Scoliosis

What is scoliosis?

Scoliosis is a sideways curve in the spine. While small curves are common, only about 2-3% of people will actually develop scoliosis. A much smaller percentage of those people will actually benefit from some form of treatment.

Why is scoliosis important to detect?

Some curves in the spine can get worse over time. In general, most scoliosis is at highest risk for progressing while your child is growing, and in particular while they are growing rapidly, such as around an adolescent growth spurt. When your child stops growing, most smaller curves will also stop progressing and tend to not cause significant problems later on in life. However, once curves get big enough, they may slowly get worse over time. This slow progression can be significant over the course of a lifetime and can lead to problems with increasing deformity, pain and decreased lung capacity and exercise tolerance leading to shortness of breath with exertion.

What causes scoliosis?

There are several causes of scoliosis. In a vast majority of scoliosis (over 80%), an underlying cause cannot be determined. This most common type of scoliosis is termed “idiopathic scoliosis.” Scoliosis can also be related to abnormal formation or segmentation of the bones of the spine during fetal development. This is known as congenital scoliosis. Syndromic scoliosis refers to curves of the spine that are related to specific diagnosed conditions, such as Marfan syndrome or neurofibromatosis. Neuromuscular scoliosis is very common in conditions that can affect the function of the nerves or muscles, such as cerebral palsy, spina bifida, spinal muscular atrophy and muscular dystrophy.

How is scoliosis found?

As the spine curves, there can be subtle changes to the appearance of the body. You or your pediatrician may notice differences in the heights of the shoulders, asymmetry or protrusion of one of the shoulder blades or one side of the back, asymmetry of the waist, hips, rib cage or chest or shifting or leaning of the body to one side.

Your child will likely be screened for scoliosis yearly by their pediatrician at their well-child checkups, particularly as they start to approach their adolescent growth spurt. Your child’s school may also perform routine screening around the same age, or as part of pre-sports participation evaluations. This screening typically involves a visual inspection of the back looking for the asymmetries noted above, as well as the forward bending test. In this test, the child bends forward at the waist like they are going to touch their toes, and the back is inspected for unevenness that can be produced as the spine twists in scoliosis.

How is scoliosis diagnosed?

If there is concern based on a screening examination for scoliosis, your provider may order an X-ray of the spine or refer you to a scoliosis specialist. A diagnosis is made based on a review of your child’s current symptoms, medical history, family history and a detailed physical exam. If imaging is necessary, an official diagnosis of scoliosis can be made if curvature of more than 10 degrees can be measured on a standing or upright X-ray. In some cases, other imaging tests such as magnetic resonance imaging (MRI) or computed tomography (CT) are used to help guide treatment.

How is scoliosis treated?

Based on your child's age and expected amount of growth remaining, magnitude of the curvature, location of the curvature, gender, medical conditions, and symptoms, you and your physician will discuss treatment options and decide on a plan together.

Observation: Observation is appropriate for most cases of scoliosis. This is common for children who have curves less than 20°, and for children who have completed growth with mild or moderate scoliosis. You may visit with your physician about every 4-6 months or longer depending on your child's risk for progression for an exam and new X-rays to monitor for any changes in your child's scoliosis.

Bracing: Bracing may be recommended for your child if they have a curve between 20-25° and 45° and have growth remaining. The goal of bracing is to limit or halt the progression of the scoliosis while your child is still growing. There are many different types of braces for scoliosis, but the most common design is a light weight, rigid plastic brace that extends from the armpits to the waist and is worn under the clothing. Braces are custom made for each patient, and a thin shirt is worn underneath the brace to prevent skin irritation. The amount of time in the brace each day will be determined by your physician, but often is 18 or more hours per day. Generally, if you choose bracing as a treatment option, he will visit with specialist approximately once every 6 months to check the brace fit and monitor the scoliosis.

Surgery: Surgery is typically offered to patients whose scoliosis has progressed to a point where they are at risk for continued progression after they have finished growing. This risk tends to increase when curves are at least 50° in the thoracic spine (chest area), and approximately 40-45 degrees in the lumbar spine (lower back).

The most common procedure performed for scoliosis is a spinal fusion. This type of procedure is appropriate for children who have completed a majority of their growth or have finished growing. For children who have a significant amount of growth remaining, generally those children under about age 10 years, a number of procedures exist to help manage scoliosis while still allowing for continued growth of the spine, chest and lungs. These procedures include growing rods, magnetically controlled growing rods (MAGEC rods), vertebral body tethering (“The Tether”), and growth guidance (“Shilla procedure”). The specific procedure recommended by your surgeon will be based on your child's remaining growth and particular curve characteristics.

If you and your surgeon choose to pursue surgery, you will be given detailed information about what will happen prior to your surgery. Below is some information of a typical patient journey, and a detailed roadmap can be downloaded here. 

• In your preoperative visit, which will usually occur 2-4 weeks prior to your scheduled surgery date, you and your child will meet with your surgeon to discuss the procedure and have special X-rays taken. You will visit the outpatient lab and have blood work done. You will learn how to get ready for surgery and meet with the anesthesia team in the Center for Preoperative Assessment and Planning (CPAP). You will learn what to expect during the operation and what to expect while in the hospital. 
• Two weeks before surgery, you will stop taking NSAID medications (Ibuprofen, aspirin, naproxen, ketorolac).
• Five days before surgery, you will use mupirocin ointment if prescribed and take bowel medications if indicated by surgery team.
• Three days before surgery, you will wash your body with antibacterial Hibiclens soap, making sure to clean your back well. You will continue to bathe with this soap until your surgery.
• One the day before surgery, your care team will call and tell you when to arrive for surgery and when to stop eating and drinking (usually after midnight). You will shower with antibacterial Hibiclens soap and wear freshly-washed clothes to sleep. 
• On the day of surgery, you will shower with antibacterial Hibiclens soap, take medications as directed by CPAP, and have nothing to eat or drink as instructed. Once you arrive at the hospital, your care team will help you get ready for surgery. After surgery, you will be transferred to recovery room and then an inpatient room at the hospital. 
• One day after surgery, while in the hospital, you will use your incentive spirometer and do exercises with physical therapy. You will be given medications to manage pain and will drink more clear liquids and advance to regular diet as your stomach tolerates. 
• Two days after surgery, while still in the hospital, you will continue to use your incentive spirometer and increase your physical activity gradually. You may be able to eat a regular diet and drink plenty of liquids.
• Three days after surgery, you will continue as the day before and prepare to go home. You may have X-rays taken, and we will be prescribed medications as needed. You will leave hospital with filled prescriptions and a follow-up appointment time.

 

We have offices across the St. Louis area, including West County, South County, St. Charles County and on the Washington University Medical Campus. For an appointment with an orthopedic spine specialist, call (314) 514-3500 or request an appointment online.

 Learn more about pediatric and adolescent orthopedic surgery.