Scoliosis

(Left) Normal spine anatomy. (Right) Scoliosis can make the spine look more like the letters "C" or "S.”

Scoliosis is a condition that causes the spine to curve sideways. There are several different types of scoliosis that affect children and adolescents. The most common type is "idiopathic," which means the exact cause is not known.

Most cases of idiopathic scoliosis occur between age 10 and the time a child is fully grown. Scoliosis is not usually painful—small curves often go unnoticed by children and their parents, and are first detected during a school screening or at a regular check-up with their pediatrician.

In many cases, scoliosis curves are small and do not require treatment. Children with larger curves may need to wear a brace or have surgery to restore normal posture.

What is scoliosis?

Scoliosis causes the bones of the spine to twist or rotate so that instead of a straight line down the middle of the back, the spine looks more like the letter "C" or "S." Scoliosis curves most commonly occur in the upper and middle back (thoracic spine). They can also develop in the lower back, and occasionally, will occur in both the upper and lower parts of the spine.

Idiopathic scoliosis curves vary in size, and mild curves are more common than larger curves. If a child is still growing, a scoliosis curve can worsen rapidly during a growth spurt.

Although it can develop in toddlers and young children, idiopathic scoliosis most often begins during puberty. Both boys and girls can be affected, however, girls are more likely to develop larger curves that require medical care.

Other less common types of scoliosis include:

• Congenital scoliosis. Problems in the spine sometimes develop before a baby is born. Babies with congenital scoliosis may have spinal bones that are not fully formed or are fused together.
• Neuromuscular scoliosis. Medical conditions that affect the nerves and muscles, such as muscular dystrophy or cerebral palsy, can lead to scoliosis. These types of neuromuscular conditions can cause imbalance and weakness in the muscles that support the spine.

What causes scoliosis?

Although doctors do not know the exact cause of idiopathic scoliosis, they do know that it is not related to specific behaviors or activities — like carrying a heavy backpack or having poor posture. 

Research shows that in some cases genetics plays a role in the development of scoliosis. Approximately 30% of patients with adolescent idiopathic scoliosis have a family history of the condition.

Nothing you have done caused your curve. Because the causes of idiopathic scoliosis are not fully understood, it is hard to determine how to prevent it. In terms of genetic causes, there really is not much to do about a child’s predisposition to developing scoliosis.

What are the symptoms associated with scoliosis?

Small curves often go unnoticed until a child hits a growth spurt during puberty and there are more obvious signs, such as:

• Tilted, uneven shoulders, with one shoulder blade protruding more than the other
• Prominence of the ribs on one side
• Uneven waistline
• One hip higher than the other

If your pediatrician suspects scoliosis, he or she may refer you to a pediatric orthopedic surgeon or a spinal deformity surgeon for a full evaluation and treatment plan.

What is the difference between idiopathic scoliosis and other types of scoliosis?

• Idiopathic scoliosis. The term "idiopathic" means unknown cause. Although we do not know for sure what causes the majority of scoliosis cases (80% to 85%), we do know it tends to run in families. Scoliosis is not a disease that is caught from someone else, like a cold. There is nothing you could have done to prevent it.
• Congenital scoliosis. The term "congenital" means that you are born with the condition. Congenital scoliosis starts as the spine forms before birth. Part of one vertebra (or more) does not form completely or the vertebrae do not separate properly. Some types of congenital scoliosis can change quickly with growth while others remain unchanged. This type of scoliosis can be associated with other health issues, such as heart and kidney problems.
• Neuromuscular scoliosis. Any medical condition that affects the nerves and muscles can lead to scoliosis. This is most commonly due to muscle imbalance and/or weakness. Common neuromuscular conditions that can lead to scoliosis include cerebral palsy, muscular dystrophy, and spinal cord injury.

How serious is adolescent scoliosis?

Adolescent scoliosis is not life threatening, and most curves do not cause serious problems. Children with scoliosis can have normal active lives, including sports participation.

If the curve gets really large, it can cause heart and lung problems. A very severe curve can also compress nerves or the spinal cord, which can result in paralysis. This is extremely rare. Proper treatment will prevent the curve from progressing to such a severe degree.

Does scoliosis cause back pain?

Adolescent scoliosis does not usually cause back pain, although larger curves may cause occasional discomfort. If the back pain is severe or is associated with weakness of the limbs or numbness, call your doctor. This may require investigations to rule out other sources of pain.

How is scoliosis diagnosed in children?

The standard screening test for scoliosis is the "Adam's forward bend test." During the test, your child will bend forward with feet together, knees straight and arms hanging free. Your doctor will observe your child from the back, looking for a difference in the shape of the ribs on each side. A spinal deformity is most noticeable in this position.

With your child standing upright, your doctor will also check to see if the hips and shoulders are level, and if the position of the head is centered over the hips. He or she will check the movement of the spine in all directions. To rule out other causes of spinal deformity, your doctor will check for limb-length discrepancies, abnormal neurological findings, and other physical problems.

X-rays will provide clear images of the bones in your child's spine. They allow your doctor to see the exact location of the curve and to measure how severe it is. In general, curves greater than 25° are considered serious enough to require treatment.

How is scoliosis treated and managed?

Your doctor will consider several things when planning your child's treatment:

• The location of the curve
• The severity of the curve
• Your child's age
• The number of remaining growing years — once an adolescent is fully grown, it is not common for a curve to rapidly worsen.

By evaluating these factors, your doctor will determine how likely it is that your child's curve will worsen and be able to suggest the best treatment option.

How is scoliosis treated without surgery?

• Observation. If your child's spinal curve is less than 25° or if he or she is almost full grown, your doctor may recommend simply monitoring the curve to make sure it does not get worse. Your doctor will recheck your child about every 6 to 12 months and schedule follow-up x-rays until your child is fully grown.
• Bracing. If the spinal curve is between 25° and 45° and your child is still growing, your doctor may recommend bracing. Although bracing will not straighten an existing curve, it often prevents it from getting worse to the point of requiring surgery.

In a recent research study of scoliosis patients with curves at a high risk for worsening, bracing significantly decreased the incidence of curves that progressed to the point of needing surgery.

There are several types of braces for scoliosis. Most of them are underarm braces that are custom-made to fit your child's body comfortably. Your doctor will recommend the type that best meets your child's needs and will determine how long the brace should be worn each day. Your child can take off the brace for sports activities.

How is scoliosis treated with surgery?

Your doctor may recommend surgery if your child's curve is greater than 45°-50° or if bracing did not stop the curve from reaching this point. Severe curves that are not treated could eventually worsen to the point where they affect lung function.

A surgical procedure called "spinal fusion" will significantly straighten the curve and then fuse the vertebrae together so that they heal into a single, solid bone. This will stop growth completely in the part of the spine affected by scoliosis.

During the procedure, the spinal bones that make up the curve are realigned. Small pieces of bone — called bone graft — are placed into the spaces between the vertebrae to be fused. Over time, the bones grows together — similar to when a broken bone heals. Metal rods are typically used to hold the bones in place until the fusion happens. The rods are attached to the spine by hooks, screws, and/or wires.

Exactly how much of the spine is fused depends upon your child's curve(s). Only the curved vertebrae are fused together. The other bones of the spine remain able to move and assist in motion.

Is spinal fusion for scoliosis successful?

Spinal fusion is very successful in stopping the curve from getting worse. Surgery is also able to straighten the curve significantly, which improves the patient's appearance.

Most children can return to sporting activities within 6 to 9 months after surgery. Because surgery causes permanent limitation of some spine movements, however, they should not participate in contact sports, like football. Spinal fusion does not increase the risk of complications during girls' future pregnancies or deliveries.

Can scoliosis curves get better on their own?

Some very small idiopathic scoliosis curves may improve without treatment but this is less common. Many children have slight curves that do not need treatment. In these cases, the children grow up to lead normal lives — but their small curves remain.

If larger curves are not treated, the best you can hope for is that they will not get worse. This depends on how much growing your child has left to do. Curves in children who are almost fully grown may stop getting worse. If your child's spine is still growing, it is more likely that the curves will worsen.

What can I do to prevent my scoliosis from getting worse?

The only treatments that have been shown to help idiopathic scoliosis are bracing and surgery. There is no evidence in the current medical literature that physical therapy, electrical stimulation, chiropractic care, or other options have any long term impact on scoliosis curves. Scoliosis Specific Exercises (SSE) may be useful together with bracing and are currently being studied.

Is it safe for my child to exercise and participate in sports?

Children with idiopathic scoliosis can participate in any sport up to their own level of tolerance. It is always a good idea for children to stay physically fit with exercise.

Will my child be able to live a normal life?

The same usually applies to people who have had surgery for scoliosis. They can have the same jobs as people who have not had scoliosis surgery. They can usually do the same sports as before surgery. They should, however, contact their doctors before starting new activities (jobs or sports) to make sure they have no specific restrictions.

Common Questions about Screening for Scoliosis

How early should children be screened for scoliosis?

Children can be screened at any age, although idiopathic scoliosis is more commonly discovered during a child's growth spurt (10 to 15 years old). The Scoliosis Research Society recommends that girls be screened twice, at 10 and 12 years of age (grades 5 and 7), and boys once at 13 or 14 years of age (grades 8 or 9). A great deal of controversy exists as to the benefits of school screening.

Do siblings of children with scoliosis need to be checked?

Because scoliosis tends to run in families, it is good to have siblings checked at their yearly physical examinations, especially during their growth spurts (10 to 15 years old).

Early detection is important and parents can help. Look at your child's back with a bathing suit on. If you see one shoulder appearing higher than the other, or one side of the ribcage sticking out more than the other side, call your pediatrician to be evaluated.

When should the child of parents who have scoliosis be examined?

Children of scoliotic parents should be checked at their yearly physical examinations, especially during their growth spurts (10 to 15 years old).

Why didn't we notice it sooner?

In many cases, curves do not appear until the early teenage years. Small curves often go unnoticed until a child hits a growth spurt during puberty. Because scoliosis is not usually painful, children and their parents may not discover it until there are more obvious signs.

In addition, adolescents tend to be modest. Many girls may be self-conscious or wear baggy clothing. It isn't until they wear more form-fitting clothes (bathing suits, t-shirts) that the curves are apparent.

Also, adolescents may not see their pediatricians on a regular basis.

Why didn't our pediatrician see it sooner?

Scoliosis curves can get worse very fast, especially during pre-adolescence. Your pediatrician may not have seen your child during this time of growth.

Common Questions about Adult Life with Scoliosis

What health problems might I have later in life as a result of scoliosis?

Problems with scoliosis later in life are related to the size and location of the curve in the spine. In general, people with curves less than 30° have the same risks for back pain as people without scoliosis. People with larger, untreated curves (over 50° to 60°) are more likely to develop back pain, particularly in the lower back.

Will I have a hump on my back when I get older?

This depends on how severe the curve is and whether it is corrected surgically.

One of my hips looks higher than the other. Can anything correct this?

If the difference is greater than 2 cm, your doctor may recommend a shoe lift to adjust your uneven posture. Scoliosis makes one leg seem longer even though there is little difference. A true leg length difference with scoliosis is typically small and doesn't need treatment.

Will having scoliosis affect my ability to have children?

No, it should not. There have been many studies on scoliosis and pregnancy, and none have shown difficulties in childbearing in patients with scoliosis. There are no increases in fetal distress, premature deliveries, or problems with delivery. Interestingly, one study shows that the need for cesarean section was half of the national average in the women with scoliosis. Your children will have a greater chance of developing scoliosis so they should be checked by their pediatricians at routine well child visits. In addition, pregnancy does not typically cause a significant increase in the degree of scoliosis in an unfused spine.

Can I have an epidural in the future?

Yes, you can get an epidural as an anesthetic for childbirth or surgery. Very severe curves, however, will make it more difficult for anesthesiologists to perform the epidural placement.

If you have had a spinal fusion, be sure your obstetrician and anesthesiologist know what levels of fusion have been performed.

Does having scoliosis make me more prone to osteoporosis?

There is some controversy about whether scoliosis might contribute to bone loss (osteoporosis), but we don't know for sure. Keeping your bones healthy by not smoking, getting adequate calcium and Vitamin D, and plenty of weight-bearing exercise, is good advice for young people, whether or not they have scoliosis.

Will having scoliosis influence what I do later in life, such as what jobs I can do?

No, it should not. However, there are some patients who may be excluded from military service if the scoliosis is severe enough.

Will the metal detectors go off in airport security after I have rods placed in my spine?

This depends on how sensitive the detector is, but it typically does not happen. If the detector does go off they are required to use a portable detector and pat down any areas that go off.

If I have a spinal fusion, will I need antibiotics before dental work?

This question refers to the possibility of infection in spine implants after dental work. Antibiotics may be prescribed before dental work as a preventative measure. Many doctors, however, do not believe that antibiotics are needed. Please talk with your spine surgeon about this before having dental work.