Scoliosis
Scoliosis | |
---|---|
Pronunciation | |
Specialty | Orthopedic surgery |
Symptoms | Sideways curve in the back[2] |
Usual onset | 10–20 years old[2] |
Causes | Usually unknown[3] |
Risk factors | Family history, cerebral palsy, Marfan syndrome, tumors such as neurofibromatosis[2] |
Diagnostic method | X-ray[2] |
Treatment | Watchful waiting, bracing, exercises, surgery[2][4] |
Frequency | 3%[5][6] |
Scoliosis (pl.: scolioses) is a condition in which a person's spine has an abnormal curve.[2] The curve is usually S- or C-shaped over three dimensions.[2][7] In some, the degree of curve is stable, while in others, it increases over time.[3] Mild scoliosis does not typically cause problems, but more severe cases can affect breathing and movement.[3][8] Pain is usually present in adults, and can worsen with age.[9] As the condition progresses, it may alter a person's life, and hence can also be considered a disability.[10]
The cause of most cases is unknown, but it is believed to involve a combination of
Treatment depends on the degree of curve, location, and cause.[2] The age of the patient is also important, since some treatments are ineffective in adults, who are no longer growing. Minor curves may simply be watched periodically.[2] Treatments may include bracing, specific exercises, posture checking, and surgery.[2][4] The brace must be fitted to the person and used daily until growing stops.[2] Specific exercises, such as exercises that focus on the core, may be used to try to decrease the risk of worsening.[4] They may be done alone or along with other treatments such as bracing.[12][13] Evidence that chiropractic manipulation, dietary supplements, or exercises can prevent the condition from worsening is weak.[2][14] However, exercise is still recommended due to its other health benefits.[2]
Scoliosis occurs in about 3% of people.
Signs and symptoms
Symptoms associated with scoliosis can include:
- Pain in the back at the site of the curve, which may radiate to the legs[16]
- Respiratory or cardiac problems in severe cases[17]
- Constipation due to curvature causing "tightening" of the stomach, intestines, etc.[18]
The signs of scoliosis can include:
- Uneven musculature on one side of the spine[19]
- Rib prominence or a prominent thoracic scoliosis[20]
- Uneven posture[20]
- Heart and lung problems in severe cases[17]
- Calcium deposits in the cartilage endplate and sometimes in the disc itself[21]
Course
People who have reached skeletal maturity are less likely to have a worsening case.[22] Some severe cases of scoliosis can lead to diminishing lung capacity, pressure exerted on the heart, and restricted physical activities.[23]
Causes
An estimated 65% of scoliosis cases are
About 38% of variance in scoliosis risk is due to genetic factors, and 62% is due to the environment.[28] The genetics are likely complex, however, given the inconsistent inheritance and discordance among monozygotic twins.[28] The specific genes that contribute to development of scoliosis have not been conclusively identified. At least one gene, CHD7, has been associated with the idiopathic form of scoliosis.[29] Several candidate gene studies have found associations between idiopathic scoliosis and genes mediating bone formation, bone metabolism, and connective tissue structure.
Adolescent idiopathic scoliosis has no clear causal agent, and is generally believed to be multifactorial; leading to "progressive functional limitations" for individuals.[32][33][34][29][35] Research suggests that Posterior Spinal Fusion (PSF) can be used to correct the more severe deformities caused by adolescent idiopathic scoliosis.[36][37][38][39][40] Such procedures can result in a return to physical activity in about 6 months, which is very promising, although minimal back pain is still to be expected in the most severe cases.[41][42][43][44][40] The prevalence of scoliosis is 1–2% among adolescents, but the likelihood of progression among adolescents with a Cobb angle less than 20° is about 10–20%.[45]
Congenital scoliosis can be attributed to a malformation of the spine during weeks three to six in utero due to a failure of formation, a failure of segmentation, or a combination of stimuli.[46] Incomplete and abnormal segmentation results in an abnormally shaped vertebra, at times fused to a normal vertebra or unilaterally fused vertebrae, leading to the abnormal lateral curvature of the spine.[47]
Vertebrae of the spine, especially in the thoracic region, are, on average, asymmetric.
Resulting from other conditions
Secondary scoliosis due to
Scoliosis associated with known syndromes is often subclassified as "syndromic scoliosis".
Another form of secondary scoliosis is degenerative scoliosis, also known as de novo scoliosis, which develops later in life secondary to degenerative (may or may not be associated with aging) changes. This is a type of deformity that starts and progresses because of the collapse of the vertebral column in an asymmetrical manner. As bones start to become weaker and the ligaments and discs located in the spine become worn as a result of age-related changes, the spine begins to curve.[76]
Diagnosis
People who initially present with scoliosis undergo a physical examination to determine whether the deformity has an underlying cause and to exclude the possibility of the underlying condition more serious than simple scoliosis.[citation needed]
The person's
When a person can cooperate, he or she is asked to bend forward as far as possible. This is known as the Adams forward bend test[77] and is often performed on school students. If a prominence is noted, then scoliosis is a possibility and an X-ray may be done to confirm the diagnosis.
As an alternative, a scoliometer may be used to diagnose the condition.[78]
When scoliosis is suspected, weight-bearing, full-spine AP/
The standard method for assessing the curvature quantitatively is measuring the Cobb angle, which is the angle between two lines, drawn perpendicular to the upper endplate of the uppermost vertebra involved and the lower endplate of the lowest vertebra involved. For people with two curves, Cobb angles are followed for both curves. In some people, lateral-bending X-rays are obtained to assess the flexibility of the curves or the primary and compensatory curves.[citation needed]
Congenital and idiopathic scoliosis that develops before the age of 10 is referred to as early-onset scoliosis.[81] Progressive idiopathic early-onset scoliosis can be a life-threatening condition with negative effects on pulmonary function.[82][83] Scoliosis that develops after 10 is referred to as adolescent idiopathic scoliosis.[3] Screening adolescents without symptoms for scoliosis is of unclear benefit.[84]
Definition
Scoliosis is defined as a three-dimensional deviation in the axis of a person's spine.[45][7] Most instances, including the Scoliosis Research Society, define scoliosis as a Cobb angle of more than 10° to the right or left as the examiner faces the person, i.e. in the coronal plane.[85]
Scoliosis has been described as a biomechanical deformity, the progression of which depends on asymmetric forces otherwise known as the Hueter–Volkmann Law.[31]
Management
Scoliosis curves do not straighten out on their own. Many children have slight curves that do not need treatment. In these cases, the children grow up to lead normal body posture by itself, even though their small curves never go away. If the patient is still growing and has a larger curve, it is important to monitor the curve for change by periodic examination and standing x-rays as needed. The rise in spinal abnormalities require examination by a neurosurgeon to determine if active treatment is needed.[86]
The traditional medical management of scoliosis is complex and is determined by the severity of the curvature and skeletal maturity, which together help predict the likelihood of progression. The conventional options for children and adolescents are:[87]
- Observation
- Bracing
- Surgery
- Physical therapy. Evidence suggests use of scoliosis specific exercises might prevent the progression of the curve along with possible bracing and surgery avoidance.[88]
For adults, treatment usually focuses on relieving any pain:[89][90]
- Pain medication
- Posture checking
- Bracing
- Surgery[91]
Treatment for idiopathic scoliosis also depends upon the severity of the curvature, the spine's potential for further growth, and the risk that the curvature will progress. Mild scoliosis (less than 30° deviation) and moderate scoliosis (30–45°) can typically be treated conservatively with bracing in conjunction with scoliosis-specific exercises.[4] Severe curvatures that rapidly progress may require surgery with spinal rod placement and spinal fusion. In all cases, early intervention offers the best results.[citation needed]
A specific type of physical therapy may be useful.[92][4] Evidence to support its use, however, is weak.[2][14] Low quality evidence suggests scoliosis-specific exercises (SSE) may be more effective than electrostimulation.[93] Evidence for the Schroth method is insufficient to support its use.[94] Significant improvement in function, vertebral angles and trunk asymmetries have been recorded following the implementation of Schroth method in terms of conservative management of scoliosis. Some other forms of exercises interventions have been lately[when?] used in the clinical practice for therapeutic management of scoliosis such as global postural reeducation and the Klapp method.[88]
Bracing
Bracing is normally done when the person has bone growth remaining and is, in general, implemented to hold the curve and prevent it from progressing to the point where surgery is recommended. In some cases with juveniles, bracing has reduced curves significantly, going from a 40° (of the curve, mentioned in length above) out of the brace to 18°. Braces are sometimes prescribed for adults to relieve pain related to scoliosis. Bracing involves fitting the person with a device that covers the torso; in some cases, it extends to the neck (example being the Milwaukee Brace).[95]
The most commonly used brace is a
Indications for bracing: people who are still growing who present with Cobb angles less than 20° should be closely monitored. People who are still growing who present with Cobb angles of 20 to 29° should be braced according to the risk of progression by considering age, Cobb angle increase over a six-month period, Risser sign, and clinical presentation. People who are still growing who present with Cobb angles greater than 30° should be braced. However, these are guidelines and not every person will fit into this table.
For example, a person who is still growing with a 17° Cobb angle and significant thoracic rotation or flatback could be considered for nighttime bracing. On the opposite end of the growth spectrum, a 29° Cobb angle and a Risser sign three or four might not need to be braced because the potential for progression is reduced.[98] The Scoliosis Research Society's recommendations for bracing include curves progressing to larger than 25°, curves presenting between 30 and 45°, Risser sign 0, 1, or 2 (an X-ray measurement of a pelvic growth area), and less than six months from the onset of menses in girls.[99]
Evidence supports that bracing prevents worsening of disease, but whether it changes quality of life, appearance, or back pain is unclear.[100]
Surgery
Surgery is usually recommended by orthopedists for curves with a high likelihood of progression (i.e., greater than 45–50° of magnitude), curves that would be cosmetically unacceptable as an adult, curves in people with spina bifida and cerebral palsy that interfere with sitting and care, and curves that affect physiological functions such as breathing.[101][102]
Surgery is indicated by the Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) at 45–50°[4] and by the Scoliosis Research Society (SRS) at a Cobb angle of 45°.[103] SOSORT uses the 45–50° threshold as a result of the well-documented, plus or minus 5° measurement error that can occur while measuring Cobb angles.[103]
Surgeons who are specialized in spine surgery perform surgery for scoliosis. To completely straighten a scoliotic spine is usually impossible, but for the most part, significant corrections are achieved.[104]
The two main types of surgery are:[105]
- Anterior fusion: This surgical approach is through an incision at the side of the chest wall.
- Posterior fusion: This surgical approach is through an incision on the back and involves the use of metal instrumentation to correct the curve.
One or both of these surgical procedures may be needed. The surgery may be done in one or two stages and, on average, takes four to eight hours.
A new tethering procedure (anterior vertebral body tethering) may be appropriate for some patients.[106]
Spine surgery can be painful and may also be associated with post-surgical pain.
Prognosis
A 50-year follow-up study published in the
Generally, the prognosis of scoliosis depends on the likelihood of progression. The general rules of progression are larger curves carry a higher risk of progression than smaller curves, and thoracic and double primary curves carry a higher risk of progression than single lumbar or thoracolumbar curves. In addition, people not having yet reached skeletal maturity have a higher likelihood of progression (i.e., if the person has not yet completed the adolescent growth spurt).[110]
Epidemiology
Scoliosis affects 2–3% of the United States population, or about five to nine million cases.
Although fewer cases are present since using Cobb angle analysis for diagnosis, scoliosis remains significant, appearing in otherwise healthy children. Despite the fact that scoliosis is a disfigurement of the spine, it has been shown to influence the pneumonic function, balance while standing and stride execution in children. The impact of carrying backpacks on these three side effects have been broadly researched.[113] Incidence of idiopathic scoliosis (IS) stops after puberty when skeletal maturity is attained, however further curvature may occur during late adulthood due to vertebral osteoporosis and weakened musculature.[4]
History
Ever since the condition was discovered by the
The American orthopaedic surgeon Alfred Shands Jr. discovered that two percent of patients had non-disease related scoliosis, later termed idiopathic scoliosis, or the "cancer of orthopaedic surgery". These patients were treated with questionable remedies.[115] A theory at the time—now discredited—was that the condition needed to be detected early to halt its progression, and so some schools made screening for scoliosis mandatory. Measurements of shoulder height, leg length and spinal curvature were made, and the ability to bend forwards, along with body posture, was tested, but students were sometimes misdiagnosed because of their poor posture.[citation needed]
An early treatment was the Milwaukee brace, a rigid contraption of metal rods attached to a plastic or leather girdle, designed to straighten the spine. Because of the constant pressure applied to the spine, the brace was uncomfortable. It caused jaw and muscle pain, skin irritation, as well as low self-esteem.[citation needed]
Surgery
In 1962, the American orthopaedic surgeon Paul Harrington introduced a metal spinal system of instrumentation that assisted with straightening the spine, as well as holding it rigid while fusion took place. The now obsolete Harrington rod operated on a ratchet system, attached by hooks to the spine at the top and bottom of the curvature that when cranked would distract—or straighten—the curve. The Harrington rod obviates the need for prolonged casting, allowing patients greater mobility in the postoperative period and significantly reducing the quality of life burden of fusion surgery. The Harrington rod was the precursor to most modern spinal instrumentation systems. A major shortcoming was that it failed to produce a posture wherein the skull would be in proper alignment with the pelvis, and it did not address rotational deformity. As the person aged, there would be increased wear and tear, early onset arthritis, disc degeneration, muscular stiffness, and acute pain. "Flatback" became the medical name for a related complication, especially for those who had lumbar scoliosis.[116]
In the 1960s, the gold standard for idiopathic scoliosis was a posterior approach using a single Harrington rod. Post-operative recovery involved bed rest, casts, and braces. Poor results became apparent over time.[117]
In the 1970s, an improved technique was developed using two rods and wires attached at each level of the spine. This segmented instrumentation system allowed patients to become mobile soon after surgery.[117]
In the 1980s,
Evolution
There are links between human spinal morphology, bipedality, and scoliosis which suggest an evolutionary basis for the condition. Scoliosis has not been found in chimpanzees or gorillas.[118] Thus, it has been hypothesized that scoliosis may actually be related to humans' morphological differences from these apes.[118] Other apes have a shorter and less mobile lower spine than humans. Some of the lumbar vertebrae in Pan are "captured", meaning that they are held fast between the ilium bones of the pelvis. Compared to humans, Old World monkeys have far larger erector spinae muscles, which are the muscles which hold the spine steady.[118] These factors make the lumbar spine of most primates less flexible and far less likely to deviate than those of humans. While this may explicitly relate only to lumbar scolioses, small imbalances in the lumbar spine could precipitate thoracic problems as well.[118]
Scoliosis may be a byproduct of strong selection for
Society and culture
The cost of scoliosis involves both monetary loss and lifestyle limitations that increase with severity. Respiratory deficiencies may arise from thoracic deformities and cause abnormal breathing.[121] This directly affects capacity for exercise and work, decreasing the overall quality of life.[4]
In the
The month of June is recognized as Scoliosis Awareness Month to highlight and spread awareness of scoliosis. It emphasizes its wide impact and the need for early detection.[123]
Research
See also
References
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External links
- Scoliosis at Curlie
- Early Onset Scoliosis is the abnormal, side-to-side curve of the spine in children under five years old, often including children with congenital scoliosis (present at birth, with spine abnormalities) and infantile scoliosis (birth to three years).
- Questions and Answers about Scoliosis in Children and Adolescents – US National Institute of Arthritis and Musculoskeletal and Skin Diseases