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Scoliosis

Topic Overview

What is scoliosis?

Scoliosis is a problem with the curve in your spine. Some curves in your spine are normal. But a few people have spines that make a large curve from side to side in the shape of the letter "S" or the letter "C." If this curve is severe, it can cause pain and make breathing difficult.

The good news is that most cases of scoliosis are mild. If found early, they can usually be prevented from getting worse.

What causes scoliosis?

In most cases, the cause of scoliosis is not known. Scoliosis usually starts in childhood. Scoliosis that is severe enough to need treatment is most common in girls.

A curve in the spine may get worse as your child grows, so it is important to find any problem early.

What are the symptoms?

Scoliosis most often causes no symptoms in your child until the spinal curve becomes large. You might notice these early signs:

  • Your child has one shoulder or hip that looks higher than the other.
  • Your child's head does not look centered over the body.
  • Your child has one shoulder blade that sticks out more than the other.
  • Your child's waistline is flat on one side, or the ribs look higher on one side when your child bends forward at the waist.

In adults, scoliosis may cause back pain and trouble breathing.

How is scoliosis diagnosed?

The doctor will check to see if your child's back or ribs are even. If the doctor finds that one side is higher than the other, your child may need an X-ray so the spinal curve can be measured.

Scoliosis is most serious in young children who are still growing. A curve in the spine may get worse as your child grows. So many experts believe screening your child for scoliosis is important so that any curve in the spine can be found early and watched closely.

How is it treated?

Mild cases of scoliosis usually do not need treatment. Your doctor will check the curve of your child's spine every 4 to 6 months. If the curve gets worse, your child may need to wear a brace until he or she has finished growing. In severe cases, or if bracing doesn't help, your child may need to have surgery.

Scoliosis and its treatment can be a severe strain on your child. Wearing a brace can feel and look odd. It also limits your child's activity. Your child needs your support and understanding to get through treatments successfully.

What increases the risk of scoliosis?

Your child may be more likely to have scoliosis if someone in your family has had it and if your child is a girl. Other things that increase the chance of scoliosis include:

  • One of the bones in your child's spine has moved forward out of place compared to the rest of the spine.
  • Your child's arms or legs are missing or are abnormally short.
  • Your child has a disorder that affects the nerves, muscles, or bones.

Frequently Asked Questions

Learning about scoliosis:

Being diagnosed:

Getting treatment:

Ongoing concerns:

Living with scoliosis:

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  Scoliosis: Should I (or My Child) Have Surgery?

Cause

In most cases, the cause of scoliosis is not known. This is called idiopathic scoliosis. It develops mostly in children and teens and appears to be related to several things, including genetics, as it often runs in families.

There are two types of scoliosis: nonstructural and structural.

Nonstructural (functional) scoliosis

Nonstructural (functional) scoliosis involves a curve in the spine, without rotation, that is reversible because it is caused by a condition such as:

  • Pain or a muscle spasm.
  • A difference in leg length.

Structural scoliosis

Structural scoliosis involves a curve in the spine, with rotation, that is irreversible and is usually caused by an unknown factor (idiopathic) or a disease or condition such as:

  • Disorders that were present at birth (congenital), such as spina bifida, in which the spinal canal does not close properly; or a disorder that affects the formation of bones. These curves can be harder to correct. They often get worse as the child grows, especially during the teen years.
  • Nerve or muscle disorders, such as cerebral palsy, Marfan's syndrome, or muscular dystrophy.
  • Injuries.
  • Infections.
  • Tumors.

In adults, scoliosis may result from changes in the spine due to aging (degenerative changes).

Symptoms

In children and teens, scoliosis typically does not cause symptoms and is not obvious until the curve of the spine becomes moderate or severe. It may first become noticeable to a parent who observes that the child's clothes do not fit right or that hems hang unevenly. The child's spine may look crooked, or the ribs may stick out.

In a child who has scoliosis:

  • One shoulder may appear higher than the other.
  • One hip may appear higher than the other.
  • The child's head is not centered over his or her body.
  • One shoulder blade may stick out more than the other.
  • The ribs are higher on one side when the child bends forward from the waist.
  • The waistline may be flat on one side.

Most of the time scoliosis does not cause pain in children or teens. When back pain is present with scoliosis, it may be because the curve in the spine is causing stress and pressure on the spinal discs, nerves, muscles, ligaments, or facet joints. It is not usually caused by the curve itself. Pain in a teen who has scoliosis may indicate another problem, such as a bone or spinal tumor. If your child has pain associated with scoliosis, it is very important that he or she see a doctor to find out what is causing the pain.

Adults who have scoliosis may or may not have back pain. In most cases where back pain is present, it is hard to know whether scoliosis is the cause. But if scoliosis in an adult gets worse and becomes severe, it can cause back pain and difficulty breathing.

Some other conditions, such as kyphosis, cause symptoms similar to scoliosis.

What Happens

Idiopathic scoliosis, the most common type, does not have a known cause. Children who have this type of scoliosis usually first develop symptoms in childhood. Most cases of scoliosis are mild, involving small curves in the spine that do not get worse. Small curves usually do not cause pain or other problems. Usually a doctor examines the child every 4 to 6 months to watch for any changes.

In moderate or severe cases of scoliosis, the curves continue to get worse. During periods of growth, such as during the teenage growth spurt, the curves may get worse. Mild to moderate curves often stop progressing when the skeleton stops growing, while larger curves may get worse throughout adulthood unless they are treated.

Only about 1 out of 10 children who are diagnosed with scoliosis require treatment (either bracing or surgery).1

Things that may point to the potential increase in a spinal curve include:

  • The age of the child and the development stage, or maturity, of his or her skeleton when scoliosis is diagnosed. The less mature the skeleton is when scoliosis starts, the greater the chance that scoliosis will get worse. Skeletal age, as determined by the Risser sign, is also used to find out the risk that the curve will get worse.
  • The size of the curve. The larger the curve, the greater the risk that it will get worse.
  • The location and shape of the curve. Curves in the upper back are more likely to get worse than curves in the lower back.

Girls are more likely than boys to have larger curves and more severe scoliosis.

As scoliosis gets worse, the bones of the spine rotate toward the inner part of the curve. If the upper part of the spine is affected, the ribs may crowd together on one side of the body and become widely separated on the other side. The curve may force the space between the spinal bones to narrow. The spinal bones may also become thicker on the outer edge of the curve.

In severe curves, problems with the shape of the rib cage may reduce the amount of air that the lungs can hold and may cause the heart to work harder to pump blood through the compressed lung tissue. Over time, this can lead to heart failure.

Although it is uncommon, babies can be born with scoliosis (congenital) or can develop it during the first 3 years of their lives (infantile scoliosis). Scoliosis that is present at birth or that develops in infants may be worse in the long run than scoliosis that develops later in life. This is because the more growing the skeleton has to do, the worse the curve may get. But in some cases congenital curves do not get worse. And some curves that are present during infancy get better on their own without treatment.

What Increases Your Risk

Things that increase a person's risk for scoliosis include:

  • Family history. Scoliosis is known to run in families. Children—especially daughters—of women who have scoliosis are at increased risk for having scoliosis.2
  • Being female. Girls are more likely than boys to have a significant curve that requires treatment.

Scoliosis is more common in people who have:

  • A spinal bone that is pushed forward (forward displacement), usually in the lower back (spondylolisthesis).
  • Missing or abnormally short arms or legs.
  • Other disorders related to tissue development while in the womb.

When To Call a Doctor

Call your doctor to have your child evaluated for scoliosis if:

  • You observe a curve in your child's spine.
  • You notice that something about your child's posture looks unusual, such as ribs that stick out, one shoulder that is higher than the other, one hip that is higher than the other, or an uneven waistline.
  • You observe that your child's clothes don't fit properly or that his or her hems don't hang evenly.
  • A school screening program recommends that your child see a doctor.

Watchful waiting

If you suspect that your child has a spinal curve, ask a health professional to look at it. Early detection could lead to early treatment and could prevent a curve from getting worse.

If the results of a school screening program suggest that your child may have a spinal curve, follow up with your doctor. Most curves that are found through school screening programs are normal variations in the spine or mild scoliosis, and these curves usually require only regular observation.

Who to see

The following health professionals could identify and monitor scoliosis:

A doctor who specializes in surgery of the bones (orthopedic surgeon) may be consulted if the person has a moderate curve or if the curve is getting worse. The orthopedic surgeon will evaluate the curve and may recommend bracing or surgery.

A health professional who fits people with specially designed assistive devices (orthotist) can build and fit a custom brace.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Scoliosis testing usually begins with a history and physical exam. This includes the forward-bending test, a simple test in which the child bends forward at the waist, arms hanging loosely and palms touching, and the examiner looks for unevenness in the child's back or ribs. A scoliometer can be used to measure and estimate the rotation of the spinal curve.

If the findings of the history and physical exam show a significant spinal curve, an X-ray of the spine may be taken to get a more precise measurement of the spinal curve.

Skeletal age, as determined by the Risser sign, is also a helpful measure to find out the risk that the curve will get worse.

If someone in your family has scoliosis, your children should be checked regularly.

Neurological testing may be done on children who have scoliosis to see if they have certain disorders that are often associated with scoliosis, such as cerebral palsy or muscular dystrophy.

Early detection

Screening means doing a simple test to see whether further testing might be needed. Some states require screening for scoliosis by law. But experts don't agree with whether or not to screen for scoliosis.3, 4 Screening can lead to early treatment and may prevent curves from getting worse, but screening can also lead to more testing or treatment for children who would not have needed it. Some experts believe that children (especially daughters) of women who have scoliosis should be screened for scoliosis regularly throughout their late childhood and teen years.2 If you are concerned about screening for scoliosis, talk to your child's doctor.

Treatment Overview

The goal of treatment for scoliosis is to prevent the spinal curve from getting worse and to correct or stabilize a severe spinal curve. Fortunately, few people who have spinal curves require treatment.

The type of treatment depends on the cause of scoliosis. Scoliosis that is caused by another condition (nonstructural scoliosis) usually improves when the condition, such as muscle spasms or a difference in leg length, is treated. Scoliosis that is caused by a disease or by an unknown factor (structural scoliosis) is more likely than nonstructural scoliosis to need treatment.

  • Nonsurgical treatment. This includes either routine exams by a doctor to check for any curve progression or the use of a brace to stop a spinal curve from getting worse. Children typically have these checkups about every 4 to 6 months. Adults are usually checked about once each year.
  • Surgical treatment. Surgery can sometimes decrease the curve and can usually stabilize the spine so the curve does not get worse.

Treatment is based on the age of the person, the size of the curve, and the risk of progression. The risk of progression is based on age at diagnosis, the size of the curve (as measured using X-rays of the spine), and skeletal age (which can be determined by the Risser sign).

  • Mild curves are usually checked by the doctor every 4 to 6 months until the bones stop growing, to be sure the curves aren't getting worse.
  • Moderate curves may need to be braced until the bones stop growing, to keep the curves from getting worse.
  • Severe curves or moderate curves that are getting worse may need surgery.

What to think about

Most cases of scoliosis are mild and do not require treatment.

The timing of surgery for scoliosis in children is controversial. Spinal fusion stops the growth of the fused part of the spine, so some experts believe that surgery should be delayed until the child is at least 10 years old and preferably 12. But even after surgery the rest of the spine will continue to grow normally in children who are still growing.

Prevention

Scoliosis cannot be prevented. Treatment is aimed at preventing the curve from getting worse.

Home Treatment

If your child or teen has been diagnosed with mild scoliosis, it is important that a doctor check the child's spine every 4 to 6 months to see whether the curve is getting worse. Most spinal curves do not progress to the point where treatment is needed. But it is important to check for curve progression, because early treatment can often stop it.

Impact of scoliosis on a child or teen

Treatment for moderate or severe scoliosis can dramatically impact your child's life. If your child has scoliosis, it is important that your family be sensitive to the difficulty of having scoliosis and wearing a brace. A scoliosis clinic, where other children are being treated, can provide a supportive environment for your child.

Adult scoliosis

Adults who have scoliosis may have back pain. In addition to medicine, other steps that help to maintain or promote good health, such as regular exercise and proper back care, may help relieve back pain for some adults.

Medications

When back pain is present with scoliosis, it may be that the curve in the spine is causing stress and pressure on the spinal discs, nerves, muscles, ligaments, or facet joints. It is not usually caused by the curve itself. Some people may use nonprescription medicines such as aspirin and ibuprofen to treat back pain. While these medicines may relieve symptoms of back pain temporarily, they do not heal scoliosis or back injuries, nor do they stop the pain from coming back.

Surgery

Surgery may be used to treat severe scoliosis. The goal of surgery is to improve a severe spinal curve. The result will not be a perfectly straight spine, but the goal is to balance the spine and to make sure the curve does not get worse. Surgery usually involves stabilizing the spine and keeping the curve from getting worse by permanently joining the vertebrae together.

Things that are considered before surgery include:

  • The person's age.
  • The size, direction, and location of the spinal curve(s).
  • Whether other treatment (such as bracing) has failed.

Surgery may be considered if:

  • Your child has a moderate to severe curve or yours is severe, and the curve is getting worse
  • You have pain or trouble doing your daily activities.
  • Bracing cannot be used or does not work.
Click here to view a Decision Point.Scoliosis: Should I (or My Child) Have Surgery?

Surgery choices

The main type of surgery for scoliosis involves attaching rods to the spine and doing a spinal fusion. Spinal fusion is used to stabilize and reduce the size of the curve and stop the curve from getting worse by permanently joining the vertebrae into a solid mass of bone.

Other techniques are sometimes used, including instrumentation without fusion, which attaches devices such as metal rods to the spine to stabilize a spinal curve without fusing the spine together. This is only done in very young children when a fusion, which stops the growth of the fused part of the spine, is not desirable. The child usually has to wear a brace full-time after having this surgery.

What to think about

The timing of surgery for scoliosis in children is controversial. Spinal fusion stops the growth of the fused part of the spine, so some experts believe that surgery should be delayed until the child is at least 10 years old and preferably 12. But even after surgery the rest of the spine will continue to grow normally in children who are still growing.

Surgical treatment in children and teens usually requires several days in the hospital and limitations on activity for approximately a year. In adults, the average hospital stay is longer.

Adults who have surgery for scoliosis that results from changes in the spine due to aging (degenerative scoliosis) are more likely than children to have significant complications. Even though surgery usually reduces their pain, other complications, such as wound infections, may occur.

Other Treatment

Treatment other than surgery for scoliosis includes:

  • Observation. In a child who is still growing, a mild spinal curve may require only regular checkups every 4 to 6 months to see whether the curve is getting worse.
  • Wearing a brace. Bracing (orthotic) treatment may be used for a child who has a moderate curve. Bracing may prevent the curve from getting worse as the child grows. Brace treatment is usually continued until the skeleton stops growing.

There is no evidence that corrective exercises, electrical stimulation, or spinal manipulation are effective treatments for scoliosis.

Other Places To Get Help

Organizations

North American Spine Society
Web Address: www.spine.org

American Academy of Orthopaedic Surgeons (AAOS)
6300 North River Road
Rosemont, IL  60018-4262
Phone: (847) 823-7186
Fax: (847) 823-8125
Email: orthoinfo@aaos.org
Web Address: www.orthoinfo.aaos.org
 

The American Academy of Orthopaedic Surgeons (AAOS) provides information and education to raise the public's awareness of musculoskeletal conditions, with an emphasis on preventive measures. The AAOS website contains information on orthopedic conditions and treatments, injury prevention, and wellness and exercise.


References

Citations

  1. Staheli LT (2006). Spine and pelvis. In Practice of Pediatric Orthopedics, pp. 197–226. Philadelphia: Lippincott Williams and Wilkins.
  2. Hu SS, et al. (2006). Lumbar disc herniation section of Disorders, diseases, and injuries of the spine. In HB Skinner, ed., Current Diagnosis and Treatment in Orthopedics, 4th ed., pp. 246–249. New York: McGraw-Hill.
  3. U.S. Preventive Services Task Force (2004). Screening for Idiopathic Scoliosis in Adolescents: Recommendation Statement. Available online: http://www.uspreventiveservicestaskforce.org/uspstf/uspsaisc.htm.
  4. Richards BS, Vitale M (2007). SRS/AAOS Position statement: Screening for idiopathic scoliosis in adolescents. An information statement. Available online: http://www.aaos.org/about/papers/position/1122.asp.

Other Works Consulted

  • American Academy of Orthopaedic Surgeons and American Academy of Pediatrics (2010). Scoliosis. In JF Sarwark, ed., Essentials of Musculoskeletal Care, 4th ed., pp. 1164–1169. Rosemont, IL: American Academy of Orthopaedic Surgeons.
  • Erickson MA (2012). Orthopedics. In WW Hay Jr et al., eds., Current Diagnosis and Treatment: Pediatrics, 21st ed., pp. 830–848. New York: McGraw-Hill.
  • Negrini S, et al. (2010). Braces for idiopathic scoliosis in adolescents (Review). Cochrane Database of Systematic Reviews (1).
  • Paul SM (2010). Scoliosis and other spinal deformities. In WR Frontera, ed., DeLisa's Physical Medicine and Rehabilitation, 5th ed., vol. 1, pp. 883–906. Philadelphia: Lippincott Williams and Wilkins.
  • Rowe DE (2003). The Scoliosis Research Society Brace Manual. Available online: http://www.srs.org/professionals/education_materials/SRS_bracing_manual/section1.pdf.

Credits

By Healthwise Staff
John Pope, MD - Pediatrics
Robert B. Keller, MD - Orthopedics
Last Revised July 26, 2013

Last Revised: July 26, 2013

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