Avoiding scoliosis and maintaining good posture are universal concerns among parents today. Many of these parents may be surprised to know that small curves are a normal part of spine anatomy.
But children whose curvature exceeds a limited range of variation–curving to either the right or left side in an “S” shape—do require medical attention, and may be diagnosed with scoliosis. Together with kyphosis, another type of curvature, scoliosis comprises a significant proportion of spinal deformity diagnoses seen by pediatric orthopedists.
Scoliosis is diagnosed as one of three types: idiopathic, of unknown origin; congenital scoliosis, in which the bones are asymmetrical at birth and the vertebrae may be partially formed (hemivertebra) or wedge-shaped; and neuromuscular scoliosis, in which the scoliosis is symptomatic of a systemic condition such as cerebral palsy, muscular dystrophy, or paralysis.
Idiopathic scoliosis—the most frequently seen form of the condition—may first be recognized during a routine pediatrician’s visit or in a school screening. “School screenings are an important safeguard for many children, especially for children who may not have a regular healthcare provider.” notes Daniel W. Green, MD, Associate Attending Orthopedic Surgeon at Hospital for Special Surgery (HSS). While children with idiopathic scoliosis may not experience any pain, parents may see cosmetic signs of the condition, such as a shoulder that appears higher than the other or protruding ribs on one side, owing to a twisting aspect of the spine.
Patients with idiopathic scoliosis are further categorized by age: infantile scoliosis, affecting children from birth to three years of age; juvenile scoliosis from 3 to 9 years of age; and adolescent scoliosis, from 10 to18 years of age. Adolescent idiopathic scoliosis is seen more frequently in girls than in boys.
In all its forms, early diagnosis of scoliosis is a primary goal. Treatment is guided by the specific scoliosis type, the amount of growth the child has left, the degree of the deformity, and anticipated progression of the condition. “Children with infantile and juvenile scoliosis have the greatest risk of curve progression, as well as the greatest risk of developing secondary pulmonary complications from scoliosis,” explains Roger F. Widmann, MD, Chief of Pediatric Orthopedic Surgery at HSS.
Case Study: a 15 year old male with adolescent idiopathic scoliosis. (pdf)
Neuromuscular scoliosis is rarely diagnosed at birth, since it is an acquired form of scoliosis in which development and progression of the scoliosis is often dependent upon the severity of the underlying medical condition, such as cerebral palsy.
Children with suspected idiopathic scoliosis should see a pediatric orthopedist who can confirm the diagnosis with physical examination and x-rays. A curve of greater than 10 degrees on x-ray is considered to be scoliosis. At HSS, in children younger than ten years of age, an MRI of the entire spine is recommended. According to Dr. Green, “In some cases, even though the vertebral bones may be healthy, the spinal cord may not be.” MRI images can help the orthopedist detect the presence of other problems such as syrinx—a cyst in the spinal cord, or tethered cord, in which the spinal cord is abnormally attached to the bony spine.
Case Study: an active 14 year old girl with juvenile idiopathic scoliosis. (pdf)
Treatment for scoliosis is focused on slowing or preventing progression of the curve and on cosmetic improvement. For patients with smaller curves, those greater than 10 degrees and up to 20 degrees, the pediatric orthopedist may recommend continued observation. For curves in the range of 20-40 degrees, in a growing child, bracing can be very effective.
Children with more advanced scoliosis, those with a curve of 45 degrees or more, may be candidates for surgery, requiring either the placement of growing rods or spine fusion. “In younger patients with significant growth remaining, growing rods may be preferable,” says Dr. Green. In this procedure, two adjustable rods are anchored to the spine to hold it in proper alignment. As the child grows, the rods can be adjusted in length. “Growing rods are also very effective in that the child’s lungs and chest cavity can continue to grow along with the spine. In addition, spinal fusion can be delayed until the child is significantly older,” says Dr. Widmann.
Traditional scoliosis surgery is usually reserved for older children, using instrumentation to bring the spine into alignment and bone grafts to effect a fusion of the spine that maintains the correction. In order to decrease the risk of neurologic injury, at HSS sophisticated nerve monitoring is conducted throughout the surgery. “This monitoring provides us with almost instant feedback, allowing the surgical team to adjust the deformity correction as needed or, if need be, to change the implants,” explains Dr. Green.
“Surgery generally results in both excellent correction of the curve and excellent improvement in spinal alignment,” says Dr. Widmann. Left untreated, a curve that continues to progress can eventually have a negative impact on both heart and lung function. Moreover, according to Dr. Green, at later stages surgeries are both lengthier and tend to have a less satisfactory cosmetic result.
Scoliosis surgery generally involves a four to six day hospital stay, and most children are back to school within three to four weeks. Young athletes are usually back to competitive athletics in four to six months following surgery.
Mature patients with curves less than 45 degrees are not candidates for spinal fusion surgery, since many of these curves will progress slowly or not at all during adult life. Curves measuring greater than 50 degrees are generally managed surgically, since these curves may progress up to one degree per year after maturity is reached. This can present problems for the patient later in adult life.
Numerous interesting research initiatives are underway to improve our spine instrumentation for children and teenagers with scoliosis. In addition, genetic tests may be available in a few years that will help us predict which children will progress to have severe deformities and which ones won’t. Researchers are also trying to find a way to surgically modulate a mild curve at an earlier stage and prevent it from progressing—or even reverse the condition.
Even now, advances in treatment are available at HSS. The Hospital is one of the few centers in the Northeast U.S. to receive approval to use Vertical Expandable Prosthetic Titanium Rib prostheses (VEPTR). This device is used to treat thoracic insufficiency syndrome (TIS), a congenital condition in which severe deformities of the chest, spine, and ribs prevent normal breathing as well as lung growth and development. By straightening the spine and separating the ribs, the VEPTR device can prevent deterioration of thoracic function and control spinal deformity.
Summary prepared by Nancy Novick