What is Scoliosis?
Scoliosis is a sideways curvature of the spine accompanied by a twisting of the spine. This can cause the shoulders, hips or waist to appear uneven.
The twist is best seen by others when you bend forwards at the hips.
Why do I have scoliosis?
Scoliosis in NOT a diagnosis on its only: it describes the shape of the spine (bending to the side and rotated).
There are multiple causes of scoliosis- it is essential to determine the cause of the scoliosis to determine what the natural history will be be and what the appropriate management is.
By far the most common “cause” of scoliosis. The exact underlying reason for the curve is not known. There are genetic influences but oftentimes there is no reason found
(a) adolescent idiopathic scoliosis
This occurs as the child approaches maturity and is going through their major adolescent growth spurt.
(b) early onset scoliosis
This is a curve that occurs in a younger child for no known reason.
A structural problem that has been present from the early formation of the spine before birth. This can be extremely variable in outcomes: ranging from no symptoms and no treatment necessary to a progressive problem that needs early surgery.
This type of scoliosis happens because abnormal nerves or muscles are weak and failing to hold the spine up straight.
Common neurological conditions that can cause scoliosis include :
- Cerebral palsy
- Muscular dystrophy
Scoliosis: what makes it get worse?
While the reasons why the scoliosis occurred may remain a mystery, we do have much clearer information about what makes curves get worse. The combination of growth and gravity are the two forces that are drive curves to become worse. The faster the growth the more likely the scoliosis will get worse.
The bones of the spine, which should be square shaped, are each growing. If they are growing fast and under pressure from a curve they tend to grow more wedge shaped (triangular).
The shape problem becomes fixed in the shape of the individual bones and joints. Part of the assessment of the scoliosis will be to determine how much growing we expect is still remaining and what the risks are of developing a much bigger curve
What are the treatment options for Scoliosis?
Many curves are mild enough (generally less than 25 degrees) that they do not require active treatment. Although they may well not increase with time they certainly need ongoing observation with xrays until the child is skeletally mature.
It is important to remember that there is nothing weak nor brittle about your spine; you can participate in all physical activities that you want.
Physiotherapy may assist with symptoms and addressing associated asymmetries in the surrounding musculature, such as those present around the shoulder girdle, hips and spine.
There are physiotherapy scoliosis specific exercise (PSSE) methods that aim to improve the postural components of the curve, improve flexibility of the restricted regions and improving the strength of specific postural weaknesses identified. The most widely known PSSE is the Schroth based method (BSBTS).
When do you use a brace?
For those who patients who have significant growth remaining and have an acceptable curve (usually between 25 and 40 degrees) the best way to maintain this curve is brace treatment. In recent years we have had very solid evidence that braces work in preventing worsening of the scoliosis, and avoiding the progression to a level that requires surgery.
The brace studies have shown that there is a direct relationship between the time that a brace is worn and the effectiveness of the brace. Use of the brace less than 12 hours per day does not show effectiveness.
Progressing upwards to about 20 hours per day shows a steady improvement in the results. We encourage normal physical activity and for these purposes removing the brace is a good idea to maintain strength and movement with physical exercise.
A seven year old female with a severe unbraceable scoliosis. After two plasters the curve has gone from 69 degrees down to 38 degrees and she can now be fitted for a brace.
- Degree of curve
- Location of curve
- Age/maturity of patient
- Underlying conditions(s)
Posterior instrumentation and fusion.
This is the most common surgical procedure used for adolescent idiopathic scoliosis.
It is performed from behind. Philosophically, we are committed to “selective” position instrumentation to ensure the levels fused are kept to a minimum.
Vertebral Body tethering (VBT)
This is a new procedure that is used with the skeletally immature patient where a brace has failed or can be expected to fail.
Like anterior fusion surgery the surgery is done from the front of the spine. Rather than correct the scoliosis with a rod, a polyester tether is placed between the vertebrae to gain compression and correction.
The discs are left intact so that the vertebrae do not fuse to each other. This will allow the immature to continue growing and hopefully further improve the correction.
Why has VBT become so popular?
The early return to activity appears to be quicker with VBT than fusion techniques. The spine continues to grow with VBT which then allows further improvement of the scoliosis (as shown below). It appears that there remains movement in the instrumented spine and in addition there is improved motion in the non-instrumented lumbar spine compared to a posterior fusion.
These are sometimes used in the very young child whose curve is not controlled by brace/plaster and yet is too young for definitive scoliosis instrumentation (either fusion or VBT). There are two main types used:
(1) Traditional growing rods
Two rods are placed posteriorly with attachments to the spine at the top and at the bottom of the curve with no attempt to fuse the spine. Every six-nine months the child returns to theatre and the rods are lengthened. This procedure has been associated with a many problems including infection, skin breakdown, multiple surgeries and premature fusion.
(2) Magnetically controlled growth rods
One or two rods are placed posteriorly with attachments at the top and at the bottom of the curve(s)and then the rods are very slowly lengthened using an externally held magnet to gradually lengthen the rod. Whilst this requires fewer planned returns to theatre than the traditional growing rods they have not worked out as well as originally hoped for. Problems include premature fusion of the spine as well as mechanical issues with the implants.