X-rays are obtained to assess the flexibility of the curves or the primary and compensatory curves.
, which became available in 2009 and is still under investigation, attempts to gauge the likelihood of curve progression.
Through a genome-wide association study, geneticists have identified single nucleotide polymorphism markers in the DNA that are significantly associated with adolescent idiopathic scoliosis. Fifty-three genetic markers have been identified. Scoliosis has been described as a biomechanical deformity, the progression of which is dependent on asymmetric forces otherwise known as the Heuter-Volkmann law.
, which together help predict the likelihood of progression.
The conventional options are, in order:
A growing body of scientific research testifies to the efficacy of specialized treatment programs of physical therapy, which may include bracing. Debate in the scientific community about whether chiropractic and physical therapy can influence scoliotic curvature is partly complicated by the variety of methods proposed and employed: Some are supported by more research than others.
The Schroth method has proven effective at reversing abnormal scoliotic curvatures by an average of 10% in 4- to 6-week in-patient programs, and by 30% or more in an out-patient program over a period of a year. One study of nearly 200 adolescent Schroth patients found no curve progression three years following the in-patient program. Several studies have documented the Schroth method's efficacy in substantially reducing or eliminating pain, which tends to be a problem, in particular, for adults.
Small curvatures between 15 and 20° during growth may be treated with the physio-logic-program, curvatures between 20 and 30° during growth spurt with "3D-made-easy". This program has been tested in the environment of in-patient treatment as well. In curvatures exceeding 30°, a combination of the methods described together with the Schroth program may be helpful, and a specialized centre with trained and certified staff should be taken into account. Out-patient rehabilitation treatments today may reach the same outcome as in-patient programs. Out-patient programs may be successful when pattern-specific programs are provided. A certain intensity is necessary to allow the very best compliance with conservative treatment, and to acquire strategies for coping with scoliosis and with the conservative treatment.
The indications for treatment depend on degree of curvature, maturity of the patient, and the individual curve pattern. While evidence supporting such conservative, non-invasive treatments is weak, today conservative management of scoliosis can be regarded as being evidence-based; no substantial evidence has been found to support surgical intervention.
(OT) helps those having experienced an injury or illness regain or maintain the ability to participate in their everyday activities. For those with scoliosis, an occupational therapist can provide assistance through assessment, intervention, and ongoing evaluation of the condition, which will help them manage physical symptoms so they can participate in daily activities
, such as those in self-care, productivity, and leisure.
One intervention involves bracing. During the past several decades, a large variety of bracing devices have been developed for the treatment of scoliosis. Studies demonstrate that presenting force sideways across a joint by bracing prevents further curvature of the spine in idiopathic scoliosis, while other studies have also shown that braces can be used by individuals with scoliosis during physical activities.
Other interventions include postural strategies such as posture training in sitting, standing, and sleeping positions and in using positioning supports such as pillows, wedges, rolls, and corsets.
Adaptive and compensatory strategies are also employed to help facilitate individuals to returning daily activities.
by maintaining range of motion, preventing deformity of the rib cage, and reducing pain during activities such as bending or lifting.
Occupational therapists are often involved in the process of selection and fabrication of customized cushions. These individualized postural supports are used to maintain the current spinal curvature, or they can be adjusted to assist in the correction of the curvature. This type of treatment can help to maintain mobility for a wheelchair user by preventing the deformity of the rib cage and maintaining an active range of motion in the arms.
For other self-care activities (such as dressing, bathing, grooming, personal hygiene, and feeding), several strategies can be used as a part of occupational therapy treatment. Environmental adaptations for bathing could include a bath bench, grab bars installed in the shower area, or a handheld shower nozzle. For activities such as dressing and grooming, various assistive devices and strategies can be used to promote independence. An occupational therapist may recommend a long-handled reacher that can be used to assist independent dressing by allowing a person to avoid painful movements such as bending over; a long-handled shoehorn can be used for putting on and removing shoes. Problems with activities such as cutting meat and eating can be addressed by using specialized cutlery, kitchen utensils, or dishes.
has undergone dramatic changes over the past 20 years; the availability and quality of the technology has improved greatly. As a result of using assistive technology, functional changes may range from improvements in abilities, performance in daily activities, participation levels, and quality of life.
A common assistive technology intervention is specialized seating and postural control. It is widely known that, for children with poor postural control, a comfortable seating system that provides them with the support needed to maintain a sitting position can be essential for raising their overall level of well-being. A child's well-being in a productive sense involves the ability to participate in classroom and play activities. Specialized wheelchair seating has been identified as the most common prescription in the management of scoliosis in teenagers with muscular dystrophy
.
With comfortable wheelchair seating, teenagers are able to participate in classroom activities for longer periods with less fatigue. By tilting the seating position 20 degrees forward (toward the thighs), seating pressure is significantly redistributed, and, therefore, sitting is more comfortable. If an office worker with scoliosis can sit for longer periods, increased work output is likely to occur and could improve quality of life. Tall, forward sloping seats or front parts of seats, and when possible with tall desk with the opposite slope, can, in general, reduce pains and the need of bending significantly while working or studying, and that is particularly important with braced, fragile, or tender backs. And open hip angle can benefit the used lung volume and respiration.
For those not using a wheelchair, bracing may be used to treat scoliosis. Lifestyle changes are made to compensate for the proper use of spine braces.
Bracing is a common strategy recommended by an OT, in particular, for individuals engaging in sports and exercise. An OT is responsible for educating an individual on the advantages and disadvantages of different braces, proper ways to wear the brace, and the day-to-day care of the brace.
To help a person manage heart and lung symptoms such as shortness of breath or chest pains, an occupational therapist can teach the individual energy conservation techniques. This includes scheduling routine breaks during the activity, as suitable for the individual. For example, an occupational therapist can recommend that a swimmer take breaks between laps to conserve energy. Other energy conservation strategies knowing the benefits of scheduled rest and efficient breathing techniques. Adapting or modifying the exercise or sport is another way a person with scoliosis can do it. Adapting the activity may change the difficulty of the sport or exercise. For example, it might mean taking breaks throughout an exercise. If a person with scoliosis is unable to participate in a sport or exercise, an OT can help the individual explore other physical activities that are suitable to his/her interests and capabilities. An OT and the person with scoliosis can explore enjoyable and meaningful participation in the sport/exercise in another capacity, such as coaching or refereeing.
-like appliance that fits from armpits to hips and is custom-made from fiberglass or plastic. It is sometimes worn 22–23 hours a day, depending on the doctor's prescription, and applies pressure on the curves in the spine. The effectiveness of the brace depends not only on brace design and orthotist skill but on patient compliance and amount of wear per day.
The typical use of braces is for idiopathic curves that are not grave enough to warrant surgery, but they may also be used to prevent the progression of more severe curves in young children, to buy the child time to grow before performing surgery, which would prevent further growth in the part of the spine affected.
Bracing may cause emotional and physical discomfort. Physical activity may become more difficult because the brace presses against the stomach, making it difficult to breathe. Children may lose weight from the brace, due to increased pressure on the abdominal area.
The Scoliosis Research Society's recommendations for bracing include curves progressing to larger than 25 degrees, curves presenting between 30 and 45 degrees, Risser Sign
0, 1, or 2 (an X-ray measurement of a pelvic growth area), and less than 6 months from the onset of menses in girls.
Progressive scolioses exceeding 25° Cobb in the pubertal growth spurt should be treated with a pattern-specific brace like the Chêneau brace and its derivates with an average brace-wearing time of 16 hours/day (23 hours/day assures the best possible result).
The latest standard of brace construction is with CAD/CAM technology. With the help of this technology it has been possible to standardize the pattern-specific brace treatment. Severe mistakes in brace construction are largely ruled out with the help of these systems. This technology also eliminates the need to make a plaster cast for brace construction. The measurements can be taken any place and is simple (and not comparable to plastering). In Germany, available CAD/CAM braces are known such as the Regnier-Chêneau brace, the Rigo-System-Chêneau-brace (RSC brace), and the Gensingen Brace, according to Weiss. Many patients prefer the "Chêneau light" brace: It has the best in-brace corrections reported in international literature and is easier to wear than other braces in use today. However, this brace is not available for all curve patterns.
In infantile and sometimes juvenile scoliosis, a plaster jacket applied early may be used instead of a brace. It has been proven possible to permanently correct cases of infantile idiopathic scoliosis by applying a series of plaster casts (EDF: elongation, derotation, flexion) on a specialized frame under corrective traction, which helps to "mould" the infant's soft bones and work with their growth spurts. This method was pioneered by UK scoliosis specialist Min Mehta. Today, however, CAD/CAM braces are available for young children with a certain standard. Therefore, plaster jackets are now generally regarded as outdated.
and cerebral palsy
that interfere with sitting and care, and curves that affect physiological functions such as breathing.
Surgery for scoliosis is performed by a surgeon
specializing in spine surgery. For various reasons, it is usually impossible to completely straighten a scoliotic spine, but in most cases significant corrections are achieved.
There are two main types of surgery:
One or both of these surgical procedures may be needed. The surgery may be done in one or two stages and, on average, will take four to eight hours.
is the most widely performed surgery for scoliosis. In this procedure, bone (either harvested from elsewhere in the body autograft or from a donor allograft) is grafted
to the vertebrae so that when it heals they will form one solid bone mass and the vertebral column
becomes rigid. This prevents worsening of the curve, at the expense of some spinal movement. This can be performed from the anterior (front) aspect of the spine by entering the thoracic
or abdominal cavity
or, more commonly, performed from the back (posterior). A combination is used in more severe cases.
Spinal fusions were once performed without metal implants. In this technique, a cast
was applied after the surgery, usually under traction
to pull the curve as straight as possible and then hold it there while fusion took place. Casting left patients largely immobilized for a period of weeks to months, with significant burden on patient quality of life. Additionally, there was a relatively high risk of pseudarthrosis
(fusion failure) at one or more levels, and significant correction could not always be achieved.
In 1962, Paul Harrington
introduced a metal spinal system of instrumentation that assisted with straightening the spine, as well as holding it rigid while fusion took place. The original (now obsolete) Harrington rod operated on a ratchet system, attached by hooks to the spine at the top and bottom of the curvature that when cranked would distract, or straighten, the curve. The Harrington rod represented a major advance in the field, as it obviated the need for prolonged casting, allowing patients greater mobility in the post-operative period and significantly reducing the quality of life burden of fusion surgery. Additionally, as the first system to apply instrumentation directly to the spine, the Harrington rod was the precursor to most modern spinal instrumentation systems. A major shortcoming of the Harrington method was that it failed to produce a posture wherein the skull would be in proper alignment with the pelvis, and it did not address rotational deformity. As a result, unfused parts of the spine would try to compensate for this in the effort to stand up straight. As the person aged, there would be increased wear and tear, early-onset arthritis, disc degeneration, muscular stiffness, and pain with eventual reliance on painkillers, further surgery, inability to work full-time, and disability. "Flatback" became the medical name for a related complication, especially for those who had lumbar scoliosis.
Modern spinal systems are attempting to address sagittal imbalance and rotational defects unresolved by the Harrington rod system. They involve a combination of rods, screws, hooks, and wires fixing the spine, and can apply stronger, safer forces to the spine than the Harrington rod. This technique is known as the Cotrel-Dubousset instrumentation
, currently the most common technique for the procedure.
In general, modern spinal fusions have good outcomes with high degrees of correction and low rates of failure and infection. Patients with fused spines and permanent implants tend to have normal lives with unrestricted activities when they are younger; it remains to be seen whether those that have been treated with the newer surgical techniques develop problems as they age.
Pedicle screw-only posterior spinal fusion
may improve major curve correction at 2 years among patients with adolescent idiopathic scoliosis (AIS) as compared to hybrid instrumentation (proximal hooks with distal pedicle screws) (65% versus 46%) according to a retrospective matched cohort study
. The prospective cohorts were matched to the retrospective cohorts according to patient age, fusion levels, Lenke curve type, and operative method. The two groups were not significantly different in regard to age, Lenke AIS curve type, or Riser grade. The numbers of fused vertebrae were significantly different (11.7±1.6 for pedicle screw versus 13.0±1.2 for hybrid group). This study's results may be biased due to the pedicle screw group's being analyzed prospectively versus retrospective analysis of the hybrid instrumentation group.
Thoracoplasty is the removal (or resection) of typically four to six segments of adjacent ribs that protrude. Each segment is one to two inches long. The surgeon decides which ribs to resect based on either their prominence or their likelihood to be realigned by correction of the curvature alone. The ribs grow back, and will grow back straight.
Thoracoplasty has risks, such as increased pain in the rib area during recovery or reduced pulmonary function (10–15 percent is typical) following surgery. This impairment can last anywhere from a few months to two years. Because thoracoplasty may lengthen the duration of surgery, patients may also lose more blood or develop complications from the prolonged anesthesia. A more significant, though far less common, risk is that the surgeon will inadvertently puncture the pleura, a protective coating over the lungs. This could cause blood or air to drain into the chest cavity, conditions called a haemothorax or pneumothorax, respectively.
In case one decides to undergo surgery, a specialized center should be preferred.
Although these methods are novel and promising, these treatments are suitable only for growing patients. Spinal fusion remains the "gold standard" of surgical treatment for scoliosis.
A scoliosis spinal columns curve of 10° or less affects 1.5% to 3% of individuals. The prevalence of curves less than 20° is about equal in males and females. It is most common during late childhood, in particular, in girls.
is a professional organization of physicians and allied health personnel. Their primary focus is on providing continuing medical education for healthcare professionals and on funding/supporting research in spinal deformities. Founded in 1966, the SRS has gained recognition as one of the world's premier spine societies. Strict membership criteria ensure that the individual Fellows support that commitment. Current membership includes over 1,000 of the world's leading spine surgeons as well as some researchers, physician assistants, and orthotists who are involved in research and treatment of spinal deformities. The purpose of the Scoliosis Research Society is to foster the optimal care of all patients with spinal deformities.
Skolyoz Destek Grubu also advocates, both independently and in collaboration with organisations with similar objectives.
Vertebral column
In human anatomy, the vertebral column is a column usually consisting of 24 articulating vertebrae, and 9 fused vertebrae in the sacrum and the coccyx. It is situated in the dorsal aspect of the torso, separated by intervertebral discs...
is curved from side to side. Although it is a complex three-dimensional deformity, on an X-ray, viewed from the rear, the spine of an individual with scoliosis may look more like an "S" or a "C" than a straight line. Scoliosis is typically classified as either congenital (caused by vertebral anomalies present at birth), idiopathic
Idiopathic
Idiopathic is an adjective used primarily in medicine meaning arising spontaneously or from an obscure or unknown cause. From Greek ἴδιος, idios + πάθος, pathos , it means approximately "a disease of its own kind". It is technically a term from nosology, the classification of disease...
(cause unknown, subclassified as infantile, juvenile, adolescent, or adult, according to when onset occurred), or neuromuscular (having developed as a secondary symptom of another condition, such as spina bifida
Spina bifida
Spina bifida is a developmental congenital disorder caused by the incomplete closing of the embryonic neural tube. Some vertebrae overlying the spinal cord are not fully formed and remain unfused and open. If the opening is large enough, this allows a portion of the spinal cord to protrude through...
, cerebral palsy
Cerebral palsy
Cerebral palsy is an umbrella term encompassing a group of non-progressive, non-contagious motor conditions that cause physical disability in human development, chiefly in the various areas of body movement....
, spinal muscular atrophy
Spinal muscular atrophy
Spinal Muscular Atrophy is a neuromuscular disease characterized by degeneration of motor neurons, resulting in progressive muscular atrophy and weakness. The clinical spectrum of SMA ranges from early infant death to normal adult life with only mild weakness...
, or physical trauma
Physical trauma
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
).
Signs and symptoms
Patients having reached skeletal maturity are less likely to have a worsening case. Some severe cases of scoliosis can lead to diminishing lung capacity, putting pressure on the heart, and restricting physical activities.The signs of scoliosis can include:
- Uneven musculature on one side of the spine
- A ribRibIn vertebrate anatomy, ribs are the long curved bones which form the rib cage. In most vertebrates, ribs surround the chest, enabling the lungs to expand and thus facilitate breathing by expanding the chest cavity. They serve to protect the lungs, heart, and other internal organs of the thorax...
prominence and/or a prominent shoulder blade, caused by rotation of the ribcage in thoracic scoliosis - Uneven hips/leg lengths
- Slow nerve action (in some cases)
Associated conditions
Scoliosis is sometimes associated with other conditions such as Ehlers–Danlos syndrome (hyperflexibility, "floppy baby" syndrome, and other variants of the condition), Charcot–Marie–Tooth disease, Prader–Willi syndrome, kyphosisKyphosis
Kyphosis , also called roundback or Kelso's hunchback, is a condition of over-curvature of the thoracic vertebrae...
, cerebral palsy
Cerebral palsy
Cerebral palsy is an umbrella term encompassing a group of non-progressive, non-contagious motor conditions that cause physical disability in human development, chiefly in the various areas of body movement....
, spinal muscular atrophy
Spinal muscular atrophy
Spinal Muscular Atrophy is a neuromuscular disease characterized by degeneration of motor neurons, resulting in progressive muscular atrophy and weakness. The clinical spectrum of SMA ranges from early infant death to normal adult life with only mild weakness...
, muscular dystrophy
Muscular dystrophy
Muscular dystrophy is a group of muscle diseases that weaken the musculoskeletal system and hamper locomotion. Muscular dystrophies are characterized by progressive skeletal muscle weakness, defects in muscle proteins, and the death of muscle cells and tissue.In the 1860s, descriptions of boys who...
, familial dysautonomia
Familial dysautonomia
Familial dysautonomia is a disorder of the autonomic nervous system which affects the development and survival of sensory, sympathetic and some parasympathetic neurons in the autonomic and sensory nervous system resulting in variable symptoms including: insensitivity to pain, inability to produce...
, CHARGE syndrome
CHARGE syndrome
CHARGE syndrome , is a syndrome caused by a genetic disorder. It was first described in 1979.In 1981, the term "CHARGE" came into use as an acronym for the set of unusual congenital features seen in a number of newborn children...
, Friedreich's ataxia
Friedreich's ataxia
Friedreich's ataxia is an inherited disease that causes progressive damage to the nervous system, resulting in symptoms ranging from gait disturbance to speech problems; it can also lead to heart disease and diabetes....
, Fragile X syndrome
Fragile X syndrome
Fragile X syndrome , Martin–Bell syndrome, or Escalante's syndrome , is a genetic syndrome that is the most commonly known single-gene cause of autism and the most common inherited cause of intellectual disability...
, proteus syndrome
Proteus syndrome
Proteus syndrome, also known as Wiedemann's syndrome , is a congenital disorder that causes skin overgrowth and atypical bone development, often accompanied by tumors over half the body....
, spina bifida
Spina bifida
Spina bifida is a developmental congenital disorder caused by the incomplete closing of the embryonic neural tube. Some vertebrae overlying the spinal cord are not fully formed and remain unfused and open. If the opening is large enough, this allows a portion of the spinal cord to protrude through...
, Marfan's syndrome, neurofibromatosis
Neurofibromatosis
Neurofibromatosis is a genetically-inherited disorder in which the nerve tissue grows tumors that may be benign or may cause serious damage by compressing nerves and other tissues...
, connective tissue disorders, congenital diaphragmatic hernia
Congenital diaphragmatic hernia
Congenital diaphragmatic hernia is a congenital malformation of the diaphragm. The most common type of CDH is a Bochdalek hernia; other types include Morgagni's hernia, diaphragm eventration and central tendon defects of the diaphragm...
, hemihypertrophy
Hemihypertrophy
Hemihypertrophy is a condition in which one side of the body or a part of one side is larger than the other. Children with hemihypertrophy have an increased risk of developing certain types of cancer, including Wilms tumor and liver cancer...
, and craniospinal axis disorders (e.g., syringomyelia
Syringomyelia
Syringomyelia is a generic term referring to a disorder in which a cyst or cavity forms within the spinal cord. This cyst, called a syrinx, can expand and elongate over time, destroying the spinal cord. The damage may result in pain, paralysis, weakness, and stiffness in the back, shoulders, and...
, mitral valve prolapse
Mitral valve prolapse
Mitral valve prolapse is a valvular heart disease characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole. There are various types of MVP, broadly classified as classic and nonclassic. In its nonclassic form, MVP carries a low risk of...
, Arnold–Chiari malformation), and Amniotic Band Syndrome
Amniotic band syndrome
Amniotic band syndrome is a congenital disorder caused by entrapment of fetal parts in fibrous amniotic bands while in utero.-Epidemiology:Amniotic banding affects approximately 1 in 1,200 live births...
(ABS).
Scoliosis associated with known syndromes such as Marfan's or Prader–Willi is often sub-classified as "syndromic scoliosis."
Cause
It has been estimated that approximately 65% of scoliosis cases are idiopathicIdiopathic
Idiopathic is an adjective used primarily in medicine meaning arising spontaneously or from an obscure or unknown cause. From Greek ἴδιος, idios + πάθος, pathos , it means approximately "a disease of its own kind". It is technically a term from nosology, the classification of disease...
, approximately 15% are congenital and approximately 10% are secondary to a neuromuscular disease
Neuromuscular disease
Neuromuscular disease is a very broad term that encompasses many diseases and ailments that either directly, via intrinsic muscle pathology, or indirectly, via nerve pathology, impair the functioning of the muscles....
.
Idiopathic scoliosis is a condition which lasts a lifetime, but it does not increase the risk of mortality.
In adolescent idiopathic scoliosis, there is no clear causal agent and it is generally believed to be multifactorial, although genetics are believed to play a role. Various causes have been implicated, but none of them have consensus among scientists as the cause of scoliosis, though the role of genetic factors in the development of this condition is widely accepted. Still, at least one gene, notably CHD7
CHD7
Chromodomain-helicase-DNA-binding protein 7 also known as ATP-dependent helicase CHD7 is an enzyme that in humans is encoded by the CHD7 gene....
, has been associated with the idiopathic form of scoliosis.
In some cases, scoliosis exists at birth due to a congenital vertebral anomaly
Congenital vertebral anomaly
Congenital vertebral anomalies are a collection of malformations of the spine in animals. Most are not clinically significant, but they can cause compression of the spinal cord by deforming the vertebral canal or causing instability. This condition occurs in the womb...
. Another cause in the past was when the father had ether in his blood stream when the baby was conceived. This would happen if the man was a busy anaesthetist using ether daily in hosptal operating rooms. It no longer happens because ether is not used for anaesthetic any more.
Scoliosis secondary to neuromuscular disease may develop during adolescence
Adolescence
Adolescence is a transitional stage of physical and mental human development generally occurring between puberty and legal adulthood , but largely characterized as beginning and ending with the teenage stage...
, such as with tethered spinal cord syndrome
Tethered spinal cord syndrome
Tethered spinal cord syndrome or occult spinal dysraphism sequence refers to a group of neurological disorders related to malformations of the spinal cord. The various forms include: tight filum terminale, lipomeningomyelocele, split cord malformations, dermal sinus tracts, dermoids, and cystoceles...
. Scoliosis often presents itself, or worsens, during the adolescence growth spurt and is more often diagnosed in females versus males.
Diagnosis
Patients who initially present with scoliosis are examined to determine whether there is an underlying cause of the deformity. During a physical examination, the following is assessed:- SkinSkin-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...
for café au lait spotCafé au lait spotCafé au lait spots or Café au lait macules are pigmented birthmarks. The name café au lait is French for "milky coffee" and refers to their light-brown color...
s, indicative of neurofibromatosisNeurofibromatosisNeurofibromatosis is a genetically-inherited disorder in which the nerve tissue grows tumors that may be benign or may cause serious damage by compressing nerves and other tissues... - The feet for cavovarus deformityPes cavusHigh arch is a human foot type in which the sole of the foot is distinctly hollow when bearing weight. That is, there is a fixed plantar flexion of the foot...
- Abdominal reflexes
- Muscle tone for spasticitySpasticitySpasticity is a feature of altered skeletal muscle performance in muscle tone involving hypertonia, which is also referred to as an unusual "tightness" of muscles...
During the exam, the patient is asked to remove his or her shirt and bend forward. This is known as the Adams Forward Bend Test and is often performed on school students. If a prominence is noted, then scoliosis is a possibility and the patient should be sent for an X-ray to confirm the diagnosis.
As an alternative, a scoliometer may be used to diagnose the condition.
The patient's gait is assessed
Gait analysis
Gait analysis is the systematic study of animal locomotion, more specific as a study of human motion, using the eye and the brain of observers, augmented by instrumentation for measuring body movements, body mechanics, and the activity of the muscles. Gait analysis is used to assess, plan, and...
, and there is an exam for signs of other abnormalities (e.g., spina bifida
Spina bifida
Spina bifida is a developmental congenital disorder caused by the incomplete closing of the embryonic neural tube. Some vertebrae overlying the spinal cord are not fully formed and remain unfused and open. If the opening is large enough, this allows a portion of the spinal cord to protrude through...
as evidenced by a dimple
Dimple
A dimple is a small natural indentation in the flesh on a part of the human body, most notably in the cheek or on the chin.-More about dimples:...
, hairy patch, lipoma
Lipoma
A lipoma is a benign tumor composed of adipose tissue. It is the most common form of soft tissue tumor. Lipomas are soft to the touch, usually movable, and are generally painless. Many lipomas are small but can enlarge to sizes greater than six centimeters. Lipomas are commonly found in adults...
, or hemangioma
Hemangioma
A hemangioma of infancy is a benign self-involuting tumor of endothelial cells, the cells that line blood vessels. It usually appears during the first weeks of life and sometimes resolves by age 10. In more severe case hemangioma may have permanency, if not treated by a physician...
).
A thorough neurological examination
Neurological examination
A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired...
is also performed.
It is usual, when scoliosis is suspected, to arrange for weight-bearing full-spine AP/coronal (front-back view) and lateral/sagittal (side view) X-rays to be taken. This is to assess the scoliosis curves and the kyphosis
Kyphosis
Kyphosis , also called roundback or Kelso's hunchback, is a condition of over-curvature of the thoracic vertebrae...
and lordosis
Lordosis
Lordosis is a medical term used to describe an inward curvature of a portion of the lumbar and cervical vertebral column. Two segments of the vertebral column, namely cervical and lumbar, are normally lordotic, that is, they are set in a curve that has its convexity anteriorly and concavity...
, as these can also be affected in individuals with scoliosis. Full-length standing spine X-ray
X-ray
X-radiation is a form of electromagnetic radiation. X-rays have a wavelength in the range of 0.01 to 10 nanometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz and energies in the range 120 eV to 120 keV. They are shorter in wavelength than UV rays and longer than gamma...
s 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, and, in some instances, MRI investigation is warranted to look at the spinal cord.
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 with two curves, Cobb angles are followed for both curves. In some patients, lateral-bending X-rays are obtained to assess the flexibility of the curves or the primary and compensatory curves.
Genetic testing
Genetic testing for AISGenetic testing for AIS
AIS genetic testing is the process of analyzing the DNA of a patient who has been diagnosed with Adolescent Idiopathic Scoliosis to determine his or her likelihood of progression to a severe spinal curve....
, which became available in 2009 and is still under investigation, attempts to gauge the likelihood of curve progression.
Through a genome-wide association study, geneticists have identified single nucleotide polymorphism markers in the DNA that are significantly associated with adolescent idiopathic scoliosis. Fifty-three genetic markers have been identified. Scoliosis has been described as a biomechanical deformity, the progression of which is dependent on asymmetric forces otherwise known as the Heuter-Volkmann law.
Management
The traditional medical management of scoliosis is complex and is determined by the severity of the curvature and skeletal maturityBone age
Bone age is a way of describing the degree of maturation of child's bones. As a person grows from fetal life through childhood, puberty, and finishes growth as a young adult, the bones of the skeleton change in size and shape. These changes can be seen by x-ray. The "bone age" of a child is the...
, which together help predict the likelihood of progression.
The conventional options are, in order:
- Observation
- Physical Therapy
- Occupational Therapy
- Chiropractic or Osteopathic Therapy
- Casting (EDF)
- BracingBack braceA back brace is a device designed to limit the motion of the spine in cases of fracture or in post-operative fusions. Limiting the motion of the spine enhances the healing process and minimizes the patient's discomfort.Common back braces include:...
- Surgery
A growing body of scientific research testifies to the efficacy of specialized treatment programs of physical therapy, which may include bracing. Debate in the scientific community about whether chiropractic and physical therapy can influence scoliotic curvature is partly complicated by the variety of methods proposed and employed: Some are supported by more research than others.
Physiotherapy
The Schroth method is a noninvasive, physiotherapeutic treatment, which has been used successfully in Europe since the 1920s. Originally developed in Germany by scoliosis sufferer Katharina Schroth, this method is now taught to scoliosis patients in clinics specifically devoted to Schroth therapy in Germany, Spain, England, and North America. The method is based upon the concept of scoliosis as resulting from a complex of muscular asymmetries (especially strength imbalances in the back) that can be at least partially corrected by targeted exercises.The Schroth method has proven effective at reversing abnormal scoliotic curvatures by an average of 10% in 4- to 6-week in-patient programs, and by 30% or more in an out-patient program over a period of a year. One study of nearly 200 adolescent Schroth patients found no curve progression three years following the in-patient program. Several studies have documented the Schroth method's efficacy in substantially reducing or eliminating pain, which tends to be a problem, in particular, for adults.
Small curvatures between 15 and 20° during growth may be treated with the physio-logic-program, curvatures between 20 and 30° during growth spurt with "3D-made-easy". This program has been tested in the environment of in-patient treatment as well. In curvatures exceeding 30°, a combination of the methods described together with the Schroth program may be helpful, and a specialized centre with trained and certified staff should be taken into account. Out-patient rehabilitation treatments today may reach the same outcome as in-patient programs. Out-patient programs may be successful when pattern-specific programs are provided. A certain intensity is necessary to allow the very best compliance with conservative treatment, and to acquire strategies for coping with scoliosis and with the conservative treatment.
The indications for treatment depend on degree of curvature, maturity of the patient, and the individual curve pattern. While evidence supporting such conservative, non-invasive treatments is weak, today conservative management of scoliosis can be regarded as being evidence-based; no substantial evidence has been found to support surgical intervention.
Occupational Therapy
An occupational therapistOccupational therapist
An occupational therapist is trained in the practice of occupational therapy. The role of an occupational therapist is to work with a client to help them achieve a fulfilled and satisfied state in life through the use of "purposeful activity or interventions designed to achieve functional...
(OT) helps those having experienced an injury or illness regain or maintain the ability to participate in their everyday activities. For those with scoliosis, an occupational therapist can provide assistance through assessment, intervention, and ongoing evaluation of the condition, which will help them manage physical symptoms so they can participate in daily activities
Activities of daily living
Activities of Daily Living is a term used in healthcare to refer to daily self-care activities within an individual's place of residence, in outdoor environments, or both...
, such as those in self-care, productivity, and leisure.
One intervention involves bracing. During the past several decades, a large variety of bracing devices have been developed for the treatment of scoliosis. Studies demonstrate that presenting force sideways across a joint by bracing prevents further curvature of the spine in idiopathic scoliosis, while other studies have also shown that braces can be used by individuals with scoliosis during physical activities.
Other interventions include postural strategies such as posture training in sitting, standing, and sleeping positions and in using positioning supports such as pillows, wedges, rolls, and corsets.
Adaptive and compensatory strategies are also employed to help facilitate individuals to returning daily activities.
Self-care
Disability caused by scoliosis, as well as physical limitations during recovery from treatment related surgery, often affects an individual’s ability to perform self-care activities. One of the first treatments of scoliosis is the attempt to prevent further curvature of the spine. Depending on the size of the curvature, this is typically done in one of three ways: bracing, surgery, or postural positioning through customized cushioning. Stopping the progression of the scoliosis can prevent the loss of function in many activities of daily livingActivities of daily living
Activities of Daily Living is a term used in healthcare to refer to daily self-care activities within an individual's place of residence, in outdoor environments, or both...
by maintaining range of motion, preventing deformity of the rib cage, and reducing pain during activities such as bending or lifting.
Occupational therapists are often involved in the process of selection and fabrication of customized cushions. These individualized postural supports are used to maintain the current spinal curvature, or they can be adjusted to assist in the correction of the curvature. This type of treatment can help to maintain mobility for a wheelchair user by preventing the deformity of the rib cage and maintaining an active range of motion in the arms.
For other self-care activities (such as dressing, bathing, grooming, personal hygiene, and feeding), several strategies can be used as a part of occupational therapy treatment. Environmental adaptations for bathing could include a bath bench, grab bars installed in the shower area, or a handheld shower nozzle. For activities such as dressing and grooming, various assistive devices and strategies can be used to promote independence. An occupational therapist may recommend a long-handled reacher that can be used to assist independent dressing by allowing a person to avoid painful movements such as bending over; a long-handled shoehorn can be used for putting on and removing shoes. Problems with activities such as cutting meat and eating can be addressed by using specialized cutlery, kitchen utensils, or dishes.
Productivity
Productive activities include paid or unpaid work, household chores, school, work, and play. Recent studies in healthcare have led to the development of a variety of treatments to assist in the management of scoliosis thereby maximizing productivity for people of all ages. Assistive technologyAssistive technology
Assistive technology or adaptive technology is an umbrella term that includes assistive, adaptive, and rehabilitative devices for people with disabilities and also includes the process used in selecting, locating, and using them...
has undergone dramatic changes over the past 20 years; the availability and quality of the technology has improved greatly. As a result of using assistive technology, functional changes may range from improvements in abilities, performance in daily activities, participation levels, and quality of life.
A common assistive technology intervention is specialized seating and postural control. It is widely known that, for children with poor postural control, a comfortable seating system that provides them with the support needed to maintain a sitting position can be essential for raising their overall level of well-being. A child's well-being in a productive sense involves the ability to participate in classroom and play activities. Specialized wheelchair seating has been identified as the most common prescription in the management of scoliosis in teenagers with muscular dystrophy
Muscular dystrophy
Muscular dystrophy is a group of muscle diseases that weaken the musculoskeletal system and hamper locomotion. Muscular dystrophies are characterized by progressive skeletal muscle weakness, defects in muscle proteins, and the death of muscle cells and tissue.In the 1860s, descriptions of boys who...
.
With comfortable wheelchair seating, teenagers are able to participate in classroom activities for longer periods with less fatigue. By tilting the seating position 20 degrees forward (toward the thighs), seating pressure is significantly redistributed, and, therefore, sitting is more comfortable. If an office worker with scoliosis can sit for longer periods, increased work output is likely to occur and could improve quality of life. Tall, forward sloping seats or front parts of seats, and when possible with tall desk with the opposite slope, can, in general, reduce pains and the need of bending significantly while working or studying, and that is particularly important with braced, fragile, or tender backs. And open hip angle can benefit the used lung volume and respiration.
For those not using a wheelchair, bracing may be used to treat scoliosis. Lifestyle changes are made to compensate for the proper use of spine braces.
Leisure
There are many physical symptoms that can prevent a person from engaging in physical leisurely activities, such as chest pains, back pains, shortness of breath, and limited spinal movement. The OT's role is to help individuals with scoliosis manage these physical symptoms so they can participate in physical leisure activities.Bracing is a common strategy recommended by an OT, in particular, for individuals engaging in sports and exercise. An OT is responsible for educating an individual on the advantages and disadvantages of different braces, proper ways to wear the brace, and the day-to-day care of the brace.
To help a person manage heart and lung symptoms such as shortness of breath or chest pains, an occupational therapist can teach the individual energy conservation techniques. This includes scheduling routine breaks during the activity, as suitable for the individual. For example, an occupational therapist can recommend that a swimmer take breaks between laps to conserve energy. Other energy conservation strategies knowing the benefits of scheduled rest and efficient breathing techniques. Adapting or modifying the exercise or sport is another way a person with scoliosis can do it. Adapting the activity may change the difficulty of the sport or exercise. For example, it might mean taking breaks throughout an exercise. If a person with scoliosis is unable to participate in a sport or exercise, an OT can help the individual explore other physical activities that are suitable to his/her interests and capabilities. An OT and the person with scoliosis can explore enjoyable and meaningful participation in the sport/exercise in another capacity, such as coaching or refereeing.
Bracing
Bracing is normally done when the patient has bone growth remaining and is, in general, implemented to hold the curve and prevent it from progressing to the point where surgery is recommended. Braces are sometimes prescribed for adults to relieve pain related to scoliosis. Bracing involves fitting the patient with a device that covers the torso; in some cases, it extends to the neck. The most commonly used brace is a TLSO, a corsetCorset
A corset is a garment worn to hold and shape the torso into a desired shape for aesthetic or medical purposes...
-like appliance that fits from armpits to hips and is custom-made from fiberglass or plastic. It is sometimes worn 22–23 hours a day, depending on the doctor's prescription, and applies pressure on the curves in the spine. The effectiveness of the brace depends not only on brace design and orthotist skill but on patient compliance and amount of wear per day.
The typical use of braces is for idiopathic curves that are not grave enough to warrant surgery, but they may also be used to prevent the progression of more severe curves in young children, to buy the child time to grow before performing surgery, which would prevent further growth in the part of the spine affected.
Bracing may cause emotional and physical discomfort. Physical activity may become more difficult because the brace presses against the stomach, making it difficult to breathe. Children may lose weight from the brace, due to increased pressure on the abdominal area.
The Scoliosis Research Society's recommendations for bracing include curves progressing to larger than 25 degrees, curves presenting between 30 and 45 degrees, Risser Sign
Risser sign
The Risser sign refers to the amount of calcification of the human pelvis as a measure of maturity.On a scale of 5, it gives a measure of progression of ossification; the grade of 5 means that skeletal maturity is reached...
0, 1, or 2 (an X-ray measurement of a pelvic growth area), and less than 6 months from the onset of menses in girls.
Progressive scolioses exceeding 25° Cobb in the pubertal growth spurt should be treated with a pattern-specific brace like the Chêneau brace and its derivates with an average brace-wearing time of 16 hours/day (23 hours/day assures the best possible result).
The latest standard of brace construction is with CAD/CAM technology. With the help of this technology it has been possible to standardize the pattern-specific brace treatment. Severe mistakes in brace construction are largely ruled out with the help of these systems. This technology also eliminates the need to make a plaster cast for brace construction. The measurements can be taken any place and is simple (and not comparable to plastering). In Germany, available CAD/CAM braces are known such as the Regnier-Chêneau brace, the Rigo-System-Chêneau-brace (RSC brace), and the Gensingen Brace, according to Weiss. Many patients prefer the "Chêneau light" brace: It has the best in-brace corrections reported in international literature and is easier to wear than other braces in use today. However, this brace is not available for all curve patterns.
In infantile and sometimes juvenile scoliosis, a plaster jacket applied early may be used instead of a brace. It has been proven possible to permanently correct cases of infantile idiopathic scoliosis by applying a series of plaster casts (EDF: elongation, derotation, flexion) on a specialized frame under corrective traction, which helps to "mould" the infant's soft bones and work with their growth spurts. This method was pioneered by UK scoliosis specialist Min Mehta. Today, however, CAD/CAM braces are available for young children with a certain standard. Therefore, plaster jackets are now generally regarded as outdated.
Surgery
Surgery is usually recommended by orthopedists for curves that have a high likelihood of progression (i.e., greater than 45 to 50 degrees magnitude), curves that would be cosmetically unacceptable as an adult, curves in patients with spina bifidaSpina bifida
Spina bifida is a developmental congenital disorder caused by the incomplete closing of the embryonic neural tube. Some vertebrae overlying the spinal cord are not fully formed and remain unfused and open. If the opening is large enough, this allows a portion of the spinal cord to protrude through...
and cerebral palsy
Cerebral palsy
Cerebral palsy is an umbrella term encompassing a group of non-progressive, non-contagious motor conditions that cause physical disability in human development, chiefly in the various areas of body movement....
that interfere with sitting and care, and curves that affect physiological functions such as breathing.
Surgery for scoliosis is performed by a surgeon
Surgeon
In medicine, a surgeon is a specialist in surgery. Surgery is a broad category of invasive medical treatment that involves the cutting of a body, whether human or animal, for a specific reason such as the removal of diseased tissue or to repair a tear or breakage...
specializing in spine surgery. For various reasons, it is usually impossible to completely straighten a scoliotic spine, but in most cases significant corrections are achieved.
There are two main types of surgery:
- Anterior fusion: This surgical approach is through an incision (cut) at the side of the chest wall
- Posterior fusion: This surgical approach is through an incision on the back and involves the use of metal instrumentation to correct the curve.
One or both of these surgical procedures may be needed. The surgery may be done in one or two stages and, on average, will take four to eight hours.
Spinal fusion with instrumentation
Spinal fusionSpinal fusion
Spinal fusion, also known as spondylodesis or spondylosyndesis, is a surgical technique used to join two or more vertebrae. Supplementary bone tissue, either from the patient or a donor , is used in conjunction with the body's natural bone growth processes to fuse the vertebrae.Fusing of the...
is the most widely performed surgery for scoliosis. In this procedure, bone (either harvested from elsewhere in the body autograft or from a donor allograft) is grafted
Bone grafting
Bone grafting is a surgical procedure that replaces missing bone in order to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly....
to the vertebrae so that when it heals they will form one solid bone mass and the vertebral column
Vertebral column
In human anatomy, the vertebral column is a column usually consisting of 24 articulating vertebrae, and 9 fused vertebrae in the sacrum and the coccyx. It is situated in the dorsal aspect of the torso, separated by intervertebral discs...
becomes rigid. This prevents worsening of the curve, at the expense of some spinal movement. This can be performed from the anterior (front) aspect of the spine by entering the thoracic
Thoracic cavity
The thoracic cavity is the chamber of the human body that is protected by the thoracic wall ....
or abdominal cavity
Abdominal cavity
The abdominal cavity is the body cavity of the human body that holds the bulk of the viscera. It is located below the thoracic cavity, and above the pelvic cavity. Its dome-shaped roof is the thoracic diaphragm , and its oblique floor is the pelvic inlet...
or, more commonly, performed from the back (posterior). A combination is used in more severe cases.
Spinal fusions were once performed without metal implants. In this technique, a cast
Orthopedic cast
An orthopedic cast, body cast or surgical cast, is a shell, frequently made from plaster, encasing a limb to hold a broken bone in place until healing is confirmed...
was applied after the surgery, usually under traction
Traction (orthopedics)
In orthopedic medicine, traction refers to the set of mechanisms for straightening broken bones or relieving pressure on the spine and skeletal system.There are two types of traction: skin traction and skeletal traction....
to pull the curve as straight as possible and then hold it there while fusion took place. Casting left patients largely immobilized for a period of weeks to months, with significant burden on patient quality of life. Additionally, there was a relatively high risk of pseudarthrosis
Pseudarthrosis
Pseudarthrosis is the movement of a bone at the location of a fracture resulting from inadequate healing of the fracture.Pseudarthrosis can also result from a developmental failure.-Etymology:...
(fusion failure) at one or more levels, and significant correction could not always be achieved.
In 1962, Paul Harrington
Paul Randall Harrington
Paul Randall Harrington was an American orthopaedic surgeon. He is best known as the designer of the Harrington Rod, the first device for the straightening and immobilization of the spine inside the body. It entered common use in the early 1960s and remained the gold standard for scoliosis...
introduced a metal spinal system of instrumentation that assisted with straightening the spine, as well as holding it rigid while fusion took place. The original (now obsolete) Harrington rod operated on a ratchet system, attached by hooks to the spine at the top and bottom of the curvature that when cranked would distract, or straighten, the curve. The Harrington rod represented a major advance in the field, as it obviated the need for prolonged casting, allowing patients greater mobility in the post-operative period and significantly reducing the quality of life burden of fusion surgery. Additionally, as the first system to apply instrumentation directly to the spine, the Harrington rod was the precursor to most modern spinal instrumentation systems. A major shortcoming of the Harrington method was that it failed to produce a posture wherein the skull would be in proper alignment with the pelvis, and it did not address rotational deformity. As a result, unfused parts of the spine would try to compensate for this in the effort to stand up straight. As the person aged, there would be increased wear and tear, early-onset arthritis, disc degeneration, muscular stiffness, and pain with eventual reliance on painkillers, further surgery, inability to work full-time, and disability. "Flatback" became the medical name for a related complication, especially for those who had lumbar scoliosis.
Modern spinal systems are attempting to address sagittal imbalance and rotational defects unresolved by the Harrington rod system. They involve a combination of rods, screws, hooks, and wires fixing the spine, and can apply stronger, safer forces to the spine than the Harrington rod. This technique is known as the Cotrel-Dubousset instrumentation
Cotrel-Dubousset instrumentation
Introduced in 1984, Cotrel–Dubousset instrumentation is a treatment approach to scoliosis. Unlike Harrington rods, this treatment is more than just an osteodistraction mechanism and allows correction of some of the features of scolioisis untreatable by Harrington rods, such as rib hump....
, currently the most common technique for the procedure.
In general, modern spinal fusions have good outcomes with high degrees of correction and low rates of failure and infection. Patients with fused spines and permanent implants tend to have normal lives with unrestricted activities when they are younger; it remains to be seen whether those that have been treated with the newer surgical techniques develop problems as they age.
Pedicle screw-only posterior spinal fusion
Spinal fusion
Spinal fusion, also known as spondylodesis or spondylosyndesis, is a surgical technique used to join two or more vertebrae. Supplementary bone tissue, either from the patient or a donor , is used in conjunction with the body's natural bone growth processes to fuse the vertebrae.Fusing of the...
may improve major curve correction at 2 years among patients with adolescent idiopathic scoliosis (AIS) as compared to hybrid instrumentation (proximal hooks with distal pedicle screws) (65% versus 46%) according to a retrospective matched cohort study
Cohort study
A cohort study or panel study is a form of longitudinal study used in medicine, social science, actuarial science, and ecology. It is an analysis of risk factors and follows a group of people who do not have the disease, and uses correlations to determine the absolute risk of subject contraction...
. The prospective cohorts were matched to the retrospective cohorts according to patient age, fusion levels, Lenke curve type, and operative method. The two groups were not significantly different in regard to age, Lenke AIS curve type, or Riser grade. The numbers of fused vertebrae were significantly different (11.7±1.6 for pedicle screw versus 13.0±1.2 for hybrid group). This study's results may be biased due to the pedicle screw group's being analyzed prospectively versus retrospective analysis of the hybrid instrumentation group.
Thoracoplasty
A complementary surgical procedure a surgeon may recommend is called thoracoplasty (also called costoplasty). This is a procedure to reduce the rib hump that affects most scoliosis patients with a thoracic curve. A rib hump is evidence that there is some rotational deformity to the spine. Thoracoplasty may also be performed to obtain bone grafts from the ribs instead of the pelvis, regardless of whether a rib hump is present. Thoracoplasty can be performed as part of a spinal fusion or as a separate surgery, entirely.Thoracoplasty is the removal (or resection) of typically four to six segments of adjacent ribs that protrude. Each segment is one to two inches long. The surgeon decides which ribs to resect based on either their prominence or their likelihood to be realigned by correction of the curvature alone. The ribs grow back, and will grow back straight.
Thoracoplasty has risks, such as increased pain in the rib area during recovery or reduced pulmonary function (10–15 percent is typical) following surgery. This impairment can last anywhere from a few months to two years. Because thoracoplasty may lengthen the duration of surgery, patients may also lose more blood or develop complications from the prolonged anesthesia. A more significant, though far less common, risk is that the surgeon will inadvertently puncture the pleura, a protective coating over the lungs. This could cause blood or air to drain into the chest cavity, conditions called a haemothorax or pneumothorax, respectively.
Complications
The risk of undergoing surgery for scoliosis is estimated to be 5%. Possible complications may be inflammation of the soft tissue or deep inflammatory processes, breathing impairments, bleeding and nerve injuries. However, according to the latest evidence, the rate of complications is far higher. As early as five years after surgery another 5% require reoperation and today it is not yet clear what to expect from spine surgery in the long-term. Taking into account that signs and symptoms of spinal deformity cannot be changed by surgical intervention, surgery remains primarily a cosmetic indication, only especially in patients with adolescent idiopathic scoliosis (AIS), the most common form of scoliosis never exceeding 80°. However, the cosmetic effects of surgery are not necessarily stable.In case one decides to undergo surgery, a specialized center should be preferred.
Surgery without fusion
New implants that aim to delay spinal fusion and to allow more spinal growth in young children have been developed. For the youngest patients, whose thoracic insufficiency compromises their ability to breathe and applies significant cardiac pressure, ribcage implants that push the ribs apart on the concave side of the curve may be especially useful. These vertical expandable prosthetic titanium ribs (VEPTR) provide the benefit of expanding the thoracic cavity and straightening the spine in all three dimensions while allowing it to grow.Although these methods are novel and promising, these treatments are suitable only for growing patients. Spinal fusion remains the "gold standard" of surgical treatment for scoliosis.
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 not having yet reached skeletal maturity have a higher likelihood of progression (i.e., if the patient has not yet completed the adolescent growth spurt). Females have a greater risk of progression as well.Epidemiology
This condition affects approximately 7 million people in the United States.A scoliosis spinal columns curve of 10° or less affects 1.5% to 3% of individuals. The prevalence of curves less than 20° is about equal in males and females. It is most common during late childhood, in particular, in girls.
Scoliosis Research Society
The Scoliosis Research SocietyScoliosis Research Society
Scoliosis Research Society is a non-profit, professional, international organization, made up of physicians and allied health personnel, whose purpose is to "care for those with spinal deformity throughout life by patient care, education, research and patient advocacy." Founded in 1966 with 35...
is a professional organization of physicians and allied health personnel. Their primary focus is on providing continuing medical education for healthcare professionals and on funding/supporting research in spinal deformities. Founded in 1966, the SRS has gained recognition as one of the world's premier spine societies. Strict membership criteria ensure that the individual Fellows support that commitment. Current membership includes over 1,000 of the world's leading spine surgeons as well as some researchers, physician assistants, and orthotists who are involved in research and treatment of spinal deformities. The purpose of the Scoliosis Research Society is to foster the optimal care of all patients with spinal deformities.
About Skolyoz Destek Grubu
Skolyoz Destek Grubu is a non-profit network organization of Scoliosis patient groups, provides information on the diagnosis, treatment and care of persons living with scoliosis and supports its member organisations in the fulfilment of their missions.Skolyoz Destek Grubu also advocates, both independently and in collaboration with organisations with similar objectives.
See also
- KyphosisKyphosisKyphosis , also called roundback or Kelso's hunchback, is a condition of over-curvature of the thoracic vertebrae...
- HyperkyphosisHyperkyphosisHyperkyphosis, colloquially called “dowager’s hump,” refers to excessive kyphotic, or anteriorly concave, curvature of the thoracic region of the spine. A kyphosis angle over 40° - the 95th percentile value for young adults - is currently used to define hyperkyphosis.-Causes:In adults, osteoporosis...
- LordosisLordosisLordosis is a medical term used to describe an inward curvature of a portion of the lumbar and cervical vertebral column. Two segments of the vertebral column, namely cervical and lumbar, are normally lordotic, that is, they are set in a curve that has its convexity anteriorly and concavity...
- Pott's diseasePott's diseasePott's disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints...
- Scheuermann's diseaseScheuermann's diseaseScheuermann’s disease is a self-limiting skeletal disorder of childhood. It is also known as Sherman's Disease, Scheuermann’s kyphosis , Calvé disease and Juvenile Osteochondrosis of the Spine. It is named after Holger Werfel Scheuermann...
- SchooliosisSchooliosisSchooliosis, a pun on "school" and "scoliosis", is a term for a type of medical misdiagnosis. The word was coined by Petr Skrabanek and James McCormick....
- Neuromechanics of idiopathic scoliosisNeuromechanics of idiopathic scoliosisThe neuromechanics of idiopathic scoliosis is about the bones, muscles and joints changes in people having a spinal deformity consisting of a lateral curvature and a rotation of the vertebrae within the curve that is not explained by congenital or neuromuscular reasons.The idiopathic scoliosis...
- Back braceBack braceA back brace is a device designed to limit the motion of the spine in cases of fracture or in post-operative fusions. Limiting the motion of the spine enhances the healing process and minimizes the patient's discomfort.Common back braces include:...