Congenital scoliosis results from embryological malformation of one or more vertebrae and may occur in any location of the spine.
What Is Scoliosis and What Causes It?
The vertebral abnormalities cause curvature and other deformities of the spine because one area of the spinal column lengthens at a slower rate than the rest. The geometry and location of the abnormalities determine the rate at which the scoliosis progresses in magnitude as the child grows. Because these abnormalities are present at birth, congenital scoliosis is usually detected at a younger age than idiopathic scoliosis.
Neuromuscular scoliosis encompasses scoliosis that is secondary to neurological or muscular diseases. This includes scoliosis associated with cerebral palsy, spinal cord trauma, muscular dystrophy, spinal muscular atrophy and spina bifida. This type of scoliosis generally progresses more rapidly than idiopathic scoliosis and often requires surgical treatment.
There are several signs that may indicate the possibility of scoliosis. If one or more of the following signs is noticed, schedule an appointment with a doctor. In one study, about 23 percent of patients with idiopathic scoliosis presented with back pain at the time of initial diagnosis. Ten percent of these patients were found to have an underlying associated condition such as spondylolisthesis, syringomyelia, tethered cord, herniated disc or spinal tumor.
If a patient with diagnosed idiopathic scoliosis has more than mild back discomfort, a thorough evaluation for another cause of pain is advised. Due to changes in the shape and size of the thorax, idiopathic scoliosis may affect pulmonary function. Recent reports on pulmonary function testing in patients with mild to moderate idiopathic scoliosis showed diminished pulmonary function. Scoliosis is usually confirmed through a physical examination, an x-ray, spinal radiograph, CT scan or MRI.
The curve is measured by the Cobb Method and is diagnosed in terms of severity by the number of degrees. A positive diagnosis of scoliosis is made based on a coronal curvature measured on a posterior-anterior radiograph of greater than 10 degrees. In general, a curve is considered significant if it is greater than 25 to 30 degrees.
Curves exceeding 45 to 50 degrees are considered severe and often require more aggressive treatment. A standard exam that is sometimes used by pediatricians and in grade school screenings is called the Adam's Forward Bend Test. During this test, the patient leans forward with his or her feet together and bends 90 degrees at the waist. From this angle, any asymmetry of the trunk or any abnormal spinal curvatures can easily be detected by the examiner. This is a simple initial screening test that can detect potential problems, but cannot determine accurately the exact type or severity of the deformity.
Radiographic tests are required for an accurate and positive diagnosis. Scoliosis in children is classified by age: Infantile 0 to 3 years ; 2. Juvenile 3 to 10 years ; and 3. Adolescent age 11 and older, or from onset of puberty until skeletal maturity. Idiopathic scoliosis comprises the vast majority of cases presenting during adolescence. In children with congenital scoliosis, there is a known increased incidence of other congenital abnormalities.
These are most commonly associated with the spinal cord 20 percent , the genitourinary system 20 to 33 percent and the heart 10 to 15 percent.
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- Scoliosis: Review of diagnosis and treatment.
It is important that evaluation of the neurological, genitourinary and cardiovascular systems is undertaken when congenital scoliosis is diagnosed. Scoliosis that occurs or is diagnosed in adulthood is distinctive from childhood scoliosis, since the underlying causes and goals of treatment differ in patients who have already reached skeletal maturity. Most adults with scoliosis can be divided into the following categories: Adult scoliosis patients who were surgically treated as adolescents; 2.
Adults who did not receive treatment when they were younger; and 3. Adults with a type of scoliosis called degenerative scoliosis. In one year study, about 40 percent of adult scoliosis patients experienced a progression. Of those, 10 percent showed a very significant progression, while the other 30 percent experienced a very mild progression, usually of less than one degree per year.
Degenerative scoliosis occurs most frequently in the lumbar spine lower back and more commonly affects people age 65 and older. It is often accompanied by spinal stenosis, or narrowing of the spinal canal, which pinches the spinal nerves and makes it difficult for them to function normally. Back pain associated with degenerative scoliosis usually begins gradually and is linked with activity.
The curvature of the spine in this form of scoliosis is often relatively minor, so surgery may only be advised when conservative methods fail to alleviate pain associated with the condition. When there is a confirmed diagnosis of scoliosis, there are several issues to assess that can help determine treatment options:. In many children with scoliosis, the spinal curve is mild enough to not require treatment.
However, if the doctor is worried that the curve may be increasing, he or she may wish to examine the child every four to six months throughout adolescence. In adults with scoliosis, X-rays are usually recommended once every five years, unless symptoms are getting progressively worse.
Braces are only effective in patients who have not reached skeletal maturity.
If the child is still growing and his or her curve is between 25 degrees and 40 degrees, a brace may be recommended to prevent the curve from progressing. There have been improvements in brace design and the newer models fit under the arm, not around the neck.
Scoliosis: Review of diagnosis and treatment
There are several different types of braces available. While there is some disagreement among experts as to which type of brace is most effective, large studies indicate that braces, when used with full compliance, successfully stop curve progression in about 80 percent of children with scoliosis. For optimal effectiveness, the brace should be checked regularly to assure a proper fit and may need to be worn 16 to 23 hours every day until growth stops. In children, the two primary goals of surgery are to stop the curve from progressing during adulthood and to diminish spinal deformity.
Most experts would recommend surgery only when the spinal curve is greater than 40 degrees and there are signs of progression. This surgery can be done using an anterior approach through the front or a posterior approach through the back depending on the particular case. This is particularly the case for children and teenagers with scoliosis.
If this is a problem for you or your child, you may find it useful to contact a scoliosis support group, such as Scoliosis Association UK. In rare cases, scoliosis can lead to physical problems if it's severe. For example, significant curvature of the spine can sometimes put increased pressure on the heart and lungs. Read more about the possible complications of scoliosis.
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About eight out of every 10 cases of scoliosis are idiopathic. Idiopathic scoliosis can affect adults and children. Some cases of scoliosis are caused by conditions that affect the nerves and muscles neuromuscular conditions , such as:. Scoliosis can also develop as part of a pattern of symptoms called a syndrome.
This is known as syndromic scoliosis. Conditions that can cause syndromic scoliosis include:. In rare cases, babies can be born with scoliosis. This is known as congenital scoliosis. Congenital scoliosis is caused by the bones in the spine developing abnormally in the womb. In adults, scoliosis can sometimes be caused by gradual deterioration to the parts of the spine. This is known as degenerative scoliosis. This can occur because some parts of the spine become narrower and weaker osteoporosis with age. Scoliosis can usually be diagnosed after a physical examination of the spine, ribs, hips and shoulders.
For example, one of your shoulders may be higher than the other or there may be a bulge in your back. Initial examinations are usually carried out by a GP. If scoliosis is suspected, you should be referred to an orthopaedic specialist a specialist in conditions that affect the skeleton for further tests and to discuss treatment. The X-ray images will also help determine the shape, direction, location and angle of the curve.
Treatment is not always necessary for very young children because their condition often corrects itself as they grow. However, if the curve does not correct itself, it can reduce the space for the internal organs to develop in, so careful monitoring by a specialist is important. In some cases affecting young children, the spine may need to be guided during growth in an attempt to correct the curve. In a child aged under two years of age, this can sometimes be achieved by using a cast. A cast is an external brace to the trunk made out of a lightweight combination of plaster and modern casting materials.
The cast is worn constantly and cannot be removed, but is changed regularly to allow for growth and remodelling. However, your child may still need to use a removable brace see below after treatment. If the curve of your child's spine is getting worse, your specialist may recommend they wear a back brace while they are growing. A brace cannot cure scoliosis or correct the curve, but it may stop the curve from getting worse. If a brace is used, it will need to be carefully fitted to your child's spine.
To do this, a cast of your child's back may need to be taken. This can be done as an outpatient which means that your child will not have to stay overnight in hospital. Braces are often made of rigid plastic, although flexible braces are sometimes available. In general, modern back braces are designed so they are difficult to see under loose-fitting clothing.
It's usually recommended that the brace is worn for 23 hours a day, and is only removed for baths and showers. The brace should not interfere with normal everyday activity and can be worn during most non-contact sports. However, it should be removed during contact sports and swimming. Regular exercise is important for children wearing a brace. This helps improve muscle tone and body strength, and will help make wearing the brace more comfortable. The brace will usually have to be worn for as long as your child's body is still growing. For most children, this will mean they can stop wearing it when they are around 16 or 17 years old.
If your child has stopped growing and their scoliosis is severe, or other treatments have been unsuccessful, corrective surgery may be recommended. For younger children, generally those under the age of ten, an operation may be carried out to insert growing rods. These rods aim to allow for continued controlled growth of the spine while partially correcting the scoliosis.
After surgery to insert the rods, your child will need to return to their specialist every months to have the rods lengthened to keep up with the child's growth. This procedure will be done through a small incision, and takes place often as a day case or an overnight stay. In some cases, rods that can be lengthened using external magnets during an outpatient appointment may be used. Many children will also have to wear a brace to protect the growth rods. When your child stops growing, the adjustable rods can be removed and a spinal fusion see below will be carried out.
In teenagers and young adults whose spine has stopped growing, an operation called a spinal fusion may be carried out. This metalwork will usually be left in place permanently, unless they cause any problems. The surgery will take several hours.
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After surgery, your child will be transferred to an intensive care unit ICU or high dependency unit HDU , where they will be given fluids through a vein intravenously and pain relief. Most children are well enough to leave intensive care after a day or two, although they will often need to spend another five to 10 days in hospital. After the operation, most children can return to school after a few weeks and can play sports after a few months. Contact sports should be avoided for months. Occasionally a back brace may need to be worn to protect the metal rods after surgery.
Spinal fusion surgery is a major operation which, like any surgical procedure carries a risk of complications. It will not be recommended unless the surgeon feels the benefits outweigh these risks. It's important that parents and children understand the risks of spinal fusion surgery so that they can make an informed decision about treatment.
Make sure you discuss the potential complications with your child's surgeon. There is no reliable evidence to suggest that other therapies such as osteopathy and chiropractic can be used to correct the curvature of the spine or stop it progressing. Exercise can help significantly with any muscular pain experienced with scoliosis, and back health in general.