Scoliosis Deformity

Scoliosis is the term given to lateral, or sideways curvature of the spine, when viewing the spine from front to back. Scoliosis is relatively common, affecting up to 1-3% of the population. For most people afficted with this condition, the curves remain relatively small, have little effect on overall function of the body, and often go completely unnoticed. School screening programs have highlighted scoliosis as a known and treatable condition, and have raised awareness of its prevalence in the general population.

There are several categories of scoliosis, based on cause. The most common variety, idiopathic scoliosis, is so named because its cause is as yet unknown. Although several genetic markers for this sort of scoliosis have been discovered, transmission of scoliosis genes follows a poly- factorial type of inheritance pattern, leading to roughly 5% of children of parents with idiopathic scoliosis having scoliosis themselves. Idiopathic scoliosis is further sub-classified based on age of discovery: infantile, discovered between 1 to 3 years; juvenile, discovered between 3 to 8 years; and adolescent, discovered after 8 years of age. Typically, the earlier scoliosis is discovered, the more likely it is to progress to more severe proportions, requiring further treatment such as bracing, and possibly even surgery. Usually, once scoliosis is discovered it remains a part of that patients life for ever. However, in some children diagnosed with infantile scoliosis, the curves will disappear.

Congenital scoliosis is defined as scoliosis discovered at birth, usually presenting itself through malformed vertebra or discs. Vertebra, normally separated from one another by discs, may be fused together on on side, allowing the other side to overgrow, leading to sideways curvature; or, a partial vertebra may be present only on one side of the spine, leading to growth of that partial vertebra, pushing the spine over as the malformed vertebra grows.

Paralytic scoliosis is seen in patients with disorders of the nervous or musculature systems, leading to weakness or spasticity of the trunk muscles. This leads to a very characteristic type of scoliosis pattern in which the spine has a long, C shaped curvature.

Degenerative scoliosis occurs in later life as the vertebra, discs, and facet joints begin to wear out from degenerative causes. This can lead to uneven forces being transmitted through the spine, with the spine ultimately curving asymmetrically. This can lead to back pain, leg pain, or it may be completely asymptomatic.

Traumatic and cancer related scoliosis result form injury or destruction of vertebra by pathologic processes. These are less common causes of scoliosis.

Treatment of Scoliosis

scoliosis treatment
Scoliosis is often diagnosed in school screening programs in elementary school. A forward bending test allows the physician to view down the length of the spine from buttock to head. An un curved spine will look straight and symmetric from this perspective. A spine with scoliosis will be asymmetric from this perspective, with one side of the spine being more prominent than the other. This occurs because in scoliosis, not only are the vertebra tilted, but they also are rotated. This rotation in the thoracic spine leads to the ribs being elevated on one side while the ribs on the other side are relatively depressed. It is this rotation that results in scoliosis being visible in most patients with scoliosis.

Treatment of scoliosis is driven by several factors. Cosmesis, or the appearance of the spine, is a common worry for patients with scoliosis. Thinner people who wear tight fitting clothes, or who participate in water sports may worry about their appearance when they have scoliosis. More significant concerns arise from fears about large curves causing crowding of the internal organs, potentially interfering with lung or heart function. Thankfully, only the most severe curves (greater than 90 degrees) lead to significant changes in heart or lung function. One final concern is that progressively

worsening curves may lead to problems later in life, such as problems with carrying pregnancies to full term, pain from the curves, or becoming crippled by the scoliosis. The only studies that have shown any problems with pregnancy for patients with scoliosis revealed that girls who carried multiple pregnancies to full term before they were 23 years old developed worsening curves. Fear about significant pain developing later in life for most patients with scoliosis are unfounded. However, patients with large lumbar curves often do develop increasing low back pain later in life.

Observation

Idiopathic Scoliosis, once discovered, is usually observed with routine xray examinations throughout growth of the spine. Spinal growth continues through adolescence. For girls, spine growth typically continues rapidly for at least 18-24 months after the onset of periods (menarche). For boys, spine growth continues until there has been development of most secondary sexual characteristics such as arm pit hair growth, pubic hair growth, and lowering of the voice.

Bracing

Bracing is begun when clear evidence exists that rapid increase of the size of the curve is occurring, or when a curve reaches 25 degrees and there remains significant skeletal growth. Bracing, in general, is done with a 23 hour Boston brace or with a 12 hour Charleston night time bending brace. Braces are made of plastic, are low profile, and with somewhat loose fitting clothes, are hard to notice. Another type of brace made of straps has recently been introduced, is very low profile, but to date, there are no convincing studies that show that it is effective in preventing curves from getting bigger. Braces function by irritating the skin and muscles on the curved side of the spine, causing the body to move away from the irritation, and therefore straighten. Braces do make spines straighter while braced, but the ultimate goal of bracing is to prevent curves from getting worse. Even with bracing, some curves will progress. Chiropractic and Physical Therapy

In general, chiropractic and physical therapy are not curative for scoliosis, and claims to the contrary should be viewed with great suspicion. Although both chiropractic and physical therapy may be beneficial in relief of pain, they are not capable of changing the natural history of curve progression. Older patients ( thirties, forties, fifties, and beyond), who present themselves for treatment of back pain are in a different category, and may benefit from physical therapy especially.

Surgery

The rationale for surgery is to prevent the otherwise inevitable progression of curves, to improve cosmesis, or to try to improve pain that has occurred as a result of scoliosis. Curves are usually observed, and then braced until they reach 50 degrees in adolescents, or even less in older patients who have developed severe pain from their curves. There are many types of surgery for scoliosis. Techniques for scoliosis correction have evolved dramatically over the last 30 years. Modern techniques center primarily on fixing the curves from the back with screws and rods. Some surgeons offer surgeries through the chest, and some offer minimally invasive thoracoscopic sugeries. Each surgery has its advantages and disadvantages, and should be discussed throughly with the surgeon. It is crucial that surgery not be done by the occasional scoliosis surgeon, but instead this demanding surgery should be done only by very well trained surgeons, with a dedicated team in place to help the patient through the rigorous recovery phase after surgery.

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