Crooked Spine
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Scoliosis (: scolioses) is a condition in which a person's
spine Spine or spinal may refer to: Science Biology * Spinal column, also known as the backbone * Dendritic spine, a small membranous protrusion from a neuron's dendrite * Thorns, spines, and prickles, needle-like structures in plants * Spine (zoology), ...
has an irregular curve in the
coronal plane The dorsal plane (also known as the coronal plane or frontal plane, especially in human anatomy) is an anatomical plane that divides the body into Anatomical terms of location#Dorsal and ventral, dorsal and ventral sections. It is perpendicular t ...
. The curve is usually S- or C-shaped over three dimensions. In some, the degree of curve is stable, while in others, it increases over time. Mild scoliosis does not typically cause problems, but more severe cases can affect breathing and movement. Pain is usually present in adults, and can worsen with age. As the condition progresses, it may alter a person's life, and hence can also be considered a
disability Disability is the experience of any condition that makes it more difficult for a person to do certain activities or have equitable access within a given society. Disabilities may be Cognitive disability, cognitive, Developmental disability, d ...
. It can be compared to
kyphosis Kyphosis () is an abnormally excessive convex curvature of the Spinal column, spine as it occurs in the Thoracic spine, thoracic and sacrum, sacral regions. Abnormal inward concave ''lordotic'' curving of the Cervical spine, cervical and Lumba ...
and
lordosis Lordosis is historically defined as an ''abnormal'' inward curvature of the lumbar spine. However, the terms ''lordosis'' and ''lordotic'' are also used to refer to the normal inward curvature of the lumbar and cervical vertebrae, cervical regio ...
, other abnormal curvatures of the spine which are in the
sagittal plane The sagittal plane (; also known as the longitudinal plane) is an anatomical plane that divides the body into right and left sections. It is perpendicular to the transverse and coronal planes. The plane may be in the center of the body and divi ...
(front-back) rather than the coronal (left-right). The cause of most cases is unknown, but it is believed to involve a combination of genetic and
environmental factor An environmental factor, ecological factor or eco factor is any factor, abiotic or biotic, that influences living organisms. Abiotic factors include ambient temperature, amount of sunlight, air, soil, water and pH of the water soil in which an ...
s. Scoliosis most often occurs during growth spurts right before puberty. Risk factors include other affected family members. It can also occur due to another condition such as
muscle spasms A spasm is a sudden involuntary contraction of a muscle, a group of muscles, or a hollow organ, such as the bladder. A spasmodic muscle contraction may be caused by many medical conditions, including dystonia. Most commonly, it is a musc ...
,
cerebral palsy Cerebral palsy (CP) is a group of movement disorders that appear in early childhood. Signs and symptoms vary among people and over time, but include poor coordination, spasticity, stiff muscles, Paresis, weak muscles, and tremors. There may b ...
,
Marfan syndrome Marfan syndrome (MFS) is a multi-systemic genetic disorder that affects the connective tissue. Those with the condition tend to be tall and thin, with dolichostenomelia, long arms, legs, Arachnodactyly, fingers, and toes. They also typically ha ...
, and tumors such as
neurofibromatosis Neurofibromatosis (NF) refers to a group of three distinct genetic conditions in which tumors grow in the nervous system. The tumors are non-cancerous (benign) and often involve the skin or surrounding bone. Although symptoms are often mild, e ...
. Diagnosis is confirmed with
X-ray An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...
s. Scoliosis is typically classified as either structural in which the curve is fixed, or functional in which the underlying spine is normal. Left-right
asymmetries Asymmetry is the absence of, or a violation of, symmetry (the property of an object being invariant to a transformation, such as reflection). Symmetry is an important property of both physical and abstract systems and it may be displayed in pre ...
, of the vertebrae and their musculature, especially in the thoracic region, may cause mechanical instability of the spinal column. Treatment depends on the degree of curve, location, and cause. The age of the patient is also important, since some treatments are ineffective in adults, who are no longer growing. Minor curves may simply be watched periodically. Treatments may include bracing, specific exercises, posture checking, and surgery. The brace must be fitted to the person and used daily until growing stops. Specific exercises, such as exercises that focus on the core, may be used to try to decrease the risk of worsening. They may be done alone or along with other treatments such as bracing. Evidence that
chiropractic manipulation Spinal adjustment and chiropractic adjustment are terms used by chiropractors to describe their approaches to spinal manipulation, as well as some osteopaths, who use the term adjustment. Research has shown that chiropractic care is effective ...
, dietary supplements, or exercises can prevent the condition from worsening is weak. However, exercise is still recommended due to its other health benefits. Scoliosis occurs in about 3% of people. It most commonly develops between the ages of ten and twenty. Females typically are more severely affected than males with a ratio of 4:1. The term is .


Signs and symptoms

Symptoms associated with scoliosis can include: * Pain in the back at the site of the curve, which may radiate to the legs. Chest pain at the ribs and sternum location can sometimes be linked to scoliosis of the spine because the ribs wrap around to the chest area which can be misaligned. This can lead to injury, pain and swelling which can turn up on medical imaging (CT scans etc.). * Respiratory or cardiac problems in severe cases * Constipation due to curvature causing "tightening" of the stomach, intestines, etc. The signs of scoliosis can include: * Uneven musculature on one side of the spine * Rib prominence or a prominent
shoulder blade The scapula (: scapulae or scapulas), also known as the shoulder blade, is the bone that connects the humerus (upper arm bone) with the clavicle (collar bone). Like their connected bones, the scapulae are paired, with each scapula on either side ...
, caused by rotation of the rib cage in
thoracic The thorax (: thoraces or thoraxes) or chest is a part of the anatomy of mammals and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main ...
scoliosis * Uneven posture * Heart and lung problems in severe cases * Calcium deposits in the cartilage endplate and sometimes in the disc itself


Course

People who have reached skeletal maturity are less likely to have a worsening case. Some severe cases of scoliosis can lead to diminishing lung capacity, pressure exerted on the heart, and restricted physical activities.
Longitudinal studies A longitudinal study (or longitudinal survey, or panel study) is a research design that involves repeated observations of the same variables (e.g., people) over long periods of time (i.e., uses longitudinal data). It is often a type of observation ...
have revealed that the most common form of the condition, late-onset idiopathic scoliosis, causes little physical impairment other than back pain and cosmetic concerns, even when untreated, with mortality rates similar to the general population. Older beliefs that untreated idiopathic scoliosis necessarily progressed into severe (cardiopulmonary) disability by old age have been refuted.


Causes

An estimated 65% of scoliosis cases are
idiopathic An idiopathic disease is any disease with an unknown cause or mechanism of apparent spontaneous origin. For some medical conditions, one or more causes are somewhat understood, but in a certain percentage of people with the condition, the cause ...
(cause unknown), about 15% are
congenital A birth defect is an abnormal condition that is present at childbirth, birth, regardless of its cause. Birth defects may result in disability, disabilities that may be physical disability, physical, intellectual disability, intellectual, or dev ...
, and about 10% are secondary to a
neuromuscular disease A neuromuscular disease is any disease affecting the peripheral nervous system (PNS), the neuromuscular junctions, or skeletal muscles, all of which are components of the motor unit. Damage to any of these structures can cause muscle atrophy and we ...
. About 38% of variance in scoliosis risk is due to genetic factors, and 62% is due to the environment. The genetics are likely complex, however, given the inconsistent inheritance and discordance among monozygotic twins. The specific genes that contribute to development of scoliosis have not been conclusively identified. Several candidate gene studies have found associations between idiopathic scoliosis and genes mediating bone formation, bone metabolism, and connective tissue structure. Several genome-wide studies have identified a number of loci as significantly linked to idiopathic scoliosis. In 2006, idiopathic scoliosis was linked with three
microsatellite A microsatellite is a tract of repetitive DNA in which certain Sequence motif, DNA motifs (ranging in length from one to six or more base pairs) are repeated, typically 5–50 times. Microsatellites occur at thousands of locations within an organ ...
polymorphisms in the ''MATN1'' gene (encoding for matrilin 1, cartilage matrix protein). Fifty-three single nucleotide polymorphism markers in the DNA that are significantly associated with adolescent idiopathic scoliosis were identified through a genome-wide association study. Adolescent idiopathic scoliosis has no clear causal agent, and is generally believed to be multifactorial; leading to "progressive functional limitations" for individuals. Research suggests that Posterior Spinal Fusion (PSF) can be used to correct the more severe deformities caused by adolescent idiopathic scoliosis. Such procedures can result in a return to physical activity in about 6 months, which is very promising, although minimal back pain is still to be expected in the most severe cases. The prevalence of scoliosis is 1–2% among adolescents, but the likelihood of progression among adolescents with a
Cobb angle Cobb may refer to: People * Cobb (surname), a list of people and fictional characters with the surname Cobb * Cobb Rooney (1900–1973), American professional football running back Places New Zealand * Cobb River * Cobb Reservoir * Cobb Powe ...
less than 20° is about 10–20%. Congenital scoliosis can be attributed to a malformation of the spine during weeks three to six ''
in utero The uterus (from Latin ''uterus'', : uteri or uteruses) or womb () is the organ in the reproductive system of most female mammals, including humans, that accommodates the embryonic and fetal development of one or more fertilized eggs until bir ...
'' due to a failure of formation, a failure of segmentation, or a combination of stimuli. Incomplete and abnormal segmentation results in an abnormally shaped vertebra, at times fused to a normal vertebra or unilaterally fused vertebrae, leading to the abnormal lateral curvature of the spine. Vertebrae of the spine, especially in the thoracic region, are, on average, asymmetric. The mid-axis of these vertebral bodies tends to point systematically to the right of the median body plane. A strong asymmetry of the vertebrae and their musculature, may lead to mechanical instability of the column, especially during phases of rapid growth. The asymmetry is thought to be caused by an embryological twist of the body.


Resulting from other conditions

Secondary scoliosis due to
neuropathic Peripheral neuropathy, often shortened to neuropathy, refers to damage or disease affecting the nerves. Damage to nerves may impair sensation, movement, gland function, and/or organ function depending on which nerve fibers are affected. Neuropa ...
and
myopathic In medicine, myopathy is a disease of the muscle in which the muscle fibers do not function properly. ''Myopathy'' means muscle disease (Greek language, Greek : myo- ''muscle'' + patheia ''pathos, -pathy'' : ''suffering''). This meaning implies t ...
conditions can lead to a loss of muscular support for the spinal column so that the spinal column is pulled in abnormal directions. Some conditions which may cause secondary scoliosis include
muscular dystrophy Muscular dystrophies (MD) are a genetically and clinically heterogeneous group of rare neuromuscular diseases that cause progressive weakness and breakdown of skeletal muscles over time. The disorders differ as to which muscles are primarily affe ...
,
spinal muscular atrophy Spinal muscular atrophy (SMA) is a rare neuromuscular disorder that results in the loss of motor neurons and progressive muscle wasting. It is usually diagnosed in infancy or early childhood and if left untreated it is the most common geneti ...
,
poliomyelitis Poliomyelitis ( ), commonly shortened to polio, is an infectious disease caused by the poliovirus. Approximately 75% of cases are asymptomatic; mild symptoms which can occur include sore throat and fever; in a proportion of cases more severe ...
,
cerebral palsy Cerebral palsy (CP) is a group of movement disorders that appear in early childhood. Signs and symptoms vary among people and over time, but include poor coordination, spasticity, stiff muscles, Paresis, weak muscles, and tremors. There may b ...
, spinal cord trauma, and
myotonia Myotonia is a symptom of a small handful of certain neuromuscular disorders characterized by delayed relaxation (prolonged contraction) of the skeletal muscles after voluntary contraction or electrical stimulation, and the muscle shows an abnor ...
. Scoliosis often presents itself, or worsens, during an adolescent's growth spurt and is more often diagnosed in females than males. Scoliosis associated with known syndromes is often subclassified as "syndromic scoliosis". Scoliosis can be associated with
amniotic band syndrome Constriction ring syndrome (CRS) is a congenital disorder with unknown cause. Because of the unknown cause there are many different, and sometimes incorrect, names. It is a malformation due to intrauterine bands or rings that produce deep grooves ...
, Arnold–Chiari malformation,
Charcot–Marie–Tooth disease Charcot-Marie-Tooth disease (CMT) is an inherited neurological disorder that affects the peripheral nerves responsible for transmitting signals between the brain, spinal cord, and the rest of the body. This is the most common inherited neuropath ...
,
cerebral palsy Cerebral palsy (CP) is a group of movement disorders that appear in early childhood. Signs and symptoms vary among people and over time, but include poor coordination, spasticity, stiff muscles, Paresis, weak muscles, and tremors. There may b ...
,
congenital diaphragmatic hernia Congenital diaphragmatic hernia (CDH) is a birth defect of the diaphragm. The most common type of CDH is a Bochdalek hernia; other types include Morgagni hernia, diaphragm eventration and central tendon defects of the diaphragm. Malformation ...
,
connective tissue disorder Connective tissue diseases (also termed connective tissue disorders, or collagen vascular diseases), are medical conditions that affect connective tissue. Connective tissues protect, support, and provide structure for the body's other tissues a ...
s,
muscular dystrophy Muscular dystrophies (MD) are a genetically and clinically heterogeneous group of rare neuromuscular diseases that cause progressive weakness and breakdown of skeletal muscles over time. The disorders differ as to which muscles are primarily affe ...
,
familial dysautonomia Familial dysautonomia (FD), also known as Riley–Day syndrome, is a rare, progressive, recessive genetic disorder of the autonomic nervous system that affects the development and survival of sensory, sympathetic, and some parasympathetic neuro ...
,
CHARGE syndrome CHARGE syndrome (formerly known as CHARGE association) is a rare syndrome caused by a genetic disorder. First described in 1979, the acronym "CHARGE" came into use for newborn children with the congenital features of coloboma of the eye, heart ...
,
Ehlers–Danlos syndrome Ehlers–Danlos syndromes (EDS) is a group of 14 genetic connective-tissue disorders. Symptoms often include loose joints, joint pain, stretchy velvety skin, and abnormal scar formation. These may be noticed at birth or in early childhood. Co ...
(hyperflexibility, "floppy baby" syndrome, and other variants of the condition),
fragile X syndrome Fragile X syndrome (FXS) is a genetic neurodevelopmental disorder. The average IQ in males with FXS is under 55, while affected females tend to be in the borderline to normal range, typically around 70–85. Physical features may include a lo ...
,
Friedreich's ataxia Friedreich's ataxia (FRDA) is a rare, inherited, autosomal recessive neurodegenerative disorder that primarily affects the nervous system, causing progressive damage to the spinal cord, peripheral nerves, and cerebellum, leading to impaired ...
,
hemihypertrophy Hemihypertrophy, now more commonly referred to as hemihyperplasia in the medical literature, is a condition in which one side of the body or a part of one side of the body is larger than the other to an extent considered greater than the normal v ...
,
Loeys–Dietz syndrome Loeys–Dietz syndrome (LDS) is an autosomal dominant genetic connective tissue disorder. It has features similar to Marfan syndrome and Ehlers–Danlos syndrome. The disorder is marked by aneurysms in the aorta, often in children, and the aorta m ...
,
Marfan syndrome Marfan syndrome (MFS) is a multi-systemic genetic disorder that affects the connective tissue. Those with the condition tend to be tall and thin, with dolichostenomelia, long arms, legs, Arachnodactyly, fingers, and toes. They also typically ha ...
,
nail–patella syndrome Nail–patella syndrome is a genetic disorder that results in small, poorly developed nail (anatomy), nails and kneecaps, but can also affect many other areas of the body, such as the elbows, chest, and hips. The name "nail–patella" can be very ...
,
neurofibromatosis Neurofibromatosis (NF) refers to a group of three distinct genetic conditions in which tumors grow in the nervous system. The tumors are non-cancerous (benign) and often involve the skin or surrounding bone. Although symptoms are often mild, e ...
,
osteogenesis imperfecta Osteogenesis imperfecta (; OI), colloquially known as brittle bone disease, is a group of genetic disorders that all result in bones that bone fracture, break easily. The range of symptoms—on the skeleton as well as on the body's other Or ...
,
Prader–Willi syndrome Prader–Willi syndrome (PWS) is a rare genetic disorder caused by a loss of function of specific genes on chromosome 15. In newborns, symptoms include hypotonia, weak muscles, poor feeding, and slow development. Beginning in childhood, those ...
,
proteus syndrome Proteus syndrome is a rare genetic disorder that can cause tissue overgrowth involving all three Germ layer, embryonic lineages. Patients with Proteus syndrome tend to have an increased risk of embryonic tumor development.Freedberg, et al. (2003). ...
,
spina bifida Spina bifida (SB; ; Latin for 'split spine') is a birth defect in which there is incomplete closing of the vertebral column, spine and the meninges, membranes around the spinal cord during embryonic development, early development in pregnancy. T ...
,
spinal muscular atrophy Spinal muscular atrophy (SMA) is a rare neuromuscular disorder that results in the loss of motor neurons and progressive muscle wasting. It is usually diagnosed in infancy or early childhood and if left untreated it is the most common geneti ...
,
syringomyelia Syringomyelia is a generic term referring to a disorder in which a cyst or cavity forms within the spinal cord. Often, syringomyelia is used as a generic term before an etiology is determined. This cyst, called a syrinx, can expand and elongate ...
, and
pectus carinatum Pectus carinatum, also called pigeon chest or pidgon breast, is a malformation of the chest characterized by a protrusion of the Human sternum, sternum and ribs. It is distinct from the related malformation pectus excavatum. Pectus carinatum has ...
. Another form of secondary scoliosis is degenerative scoliosis, also known as de novo scoliosis, which develops later in life secondary to degenerative (may or may not be associated with aging) changes. This is a type of deformity that starts and progresses because of the collapse of the vertebral column in an asymmetrical manner. As bones start to become weaker and the ligaments and discs located in the spine become worn as a result of age-related changes, the spine begins to curve.


Diagnosis

People who initially present with scoliosis undergo a physical examination to determine whether the deformity has an underlying cause and to exclude the possibility of the underlying condition more serious than simple scoliosis. The person's gait is assessed, with an exam for
sign A sign is an object, quality, event, or entity whose presence or occurrence indicates the probable presence or occurrence of something else. A natural sign bears a causal relation to its object—for instance, thunder is a sign of storm, or me ...
s of other abnormalities (e.g.,
spina bifida Spina bifida (SB; ; Latin for 'split spine') is a birth defect in which there is incomplete closing of the vertebral column, spine and the meninges, membranes around the spinal cord during embryonic development, early development in pregnancy. T ...
as evidenced by a
dimple A dimple, also called a gelasin (, ), and a fovea buccalis, is a small natural indentation in the flesh on a part of the human body, most notably in the cheek. Numerous cultures believe that cheek dimples are a good luck charm that entices peop ...
, hairy patch,
lipoma A lipoma is a benign tumor made of adipose tissue, fat tissue. They are generally soft to the touch, movable, and painless. They usually occur just under the skin, but occasionally may be deeper. Most are less than in size. Common locations inc ...
, or
hemangioma A hemangioma or haemangioma is a usually benign vascular tumor derived from blood vessel cell types. The most common form, seen in infants, is an infantile hemangioma, known colloquially as a "strawberry mark", most commonly presenting on the sk ...
). A thorough
neurological examination A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. This typically includes a physical examination and a review of the patient's medical his ...
is also performed, the
skin Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation. Other animal coverings, such as the arthropod exoskeleton, have different ...
for ''café au lait'' spots, indicative of
neurofibromatosis Neurofibromatosis (NF) refers to a group of three distinct genetic conditions in which tumors grow in the nervous system. The tumors are non-cancerous (benign) and often involve the skin or surrounding bone. Although symptoms are often mild, e ...
, the feet for cavovarus deformity, abdominal reflexes and muscle tone for
spasticity Spasticity () is a feature of altered skeletal muscle performance with a combination of paralysis, increased tendon reflex activity, and hypertonia. It is also colloquially referred to as an unusual "tightness", stiffness, or "pull" of muscles. ...
. When a person can cooperate, he or she is asked to bend forward as far as possible. This is known as the
Adams forward bend test The Adams Forward Bend Test is used in many situations to diagnose scoliosis; however, it is not a primary source for a diagnosis. This test is often used at schools and doctors' offices to check for scoliosis. The patient bends forward, as if th ...
and is often performed on school students. If a prominence is noted, then scoliosis is a possibility and an X-ray may be done to confirm the diagnosis. As an alternative, a
scoliometer A scoliometer is an instrument used to measure the distortions of the torso by a clinician to get a proper calculation/diagnosis confirmation of the condition (scoliosis). See also * Adams Forward Bend Test The Adams Forward Bend Test is used ...
may be used to diagnose the condition. When scoliosis is suspected, weight-bearing, full-spine AP/ coronal (front-back view) and
lateral Lateral is a geometric term of location which may also refer to: Biology and healthcare * Lateral (anatomy), a term of location meaning "towards the side" * Lateral cricoarytenoid muscle, an intrinsic muscle of the larynx * Lateral release ( ...
/
sagittal The sagittal plane (; also known as the longitudinal plane) is an anatomical plane that divides the body into right and left sections. It is perpendicular to the transverse plane, transverse and coronal plane, coronal planes. The plane may be in ...
(side view) X-rays are usually taken to assess the scoliosis curves and the
kyphosis Kyphosis () is an abnormally excessive convex curvature of the Spinal column, spine as it occurs in the Thoracic spine, thoracic and sacrum, sacral regions. Abnormal inward concave ''lordotic'' curving of the Cervical spine, cervical and Lumba ...
and
lordosis Lordosis is historically defined as an ''abnormal'' inward curvature of the lumbar spine. However, the terms ''lordosis'' and ''lordotic'' are also used to refer to the normal inward curvature of the lumbar and cervical vertebrae, cervical regio ...
, as these can also be affected in individuals with scoliosis. Full-length standing spine
X-ray An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...
s are the standard method for evaluating the severity and progression of scoliosis, and whether it is congenital or idiopathic in nature. In growing individuals, serial radiographs are obtained at 3- to 12-month intervals to follow curve progression, and, in some instances,
MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and rad ...
investigation is warranted to look at the spinal cord. An average scoliosis patient has been in contact with around 50–300 mGy of radiation due to these radiographs during this time period. The standard method for assessing the curvature quantitatively is measuring the
Cobb angle Cobb may refer to: People * Cobb (surname), a list of people and fictional characters with the surname Cobb * Cobb Rooney (1900–1973), American professional football running back Places New Zealand * Cobb River * Cobb Reservoir * Cobb Powe ...
, which is the angle between two lines, drawn perpendicular to the upper endplate of the uppermost vertebra involved and the lower endplate of the lowest vertebra involved. For people with two curves, Cobb angles are followed for both curves. In some people, lateral-bending X-rays are obtained to assess the flexibility of the curves or the primary and compensatory curves. Congenital and idiopathic scoliosis that develops before the age of 10 is referred to as early-onset scoliosis. Progressive idiopathic early-onset scoliosis can be a life-threatening condition with negative effects on pulmonary function. Scoliosis that develops after 10 is referred to as
adolescent idiopathic scoliosis Adolescent idiopathic scoliosis (AIS) is a disorder in which the spine starts abnormally curving sideways (scoliosis) between the ages of 10 and 18 years old. Generally, AIS occurs during the growth spurt associated with adolescence. In some teens ...
. Screening adolescents without symptoms for scoliosis is of unclear benefit.


Definition

Scoliosis is defined as a three-dimensional deviation in the axis of a person's
spine Spine or spinal may refer to: Science Biology * Spinal column, also known as the backbone * Dendritic spine, a small membranous protrusion from a neuron's dendrite * Thorns, spines, and prickles, needle-like structures in plants * Spine (zoology), ...
. Most instances, including the Scoliosis Research Society, define scoliosis as a
Cobb angle Cobb may refer to: People * Cobb (surname), a list of people and fictional characters with the surname Cobb * Cobb Rooney (1900–1973), American professional football running back Places New Zealand * Cobb River * Cobb Reservoir * Cobb Powe ...
of more than 10° to the right or left as the examiner faces the person, i.e. in the
coronal plane The dorsal plane (also known as the coronal plane or frontal plane, especially in human anatomy) is an anatomical plane that divides the body into Anatomical terms of location#Dorsal and ventral, dorsal and ventral sections. It is perpendicular t ...
. Scoliosis has been described as a biomechanical deformity, the progression of which depends on asymmetric forces otherwise known as the Hueter–Volkmann Law.


Management

Our lack of understanding of the etiology and pathogenesis of scoliosis makes it difficult to manage. Scoliosis curves do not straighten out on their own. Many children have slight curves that do not need treatment. In these cases, the children grow up to lead normal body posture by itself, even though their small curves never go away. If the patient is still growing and has a larger curve, it is important to monitor the curve for change by periodic examination and standing x-rays as needed. The rise in spinal abnormalities require examination by a neurosurgeon to determine if active treatment is needed. Although AIS normally does not cause health problems throughout development, the observable changes in appearance can have a substantial impact on teenagers, leading to quality-of-life concerns and, in extreme cases, emotional stress. The traditional medical management of scoliosis is complex and is determined by the severity of the curvature and skeletal maturity, which together help predict the likelihood of progression. The conventional options for children and adolescents are: # Observation # Bracing # Surgery # Physical therapy. Evidence suggests use of scoliosis specific exercises might prevent the progression of the curve along with possible bracing and surgery avoidance. For adults, treatment usually focuses on relieving any pain: # Pain medication # Posture checking # Bracing # Surgery Treatment for idiopathic scoliosis also depends upon the severity of the curvature, the spine's potential for further growth, and the risk that the curvature will progress. Mild scoliosis (less than 30° deviation) and moderate scoliosis (30–45°) can typically be treated conservatively with bracing in conjunction with scoliosis-specific exercises. Severe curvatures that rapidly progress may require surgery with spinal rod placement and spinal fusion. In all cases, early intervention offers the best results. A specific type of
physical therapy Physical therapy (PT), also known as physiotherapy, is a healthcare profession, as well as the care provided by physical therapists who promote, maintain, or restore health through patient education, physical intervention, disease preventio ...
may be useful. Evidence to support its use, however, is weak. Low quality evidence suggests scoliosis-specific exercises (SSE) may be more effective than electrostimulation. Evidence for the Schroth method is insufficient to support its use. Significant improvement in function, vertebral angles and trunk asymmetries have been recorded following the implementation of Schroth method in terms of conservative management of scoliosis. Some other forms of exercises interventions have been lately used in the clinical practice for therapeutic management of scoliosis such as global postural reeducation and the Klapp method.


Bracing

Bracing is normally done when the person 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. In some cases with juveniles, bracing has reduced curves significantly, going from a 40° (of the curve, mentioned in length above) out of the brace to 18°. Braces are sometimes prescribed for adults to relieve pain related to scoliosis. Bracing involves fitting the person with a device that covers the torso; in some cases, it extends to the neck (example being the Milwaukee Brace). The most commonly used brace is a TLSO, such as a
Boston brace The Boston brace, a type of thoraco-lumbo-sacral-orthosis (TLSO), is a back brace used primarily for the treatment of idiopathic scoliosis in children. It was developed in 1972 by M.E "Bill" Miller and John Hall at the Boston Children's Hospital in ...
, a
corset A corset /ˈkɔːrsɪt/ is a support garment worn to constrict the torso into the desired shape and Posture correction, posture. They are traditionally constructed out of fabric with boning made of Baleen, whalebone or steel, a stiff panel in th ...
-like appliance that fits from armpits to hips and is custom-made from fiberglass or plastic. It is typically recommended to be worn 22–23 hours a day, and applies pressure on the curves in the spine. The effectiveness of the brace depends on not only brace design and
orthotist An orthotist is a healthcare professional who specializes in the provision of orthoses. An orthotist has an overall responsibly of orthotics treatment, who can supervise and mentor the practice of other personnel. They are clinicians trained to a ...
skill, but also people's compliance and amount of wear per day. An alternative form of brace is a nighttime only brace, that is worn only at night whilst the child sleeps, and which overcorrects the deformity. Whilst nighttime braces are more convenient for children and families, it is unknown if the effectiveness of the brace is as good as conventional braces. The UK government have funded a large clinical trial (called the BASIS study) to resolve this uncertainty. The BASIS study is ongoing throughout the UK in all of the leading UK children's hospitals that treat scoliosis, with families encouraged to take part. Indications for bracing: people who are still growing who present with Cobb angles less than 20° should be closely monitored. People who are still growing who present with Cobb angles of 20 to 29° should be braced according to the risk of progression by considering age, Cobb angle increase over a six-month period, Risser sign, and clinical presentation. People who are still growing who present with Cobb angles greater than 30° should be braced. However, these are guidelines and not every person will fit into this table. For example, a person who is still growing with a 17° Cobb angle and significant thoracic rotation or flatback could be considered for nighttime bracing. On the opposite end of the growth spectrum, a 29° Cobb angle and a Risser sign three or four might not need to be braced because the potential for progression is reduced. The Scoliosis Research Society's recommendations for bracing include curves progressing to larger than 25°, curves presenting between 30 and 45°, Risser sign 0, 1, or 2 (an X-ray measurement of a pelvic growth area), and less than six months from the onset of menses in girls. Evidence supports that bracing prevents worsening of disease, but whether it changes quality of life, appearance, or back pain is unclear.


Surgery

Surgery is usually recommended by orthopedists for curves with a high likelihood of progression (i.e., greater than 45–50° of magnitude), curves that would be cosmetically unacceptable as an adult, curves in people with
spina bifida Spina bifida (SB; ; Latin for 'split spine') is a birth defect in which there is incomplete closing of the vertebral column, spine and the meninges, membranes around the spinal cord during embryonic development, early development in pregnancy. T ...
and
cerebral palsy Cerebral palsy (CP) is a group of movement disorders that appear in early childhood. Signs and symptoms vary among people and over time, but include poor coordination, spasticity, stiff muscles, Paresis, weak muscles, and tremors. There may b ...
that interfere with sitting and care, and curves that affect physiological functions such as breathing. Surgery is indicated by the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) at 45–50° and by the Scoliosis Research Society (SRS) at a Cobb angle of 45°. adolescents/surgical_treatment.htm. Accessed 27 January 2013 SOSORT uses the 45–50° threshold as a result of the well-documented, plus or minus 5° measurement error that can occur while measuring Cobb angles.
Surgeon In medicine, a surgeon is a medical doctor who performs surgery. Even though there are different traditions in different times and places, a modern surgeon is a licensed physician and received the same medical training as physicians before spec ...
s who are specialized in spine surgery perform surgery for scoliosis. To completely straighten a scoliotic spine is usually impossible, but for the most part, significant corrections are achieved. The two main types of surgery are: * Anterior fusion: This surgical approach is through an incision 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, takes four to eight hours. A new tethering procedure ( anterior vertebral body tethering) may be appropriate for some patients. Spine surgery can be painful and may also be associated with post-surgical pain. Different approaches for pain management are used in surgery including epidural administration and systemic
analgesia Pain management is an aspect of medicine and health care involving relief of pain (pain relief, analgesia, pain control) in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals ...
(also known as general analgesia). Epidural analgesia medication are often used surgically including combinations of local anesthetics and pain medications injected via an epidural injection. Evidence comparing different approaches for analgesia, side effects or benefits, and which approach results in greater pain relief and for how long after this type of surgery is of low to moderate quality.


Prognosis

A 50-year follow-up study published in the ''
Journal of the American Medical Association ''JAMA'' (''The Journal of the American Medical Association'') is a peer-reviewed medical journal published 48 times a year by the American Medical Association. It publishes original research, reviews, and editorials covering all aspects of ...
'' (2003) asserted the lifelong physical health, including cardiopulmonary and neurological functions, and mental health of people with idiopathic scoliosis are comparable to those of the general population. Scoliosis that interferes with normal systemic functions is "exceptional" and "rare", and "untreated coliosispeople had similar death rates and were just as functional and likely to lead productive lives 50 years after diagnosis as people with normal spines." In an earlier University of Iowa follow-up study, 91% of people with idiopathic scoliosis displayed normal pulmonary function, and their life expectancy was found to be 2% more than that of the general population. Later (2006–) studies corroborate these findings, adding that they are "reassuring for the adult patient who has adolescent onset idiopathic scoliosis in approximately the 50–70° range." These modern landmark studies supersede earlier studies (e.g. Mankin-Graham-Schauk 1964) that did implicate moderate idiopathic scoliosis in impaired pulmonary function. Generally, the prognosis of scoliosis depends on the likelihood of progression. The general rules of progression are larger curves carry a higher risk of progression than smaller curves, and thoracic and double primary curves carry a higher risk of progression than single lumbar or thoracolumbar curves. In addition, people not having yet reached skeletal maturity have a higher likelihood of progression (i.e., if the person has not yet completed the adolescent growth spurt).


Epidemiology

Scoliosis affects 2–3% of the United States population, or about five to nine million cases. A scoliosis (spinal column curve) of 10° or less affects 1.5–3% of individuals. The
age of onset The age of onset is the age at which an individual acquires, develops, or first experiences a condition or symptoms of a disease or disorder. For instance, the general age of onset for the spinal disease scoliosis is "10-15 years old," meaning t ...
is usually between 10 years and 15 years (but can occur younger) in children and adolescents, making up to 85% of those diagnosed. This is due to rapid growth spurts during
puberty Puberty is the process of physical changes through which a child's body matures into an adult body capable of sexual reproduction. It is initiated by hormonal signals from the brain to the gonads: the ovaries in a female, the testicles i ...
when spinal development is most susceptible to genetic and environmental influences. Because female adolescents undergo growth spurts before postural
musculoskeletal The human musculoskeletal system (also known as the human locomotor system, and previously the activity system) is an organ system that gives humans the ability to move using their muscular and skeletal systems. The musculoskeletal system provid ...
maturity, scoliosis is more prevalent among females. Although fewer cases are present since using
Cobb angle Cobb may refer to: People * Cobb (surname), a list of people and fictional characters with the surname Cobb * Cobb Rooney (1900–1973), American professional football running back Places New Zealand * Cobb River * Cobb Reservoir * Cobb Powe ...
analysis for diagnosis, scoliosis remains significant, appearing in otherwise healthy children. Despite the fact that scoliosis is a disfigurement of the spine, it has been shown to influence the pneumonic function,
balance Balance may refer to: Common meanings * Balance (ability) in biomechanics * Balance (accounting) * Balance or weighing scale * Balance, as in equality (mathematics) or equilibrium Arts and entertainment Film * Balance (1983 film), ''Balance'' ( ...
while standing and stride execution in children. The impact of carrying backpacks on these three side effects have been broadly researched. Incidence of idiopathic scoliosis (IS) stops after puberty when skeletal maturity is attained, however further curvature may occur during late adulthood due to vertebral
osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to more porous bone, and consequent increase in Bone fracture, fracture risk. It is the most common reason f ...
and weakened musculature.


History

Ever since the condition was discovered by the
Greek Greek may refer to: Anything of, from, or related to Greece, a country in Southern Europe: *Greeks, an ethnic group *Greek language, a branch of the Indo-European language family **Proto-Greek language, the assumed last common ancestor of all kno ...
physician A physician, medical practitioner (British English), medical doctor, or simply doctor is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through the Medical education, study, Med ...
Hippocrates Hippocrates of Kos (; ; ), also known as Hippocrates II, was a Greek physician and philosopher of the Classical Greece, classical period who is considered one of the most outstanding figures in the history of medicine. He is traditionally referr ...
, a cure has been sought. Treatments such as bracing and the insertion of rods into the spine were employed during the 1900s. In the mid-20th century, new treatments and improved screening methods have been developed to reduce the progression of scoliosis in patients and alleviate their associated pain. School children were during this period believed to develop poor posture as a result of working at their desks, and many were diagnosed with scoliosis. It was also considered to be caused by
tuberculosis Tuberculosis (TB), also known colloquially as the "white death", or historically as consumption, is a contagious disease usually caused by ''Mycobacterium tuberculosis'' (MTB) bacteria. Tuberculosis generally affects the lungs, but it can al ...
or
poliomyelitis Poliomyelitis ( ), commonly shortened to polio, is an infectious disease caused by the poliovirus. Approximately 75% of cases are asymptomatic; mild symptoms which can occur include sore throat and fever; in a proportion of cases more severe ...
, diseases that were successfully managed using vaccines and antibiotics. The American
orthopaedic surgeon Orthopedic surgery or orthopedics ( alternative spelling orthopaedics) is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...
Alfred Shands Jr. discovered that two percent of patients had non-disease related scoliosis, later termed ''idiopathic scoliosis'', or the "cancer of orthopaedic surgery". These patients were treated with questionable remedies. A theory at the time—now discredited—was that the condition needed to be detected early to halt its progression, and so some schools made screening for scoliosis mandatory. Measurements of shoulder height, leg length and spinal curvature were made, and the ability to bend forwards, along with body posture, was tested, but students were sometimes misdiagnosed because of their poor posture. An early treatment was the
Milwaukee brace The Milwaukee brace, also known as a cervico-thoraco-lumbo-sacral orthosis or CTLSO, is a back brace most often used in the treatment of spinal curvatures (such as scoliosis or kyphosis) in children but also, more rarely, in adults to prevent coll ...
, a rigid contraption of metal rods attached to a plastic or leather girdle, designed to straighten the spine. Because of the constant pressure applied to the spine, the brace was uncomfortable. It caused jaw and muscle pain, skin irritation, as well as low self-esteem.


Surgery

In 1962, the American orthopaedic surgeon 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 now obsolete
Harrington rod The Harrington rod (or Harrington implant) is a stainless steel surgical device. Historically, this rod was implanted along the spinal column to treat, among other conditions, a lateral or coronal-plane curvature of the spine, or scoliosis. Up ...
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 obviates the need for prolonged casting, allowing patients greater mobility in the postoperative period and significantly reducing the quality of life burden of fusion surgery. The Harrington rod was the precursor to most modern spinal instrumentation systems. A major shortcoming 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 the person aged, there would be increased wear and tear, early onset
arthritis Arthritis is a general medical term used to describe a disorder that affects joints. Symptoms generally include joint pain and stiffness. Other symptoms may include redness, warmth, Joint effusion, swelling, and decreased range of motion of ...
, disc degeneration, muscular stiffness, and acute pain. "Flatback" became the medical name for a related complication, especially for those who had
lumbar In tetrapod anatomy, lumbar is an adjective that means of or pertaining to the abdominal segment of the torso, between the diaphragm (anatomy), diaphragm and the sacrum. Naming and location The lumbar region is sometimes referred to as the lowe ...
scoliosis. In the 1960s, the gold standard for idiopathic scoliosis was a posterior approach using a single Harrington rod. Post-operative recovery involved bed rest, casts, and braces. Poor results became apparent over time. In the 1970s, an improved technique was developed using two rods and wires attached at each level of the spine. This segmented instrumentation system allowed patients to become mobile soon after surgery. In the 1980s, Cotrel–Dubousset instrumentation improved fixation and addressed
sagittal The sagittal plane (; also known as the longitudinal plane) is an anatomical plane that divides the body into right and left sections. It is perpendicular to the transverse plane, transverse and coronal plane, coronal planes. The plane may be in ...
imbalance and rotational defects unresolved by the Harrington rod system. This technique used multiple hooks with rods to give stronger fixation in three dimensions, usually eliminating the need for postoperative bracing.


Evolution

There are links between human spinal morphology, bipedality, and scoliosis which suggest an evolutionary basis for the condition. Scoliosis has not been found in
chimpanzee The chimpanzee (; ''Pan troglodytes''), also simply known as the chimp, is a species of Hominidae, great ape native to the forests and savannahs of tropical Africa. It has four confirmed subspecies and a fifth proposed one. When its close rel ...
s or
gorilla Gorillas are primarily herbivorous, terrestrial great apes that inhabit the tropical forests of equatorial Africa. The genus ''Gorilla'' is divided into two species: the eastern gorilla and the western gorilla, and either four or five su ...
s. Thus, it has been hypothesized that scoliosis may actually be related to humans' morphological differences from these apes. Other apes have a shorter and less mobile lower spine than humans. Some of the
lumbar vertebrae The lumbar vertebrae are located between the thoracic vertebrae and pelvis. They form the lower part of the back in humans, and the tail end of the back in quadrupeds. In humans, there are five lumbar vertebrae. The term is used to describe t ...
in '' Pan'' are "captured", meaning that they are held fast between the ilium bones of the pelvis. Compared to humans,
Old World monkey Old World monkeys are primates in the family Cercopithecidae (). Twenty-four genera and 138 species are recognized, making it the largest primate family. Old World monkey genera include baboons (genus '' Papio''), red colobus (genus '' Piliocolob ...
s have far larger
erector spinae muscles The erector spinae ( ) or spinal erectors is a set of muscles that straighten and rotate the back. The spinal erectors work together with the glutes ( gluteus maximus, gluteus medius and gluteus minimus) to maintain stable posture standing or ...
, which are the muscles which hold the spine steady. These factors make the lumbar spine of most primates less flexible and far less likely to deviate than those of humans. While this may explicitly relate only to lumbar scolioses, small imbalances in the lumbar spine could precipitate thoracic problems as well. Scoliosis may be a byproduct of strong selection for
bipedalism Bipedalism is a form of terrestrial locomotion where an animal moves by means of its two rear (or lower) Limb (anatomy), limbs or legs. An animal or machine that usually moves in a bipedal manner is known as a biped , meaning 'two feet' (from ...
. For a bipedal stance, a highly mobile, elongated lower spine is very beneficial. For instance, the human spine takes on an S-shaped curve with
lumbar lordosis Lordosis is historically defined as an ''abnormal'' inward curvature of the lumbar spine. However, the terms ''lordosis'' and ''lordotic'' are also used to refer to the normal inward curvature of the lumbar and cervical regions of the human spi ...
, which allows for better balance and support of an upright trunk. Selection for bipedality was likely strong enough to justify the maintenance of such a disorder. Bipedality is hypothesized to have emerged for a variety of different reasons, many of which would have certainly conferred fitness advantages. It may increase viewing distance, which can be beneficial in hunting and foraging as well as protection from predators or other humans; it makes long-distance travel more efficient for foraging or hunting; and it facilitates terrestrial feeding from grasses, trees, and bushes. Given the many benefits of bipedality which depends on a particularly formed spine, it is likely that selection for bipedalism played a large role in the development of the spine as we see it today, in spite of the potential for "scoliotic deviations". According to the fossil record, scoliosis may have been more prevalent among earlier hominids such as ''
Australopithecus ''Australopithecus'' (, ; or (, ) is a genus of early hominins that existed in Africa during the Pliocene and Early Pleistocene. The genera ''Homo'' (which includes modern humans), ''Paranthropus'', and ''Kenyanthropus'' evolved from some ''Aus ...
'' and ''
Homo erectus ''Homo erectus'' ( ) is an extinction, extinct species of Homo, archaic human from the Pleistocene, spanning nearly 2 million years. It is the first human species to evolve a humanlike body plan and human gait, gait, to early expansions of h ...
'', when bipedality was first emerging. Their fossils indicate that there may have been selected over time for a slight reduction in lumbar length to what we see today, favoring a spine that could efficiently support bipedality with a lower risk of scoliosis.


Society and culture

The cost of scoliosis involves both monetary loss and lifestyle limitations that increase with severity. Respiratory deficiencies may arise from thoracic deformities and cause abnormal breathing. This directly affects capacity for exercise and work, decreasing the overall quality of life. In the
United States The United States of America (USA), also known as the United States (U.S.) or America, is a country primarily located in North America. It is a federal republic of 50 U.S. state, states and a federal capital district, Washington, D.C. The 48 ...
, the average hospital cost for cases involving surgical procedures was $30,000 to $60,000 per person in 2010. As of 2006, the cost of bracing was up to $5,000 during rapid growth periods, when braces must be consistently replaced across multiple follow-ups. The month of June is recognized as Scoliosis Awareness Month to highlight and spread awareness of scoliosis. It emphasizes its wide impact and the need for early detection.


Research

Genetic testing Genetic testing, also known as DNA testing, is used to identify changes in DNA sequence or chromosome structure. Genetic testing can also include measuring the results of genetic changes, such as RNA analysis as an output of gene expression, or ...
for adolescent
idiopathic An idiopathic disease is any disease with an unknown cause or mechanism of apparent spontaneous origin. For some medical conditions, one or more causes are somewhat understood, but in a certain percentage of people with the condition, the cause ...
scoliosis, which became available in 2009 and is still under investigation, attempts to gauge the likelihood of curve progression.


See also

*
Back brace A back brace is a device designed to limit the motion of the spine in cases of bone fracture or in post-operative spinal fusiona, as well as a preventative measure against some progressive conditions or to correct a patient's posture. Common bac ...
*
Kyphosis Kyphosis () is an abnormally excessive convex curvature of the Spinal column, spine as it occurs in the Thoracic spine, thoracic and sacrum, sacral regions. Abnormal inward concave ''lordotic'' curving of the Cervical spine, cervical and Lumba ...
*
Lordosis Lordosis is historically defined as an ''abnormal'' inward curvature of the lumbar spine. However, the terms ''lordosis'' and ''lordotic'' are also used to refer to the normal inward curvature of the lumbar and cervical vertebrae, cervical regio ...
* Neuromechanics of idiopathic scoliosis *
Pott disease Pott's disease, or Pott disease, named for British surgeon Percivall Pott who first described the symptoms in 1799, is tuberculosis of the vertebral column, spine, usually due to haematogenous spread from other sites, often the lungs. The lowe ...
*
Scheuermann's disease Scheuermann's disease is a skeletal disorder. It describes a condition where the vertebrae grow unevenly with respect to the sagittal plane; that is, the posterior angle is often greater than the anterior. This uneven growth results in the sig ...
*
Schooliosis Schooliosis, 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. The authors asserted that there is some degree of overdiagnosis of scoliosis in school, which ...
*
Scoliosis Research Society The Scoliosis Research Society (SRS) 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 ...


References


External links


Early Onset Scoliosis
is the abnormal, side-to-side curve of the spine in children under five years old, often including children with congenital scoliosis (present at birth, with spine abnormalities) and infantile scoliosis (birth to three years).
Questions and Answers about Scoliosis in Children and Adolescents
– US National Institute of Arthritis and Musculoskeletal and Skin Diseases {{Authority control Bones of the vertebral column Congenital disorders of musculoskeletal system Deforming dorsopathies Wikipedia medicine articles ready to translate