All about Scoliosis

Your spine is one of the most important parts of your body. It starts at the top of your neck, near your hairline from the base of your skull, and runs all the way down to your lower back. Your spine is made up of small bones called vertebrae that are stacked on top of one another, creating the curve of your back. Your spine holds up your head, shoulders and upper body so you can stand up straight, and it helps you bend, twist and move around.

Your spine naturally curves in three places, near your neck, chest, and lower back, creating a shape similar to a somewhat flattened letter S. However, in some people the spine can curve either forward or sideways in places where it should not. This type of spine curvature can be a result of scoliosis.

What is scoliosis?

Scoliosis is not a disease. It just means that in an often otherwise healthy person the spine is curved or twisted. Scoliosis is a condition that causes a three-dimensional shift in the spine, most notably causing a curvature to one side or the other. The spine can also twist at the same time.

This twisting can pull the ribcage out of position. The spinal curve may develop as a single curve – often described as C-shaped – or as two curves shaped like the letter S. When the curve is S-shaped a person’s spine can appear quite straight because the two curves cancel each other out.

Types of scoliosis

There are different types of scoliosis, which relate to the age the person first gets it and the cause, if this is known.

• Congenital scoliosis – A person can be born with abnormalities in the structure of their spine. This means their spine doesn’t form properly and is more likely to bend as they grow as a child. Because of the way a baby develops during pregnancy, problems with the spine can be linked to problems with other organs, such as the kidneys.
• Idiopathic scoliosis – Scoliosis that appears in otherwise healthy 10- to 18-year-olds is termed adolescent idiopathic scoliosis (AIS). This is the most common form of scoliosis. Around eight in ten people who have scoliosis have idiopathic scoliosis. The term ‘idiopathic’ means the cause isn’t known.
• Syndromic scoliosis – Scoliosis can be part of a recognised syndrome such as Down syndrome, Marfan syndrome or Rett syndrome. People with Down syndrome, often have musculoskeletal problems, which can include scoliosis. Marfan syndrome affects the body’s connective tissues and is likely to include scoliosis too. Rett syndrome is a genetic disorder, usually affecting females, which causes severe physical and mental disability.
• Neuromuscular scoliosis – This type of scoliosis is caused by conditions that affect the nerves or muscles in the back; examples include spina bifida and cerebral palsy. It is often worse if the person cannot walk easily, or at all. If the curve continues to get worse, they will probably need scoliosis surgery.
• Early-onset scoliosis – This type of scoliosis affects young children. It is also known as infantile scoliosis in babies and children under three, and juvenile scoliosis if it develops between three and ten. It may be any of the types above. In infantile scoliosis, the spine usually curves to the left, from the chest area.
• Degenerative scoliosis, also known as adult-onset scoliosis – This describes a side-to-side curvature of the spine caused by degeneration of the facet joints and intervertebral discs which are the moving parts of the spine. This degeneration and resulting spinal asymmetry can occur slowly over time as a person ages. This is a completely different cause of scoliosis from the standard adolescent-onset scoliosis.
• Scheuermann’s kyphosis – This is a condition in which the front sections of the vertebrae, that is the small bones that make up the spine, grow more slowly than the back sections during childhood. This difference in growth means the vertebrae grow into the shape of a wedge, when they should grow into the shape of a rectangle. These wedge-shaped bones don’t stack up in a straight line. As a result, the spine develops a forward angle as it grows which leads to a hunchback or slouching posture. The forward bend of the spine is called kyphosis. The condition though very similar to scoliosis, is thought to be quite rare; however, the number of people affected is not known as it is often put down to poor posture.

What causes scoliosis?

As we have seen above, there may be different causes depending upon the type of scoliosis, or in some cases the cause may not be apparent at all. A small number of cases are caused by medical conditions, including cerebral palsy which is a condition associated with brain damage, or muscular dystrophy, a genetic condition that causes muscle weakness.

Damage to the spinal cord at any age can increase the risk of developing scoliosis. This may be through an injury, infection, such as tuberculosis, or another health condition, such as osteoporosis. Rarely, scoliosis can be caused by a spinal lesion or tumour.

Researchers have found there is a family history of the condition in some idiopathic cases, which suggests a possible genetic link, although research is ongoing.

Scoliosis is not thought to be caused by such things as bad posture, lack of exercise or poor diet.

Who is at risk of scoliosis?

Scoliosis is a condition which affects people of all ages right from birth into old age. Scoliosis in infants and juvenile scoliosis are both fairly uncommon. Most younger scoliosis patients are diagnosed as adolescents, meaning children from 11 to 15, in particular. Girls are more likely to develop scoliosis than boys; about 75% of scoliosis patients are girls but boys can and do develop scoliosis too.

Research suggests that some sports and activities are associated with a higher risk of scoliosis. The most notable examples are ballet dancers and gymnasts, where the condition is up to 12 times more prevalent.

Older individuals, that is those aged over 60 years, have a high risk of developing degenerative scoliosis, with about a four in ten chance of developing the condition.

How common is scoliosis?

Scoliosis is much more common than most people think. The latest research suggests that between 2% and 3% of children aged 10–15 years will develop scoliosis, that is between two and three in every 100 children. It is also common in older people, with nearly 40% of the over 60’s having the condition.

Symptoms of scoliosis

Scoliosis, especially in the early stages, can be hard to spot; scoliosis has typically progressed for some time before there are visual signs.

In a child with scoliosis, you might notice:

• Unevenness in the shoulders and waistline.
• Unevenness in the shoulder blades, one might stick out more than the other.
• The pelvis shifted to one side.
• The head slightly tilted.
• Unevenness in the shape of the ribcage at the back, when the child bends forward.

Children grow very quickly so the curve can develop and get worse very quickly. Common symptoms in children include a mild ache in the lower or middle back area. But often a child with scoliosis doesn’t experience any symptoms.

In adult degenerative scoliosis the signs include:

• One shoulder, often the right one, may look higher than the other.
• The shoulder blade or ribs may stick out more.
• The middle, that is the waist, may seem off-centre because the hips are uneven.
• Clothes may not fit or hang as well as they should or did before.

Scoliosis may cause lower back pain that gets worse as the curvature of the spine increases. The person may have pain or pins and needles in their legs, and it may hurt more after they have stood or sat down for a long time.

How does scoliosis affect the body?

Having a visibly curved spine may cause problems related to body image, self-esteem and overall quality of life. This is particularly the case for children and teenagers with scoliosis. For some people it can be stressful and depressing to look different, have clothes fit unevenly, or to wear a noticeable back brace that may be uncomfortable or limit activity.

When the spine abnormally twists and bends sideways enough, it can cause the hips to be out of alignment, which changes a person’s gait or how they walk. The extra compensating that a person does to maintain balance for the uneven hips and legs can cause the muscles to tire sooner. A person might also notice that one hand brushes against a hip while walking but the other does not. The deformity from spinal twisting can also increase rigidity, which reduces the spine’s flexibility for bending.

If the person’s spine rotates enough, the rib cage can twist and tighten the space available for the lungs. Their bone might push against the lungs and make breathing more difficult. Similarly, if the rib cage twists enough, reduced spacing for the heart can hamper its ability to pump blood.

Some people may get a hiatus hernia or other digestive problems because the position of their stomach is different due to the position of their spine.

In some cases of scoliosis, particularly those affecting adults, the bones in the spine compress nearby nerves.

In severe cases, this can cause problems such as:

• Back and leg pain, back muscles could become more prone to painful spasms.
• Numbness or weakness in the legs.
• A loss of bladder control known as urinary incontinence.
• A loss of bowel control known as bowel incontinence.
• In men it may cause erectile dysfunction; that is, an inability to get or maintain an erection.

How is scoliosis diagnosed?

In the UK there is no formal screening programme for scoliosis. It is important for parents to make sure that their children are receiving regular check-ups so that conditions like scoliosis can be diagnosed and managed early.

In all age groups, scoliosis can usually be diagnosed after a physical examination of the spine, ribs, hips and shoulders initially by a GP. If they suspect scoliosis, the GP may refer the person to an orthopaedic specialist or for further tests which may include an X-ray. This is to confirm the diagnosis of scoliosis and will help to determine the shape, direction, location and angle of the curve. The curve is measured on an X-ray of the spine. The angle of the curve is known as the Cobb angle. A curve of 10 degrees or less is classed as normal, a curve of between 10 and 30 degrees is classed as mild, and a curve of over 60 degrees is classed as severe.

In some cases, scans such as a magnetic resonance imaging (MRI) scan or a computerised tomography (CT) scan may also be recommended. These tests can help to identify the cause of a curved spine and the angle of the curve.

You can’t prevent scoliosis but getting an early diagnosis and treatment may stop it from getting worse or may even help to correct it.

How is scoliosis treated?

About 90% of idiopathic scoliosis cases are mild and will only require observation by a doctor every 4 to 6 months until the adolescent has reached full skeletal maturity. Any treatment is not always necessary for very young children because their condition often corrects itself as they grow. 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 that affect 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. After the cast is removed, the child may still need to use a removable brace.

If the curve of the child’s spine is getting worse, a specialist may recommend they wear a back brace whilst 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 the child’s spine and modern back braces are designed so they are difficult to see under loose-fitting clothing.

The brace should not interfere with normal everyday activity. It is worn for 23 hours a day, and is only removed for baths and showers. 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 can be worn during most non-contact sports; however, it should be removed during contact sports and swimming. Physiotherapy may be beneficial when used in combination with a back brace.

Corrective surgery may be recommended if a child’s scoliosis is severe, and the child has stopped growing, or if other treatments have been unsuccessful. 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. In teenagers and young adults whose spine has stopped growing, an operation called a spinal fusion may be carried out.

Back pain is one of the main problems caused by scoliosis in adults, so treatment is mainly aimed at pain relief. In some cases, surgery may be carried out to improve the shape of the spine as a way of helping with back and leg pains. Painkilling medication is usually recommended to help relieve the pain that can be associated with scoliosis.

Over-the-counter painkillers, such as paracetamol and ibuprofen, are often recommended initially. In some cases, corticosteroids or local anaesthetic may be injected into the back to relieve pain caused by the bones in the spine compressing or irritating nearby nerves.

Braces are not often used to treat scoliosis in adults, although they can provide pain relief in some cases. A brace may be considered as an alternative to surgery if the person is not well enough to undergo an operation.

Surgery for adults with scoliosis is usually only recommended if the curve in the spine is severe, if it’s getting significantly worse, for back pain related to standing in an abnormal posture, or if the nerves in the spine are being compressed.

There are two types of surgery:

• Decompression surgery – This is used if a disc or bone is pressing down on a nerve. The disc/bone can be removed to reduce the pressure on the nerve. It is only recommended when non-surgical treatments haven’t helped. There is good evidence that decompression surgery can be an effective treatment for people with severe pain caused by compressed nerves.
• Spinal fusion surgery – This is where the position of the spine is improved using metal rods, plates and screws before being fused into place using bone grafts.

There are a number of complementary therapies that work alongside the traditional treatments and not as an alternative to them.

These include:

• Alexander Technique – This is a system that retrains a person to be more aware of their posture. It helps them to notice the bad habits that they have picked up during their lifetime and helps to correct them. By doing this, a person may be able to ease pain caused by poor posture and learn to move with less effort.
• Aquatic physiotherapy – This is a form of treatment that uses gentle exercises in water. It should be undertaken by a physiotherapist who is qualified to recommend movements in the water and to make sure they are done properly. As with all forms of treatment, it is important to seek medical advice before taking part.
• Massage – Curvature of the spine causes the muscles in the shoulders and around the spine to misalign, which can cause tension or muscle spasms. Massage therapy can help to release some of this tension. A physiotherapist should be able to recommend an experienced practitioner of massage.
• Pilates – This is a low-impact form of exercise that aims to strengthen muscles, especially the core – that is, the stomach and back muscles – to improve general fitness and wellbeing. Pilates has something to offer people of all ages and levels of ability and fitness.
• Reflexology – Reflexologists believe that different points on the feet, lower leg, hands, face or ears correspond with different areas of the body. The therapist will then use their hands to apply pressure to the feet, lower leg, hands, ears or face, which helps the body to restore its balance, naturally helping to reduce tension and improve mood and sense of wellbeing.
• Hot and cold treatments – These provide a successful but temporary means of pain relief. Heat is good for relieving muscle pain. It can be applied using hot baths and showers, steam rooms, hot water bottles or heating pads. Cold treatments or cryotherapy, such as cold packs or ice massage, can also help to combat pain.

Final thoughts

Patients and families have varying concerns when a person is diagnosed with scoliosis.

Here are details of sources of support:

• Scoliosis Association UK is the only UK-wide patient support organisation for people with scoliosis and their families. Helpline 020 8964 1166
• British Scoliosis Society Patient area
• Every year on 16 October people from around the world join together to raise awareness of conditions such as scoliosis on World Spine Day (WSD), Twitter feed.