DEFINITION AND SYMPTOMS
The normal human spine has natural curvatures when looking at it from the side and it is straight when looking at the spine from front or back. These natural curves position the head over the pelvis and work as shock absorbers to distribute mechanical stress during movement. Any anatomic change in the normal alignment of the vertebrae, results in a spinal deformity. Some deformities are congenital and some are acquired due to arthritis, neurologic conditions, spinal fractures or focal deformities after surgery. Scoliosis and Kyphosis are two common spinal deformities. Approximately 3% of the Americans have scoliosis. Approximately 4% of the Americans have kyphosis. Most deformities are symptom-free.
Scoliosis is a deformity in which, the spine abnormally rotates and curves sideways. Scoliosis is often an S-shaped deformity in which half of the curve is on the top part of the spine and the other half curves in the opposite direction, in the lower part of the spine. Risk factors for developing scoliosis include age (puberty growth spurt), being of the female sex (8 fold increase), and family history of scoliosis. Scoliosis is often diagnosed in adolescent females and can be passed on from mothers to children. In general there are important differences to note in a diagnosis of scoliosis, it can be congenital, idiopathic, degenerative, and neuromuscular. When the exact etiology of scoliosis is unknown it is considered "idiopathic scoliosis". Idiopathic scoliosis is the most common type of scoliosis. Scoliosis related to neurologic or primary muscle disorders is called "Neuromuscular scoliosis" as seen in cerebral palsy and muscular dystrophy. In aging populations, because of arthritis, the spine can become scoliosis. The type is called "degenerative scoliosis". Carrying heavy bags to school, doing sports, or habitual poor posture does not lead to scoliosis.
Kyphosis is also known as round back or hunchback. There are multiple types of kyphosis. Some are age-related and some are developmental in nature or related to other diseases. Age-related kyphosis, often seen in elderly woman, happens as a result of brittle vertebrae (osteoporosis) and compression fracture. Fracture related kyphosis can also happen in cancer patients who have undergone chemotherapy and radiation with brittle bone and fracture.
Degenerative disc disease can result in asymmetrical space between the vertebrae and kyphosis. Congenital kyphosis develops as a result of malformations and could be quite severe. Scheuermann's disease, often seen in young boys, results in a kyphotic upper back and develops during puberty. There are less common causes of kyphosis including certain clinical syndromes, which are associated with other clinical signs (i.e. Prader Willi disease). Although mild kyphosis may be symptom free and simply missed or mixed with bad posture, severe
kyphosis can result in disfigurement as well as a painful upper back and neck.
In addition to abnormal curvature, other characteristics of scoliosis include uneven shoulders, uneven waist, one hip higher than the other, and differences in the leg length. Individuals with scoliosis often find protruded scapula, asymmetrical breast, and asymmetrical protrusions of pelvic bone, all of which stem from an abnormally curved spine. Mild curvatures will be missed by school nurses and parents. Pediatricians obtain a detailed history including family history and examine boys and girls for signs of scoliosis. X-rays are the most common and simplest way of diagnosing scoliosis. Mild cases are followed by serial x-rays and if there is rapid progression, strategies of care may be changed. If scoliosis is secondary to disease, further workup may be recommended (MRI, CT scan) and multiple specialists including physiatrist, orthopedist, neurologist and rheumatologist may be involved. Sometimes genetic testing and more sophisticated laboratory testing is conducted based on type of presentation.
X-ray is the gold standard for diagnosis of kyphosis. If kyphosis is related to fracture, further testing including CT scan and MRI may be indicated. In older patients with kyphosis, additional laboratory and imaging tests, including bone density, are recommended to identify the risk of further fracture. Appropriate treatment should be offered to strengthen the vertebrae and avoid worsening of the curvature by means of more fractures.
Most cases of scoliosis are mild but in some children the curve progresses rapidly requiring more advanced treatment. Treatment goals for scoliosis are to slow down or halt the progression of the curvature, maintain acceptable appearance and prevent complications associated with scoliosis, decrease stress on heart and lung function, reduce skeletal pain including back pain, hip and bursa pain, sacroiliac pain, muscle and tendon injuries and piriformis syndrome.
The most common treatment includes a therapy program, bracing and keeping an eye on the curvature with x-ray. For curvatures that are moderately severe, multiple factors are considered when recommending further treatments.
These factors include sex, severity of the curvature, the pattern of curvature (S-shaped versus C-shaped), location of the curvature and skeletal maturity of the child. Risk of progression is higher in females, large curves, S-shaped curvatures, thoracic curvatures and skeletally immature children (still growing).
Braces for Scoliosis
As the child is growing, a brace is recommended to slow down and halt further progression of the curvature. The brace is restrictive and is constructed from a firm plastic which contours to the body and is close fitting. The most common brace is the Boston overlap brace and extends from the upper back to the top of the hips. It is adjustable to be as comfortable as possible but still it is restrictive and compliance can be an issue. The brace is worn day and night. This can be removed for sport activities. The brace would be discontinued when skeletal maturity has been reached, which is roughly 2 years after first menstruation for girls, boys requiring daily shave, or when no changes in height have been noted for one calendar year. Approximately 30,000 American children wear braces for scoliosis.
To date, adjunct treatment including chiropractic manipulation, electrostimulation, acupuncture, therapeutic massage, traction, inversion tables and so forth have not been proven to be an effective way to halt the progression of the curvature.
Serious issues may require surgical solutions or halt the progression of the condition. Spinal fusion is the treatment of choice and often requires multiple segments to be operated on. By inserting pieces of bone or bone like material in between the vertebrae and using anchors, wires, rods and surgical instrument, specific vertebrae are fused to each other to avoid further progression of the curvature. This is a lengthy operation with lengthy recovery. Surgeries can be complicated including bleeding, infection, pain or nerve damage. If complete fusion is not achieved, revision may be necessary. In growing children, rods may need to be adjusted to accommodate for growth. Approximately 40,000 scoliosis surgeries are performed in the United States each year, some of which are minimally invasive.