Pediatric Injuries

Our Specialties

Scoliosis

Anatomy

The spinal column is made up of small bones (vertebrae) stacked on top of one another, creating the natural curves of the back. Between the vertebrae are flat, round, rubbery pads (intervertebral disks) that act as shock absorbers and allow the back to flex or bend. Muscles and ligaments connecting the vertebrae allow motion while providing support and stability for the spine and upper body. Each vertebra has an opening (foramen) in the center and these line up to form the spinal canal. Protected by the vertebrae, the spinal cord and other nerve roots travel through the spinal canal. Nerves branch out from the spinal column through vertebral openings, carrying messages between the brain and muscles. Facet joints align at the back of the spinal column, linking the vertebrae together and allowing for rotation and movement. Like all joints, cartilage covers the surface where facet joints meet.

The spine contains three segments: lumbar, thoracic and cervical. The lumbar spine consists of five vertebrae located in the lower back; lumbar vertebrae are larger because they carry more of the body's weight. The thoracic spine consists of 12 vertebrae and begins at the upper chest, extending to the middle back and connecting to the rib cage. The cervical spine includes the neck and consists of seven small vertebrae, beginning at the base of the skull and ending at the upper chest. Disks in the lumbar spine are composed of a thick outer ring of cartilage (annulus) and an inner gel-like substance (nucleus). In the cervical spine, disks are similar but smaller in size.

Description

Scoliosis is a common condition of the spine that affects many children and adolescents. Unlike a normal spine that runs straight down the middle of the back, a spine with scoliosis forms a sideways curve that may look like a letter "C" or "S." Scoliosis can cause the spine to rotate or turn, resulting in a shoulder, shoulder blade (scapula), or hip that appears higher than the other. Although small spinal curves occur in boys and girls with similar frequency, girls are more likely to have a progressively larger scoliotic curve that requires treatment. Scoliosis is not a contagious disease and there is nothing you could have done to prevent it.

Scoliosis can occur at any age. The most common type, adolescent idiopathic scoliosis, occurs between 10 years of age and when the child is fully grown. Infantile scoliosis occurs in children under 3 years of age and may result from abnormally shaped vertebrae at birth (congenital), various syndromes, neurologic disorders, or other unknown (idiopathic) causes. Juvenile scoliosis, the least common, occurs in children between 3 and 10 years of age.

  • Idiopathic scoliosis—The term "idiopathic" means unknown cause. The majority of scoliosis cases (80-85%) are idiopathic, but we do know that it tends to run in families. Approximately 30% of adolescent idiopathic scoliosis (AIS) patients have a family history of scoliosis.

    Adolescent idiopathic scoliosis is not life threatening. While most curves do not cause serious issues, a large curve may affect growth and a very large curve may cause heart and lung problems. Although quite rare, an extremely severe curve can also compress nerve roots or the spinal cord, which can result in paralysis. Proper treatment will prevent progression of the curve to such a severe degree.
  • 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. This type of scoliosis can be associated with other health issues, including 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.

Symptoms

The primary concern for patients and parents is often the cosmetic appearance of the back. Scoliosis does not typically cause pain, neurological dysfunction or respiratory problems, and the incidence of back pain among scoliosis patients is similar to that of the general population. However, larger curves may cause occasional discomfort for patients with adolescent scoliosis. If back pain is severe or associated with any weakness of the limbs, or numbness, call your physician immediately.

Left untreated, curves exceeding 50° can lead to long-term problems. In these cases, progressive deterioration of the scoliotic curve can occur, which in some patients can lead to diminished lung capacity and the development of restrictive lung disease.

Causes

Scoliosis is considered a partially genetic condition and is not preventable. According to recent research, about one in three children whose parents have scoliosis will also develop the condition.

  • Bad posture—This will not cause scoliosis, however, scoliosis could be the reason for poor posture, especially if the child leans to one side.
  • Sports activities or heavy book bags or backpacks—These do not cause scoliosis or make a curve worse. However, heavy backpacks can be related to back pain. If back pain occurs, lighten your child's load and be sure the backpack is carried properly, with straps over both shoulders.
  • Differences in leg length—This does not cause scoliosis, but a large difference can make it appear worse. Although uncommon, in this instance, a shoe lift may be recommended.
  • Injury and trauma—These are not causes of idiopathic scoliosis.

Diagnosis

Scoliosis is often first detected during a scoliosis screening at school, or a regular check-up with the pediatrician, although these may be less frequent for adolescents. Because it is rarely painful, scoliosis may not be discovered until there are obvious signs. Scoliosis curves may not appear until the teenage years, and small curves often go unnoticed until the child hits a growth spurt during puberty. A self-conscious adolescent may wear baggy clothing that conceals the curve until it is revealed by more form-fitting clothing (bathing suits, t-shirts).

During an examination, your child may be asked to bend forward while the physician looks for any deformities, limb-length discrepancies, or abnormal neurological findings. X-rays will allow your physician to confirm the diagnosis and measure the degree of the curve.

  • General recommendations for screening—Your child can be screened at any age, however idiopathic scoliosis is typically 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 (usually grades 5 and 7), and boys once at 12 or 13 years of age (usually grades 8 or 9).
  • Screenings for siblings of scoliosis patients—Scoliosis tends to run in families, so siblings should be checked at yearly physical examinations, especially during growth spurts (10 to 15 years old). Early detection is important and parents can help by looking at the back while the child wears a bathing suit. If one shoulder appears higher than the other, or one side of the ribcage protrudes more than the other, call your pediatrician.
  • Screenings for children of scoliotic parents—Children of scoliotic parents should be checked at their yearly physical examinations, especially during their growth spurts (10 to 15 years old).

Plan of Treatment

Idiopathic scoliosis curves do not straighten out on their own. Many children have slight curves that do not require treatment, and although their curves never go away, they grow up to lead normal lives. Larger curves may require treatment. If your child's spine is still growing, it is more likely that the curves will worsen. Bracing and surgery are the only treatments shown to affect idiopathic scoliosis. Physical therapy, electrical stimulation, chiropractic care, or other options typically do not have an impact on scoliosis curves. The treatment plan for your child will be determined by the severity and location of the curve, as well as your child's age and the remaining number of growth years until your child reaches skeletal maturity.

Nonsurgical Treatment

Patients who do not require surgery are able to participate in the same activities and sports as those who do not have scoliosis, and there are rarely any restrictions on activities.

  • Observation—This is appropriate when the curve is mild (less than 20°) or the child is near skeletal maturity. To be sure the curve is not progressively worsening, your physician may want to see your child every 3 to 6 months for re-examination. Many instances of scoliosis identified by school screening fall into this category.
  • Bracing—This may be recommended if the child is still growing and has a spinal curvature between 25° and 45°. The goal of bracing is to prevent worsening of the scoliotic curve to the point of needing surgery. Your physician will prescribe a type of brace and the length of time it should be worn each day. Wearing a brace should not prevent participation in sports and time spent out of the brace is allowed for involvement these activities.

Surgery

If the curve is severe (more than 45° to 50°) and the child is still growing, surgery is commonly recommended to lessen the curve and prevent it from worsening. If the patient has reached skeletal maturity, surgery may still be recommended for a scoliotic curve that exceeds 50° to 55°. During surgery, an implant made of rods, hooks, screws and/or wires is used to straighten the spine. Bone graft, either from the patient's hip region or from the bone bank, may be used to help the bone heal.

By the second day, patients are usually walking with no need for a brace. Patients are typically discharged from the hospital within 1 week and can rapidly resume their daily activities.

Complications

As with any surgery, there are some risks, and these vary from person to person. Complications are typically minor, treatable and unlikely to affect your final outcome. For most people, surgery can provide relief of symptoms and return to function with relatively low risk of complications. Overall, elderly patients have higher rates of complications from surgery, as do patients who are overweight, diabetics, smokers, or suffering from multiple medical problems. Among the general, potential risks associated with surgery are infection, bleeding and blood clots, and reactions to anesthesia. Be sure to discuss the potential risks and benefits with your surgeon prior to surgery.

Outcomes

After recovering from surgery, patients typically do not experience much pain. Normal participation in sports and other activities is usually possible within 6 to 9 months, however, due to permanent limitation of some spinal movement following surgery, participation in contact sports, such as football or rugby, is discouraged. The spine fusion should not interfere with any future pregnancies or deliveries. Discuss specific restrictions or recommendations with your child's physician.

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