Scoliosis

Scoliosis is a conditionthat involves a lateralcurvatureof the spine; that is, the spine is bent sideways. Scoliosis is incurable, but its natural course can be affected with treatments such as surgery or bracing.

Prevalence

Scoliosis curves greater than 10° affect 2-3% of the population, often children between the ages of ten and fourteen, with a greater incidence among girls. Curves greater than 20° affect about 1 in 2500 people. Curves convex to the right are more common than those to the left, and single or 'C' curves are slightly more common than double or 'S' curve patterns.

Different etiologic theories point to genetic, neuromuscular, hormonaland growthfactors, though it appears that the cause is multifactorial. The vast majority of cases (85%) have unknown causes or are idiopathic.

In one out of every 1000 cases, surgery may be necessary. Females are nine times more likely to require treatment than males, mostly since they are also more likely to have larger, progressive curves.

Symptoms

Those with scoliosis rarely complain of pain, and their condition is often discovered incidentally.

The symptoms of scoliosis are:

• Prominent shoulder blade
• Uneven hipand shoulderlevels.
• Asymmetricsize or location of breast in females.
• Unequal distance between arms and body
• Clothes that do not "hang right"
• Musclemass that causes a "hump" on one side of the spine
• A rib"hump"

Shoulders that have a lack of spine reinforcement can hurt if large amounts of weight are placed upon them. Back pain caused by scoliosis can manifest mainly in the younger of those affected (usually from childhood to the age of about 25) during times of heavy muscular growth, such as growth spurts, due to the irregular shaping of the spine and the resulting compensation that the person's body has to make for that irregular shape. This pain can be anywhere from mild pain to heavier, more debilitating pain, and is often felt in the musculature directly surrounding the spine instead of in the spine itself. Due to this muscular compensation stiffness of the back and neck can also occur, especially if the curve in the spine is located higher up in the back.

Associated conditions

Scoliosis is often associated with other conditions such as neuromuscular disorders(e.g., cerebral palsy, spinal muscular atrophy, Friedreich's ataxia); skeletal dysplasias; Marfan's syndrome; neurofibromatosis; connective tissue disorders; and craniospinal axis disorders (e.g., syringomyelia).

Investigation

Image:Scoliosis cobb.gifThose suspected of having scoliosis should undergo a thorough physical examination. During a physical examination, the following should be assessed:

• Skinfor café au laitspots indicative of neurofibromatosis
• The feet for cavovarus deformity
• The height of the iliac crestswhile standing
• Magnitude of the curve and rib hump both while standing and while leaning forward
• Asymmetric shoulder and breast levels
• Asymmetric superficial abdominal reflexes
• Inequality of lengths of the upper limbs from the floor when leaning forward

During the exam, the patient's gait should be assessed, and there should be a search for signsof spinal abnormalities (e.g., dysraphismas evidenced by a dimple, hairy patch, lipoma, or hemangioma). There should also be a thorough neurological examination. Ultimately, however, the main goal should be the assessment of curve severity and flexibility.

Radiograghic investigation such as X rayor computed tomography(CT) should also be carried out to assess the location, levels of involvement, direction and magnitude of the curves. One method for assessing the curvature is the calculation of the Cobb angle, which assesses the curve from the top endplate of the topmost involved vertebrato the bottom endplate of the bottommost involved vertebra.

A note here is that most patients will be unaware that they are afflicted with scoliosis even when curves exceed 30°.

Management

The management of scoliosis is determined by the severity of the scoliosis and the level of skeletal maturity. A number of methods are used to decide upon the most appropriate treatment. In many instances mild scoliosis requires no treatment.

The conventional options are, in order:

1. Observation
2. Physiotherapyor chiropractic
3. Bracing or casting
4. Surgery

Mild, flexible curves sometimes respond to physiotherapy and chiropractic, but should never be used alone when there is a risk of curve progression.

Bracing is only performed by the medical profession when the patient is in their growing years. (However, some controversial alternative treatments also advocate bracing of adults for correction; none of these have been subjected to rigorous peer reviewed study, and their efficacy is at best uncertain.) This holds the spine and prevents the curve from progressing. If a curve is maintained below 40° as the patient finishes growing, it is unlikely for it to continue progression when the brace is removed ? if the curve exceeds this, surgery is often performed.

Bracing involves fitting the patient with a brace that covers the torso and in some cases it extends to the neck. The most commonly used brace is a TLSOor Boston Brace, a corset-like appliance from armpits to hips, custom-made from plastic. It is usually worn 23 hours a day and applies inward pressure on the curves in the spine. In infantile and sometimes juvenile scoliosis a body cast or plaster jacket can be used instead.

Surgery

Spinal fusionis the most widely performed surgery for scoliosis. In this procedure bone (either harvested from elsewhere on the body, or donor bone) is grafted to the vertebrae so that when it heals, they will form one solid bone mass. This restricts spinal movement and prevents worsening of the curve, and straightens the curve as much as possible.

Originally spinal fusions were done without metal implants. A cast was applied after the surgery, usually under traction to pull the curve as straight as possible and then hold it there while fusion took place. Unfortunately, there was a relatively high risk of fusion failure at one or more levels (pseudarthrosis), and significant correction could not always be achieved.

The solution is metal instrumentation. This serves 2 purposes - it helps to straighten the spine, and then holds it rigid while fusion takes place. The original, now obsolete, spinal systemwas the Harrington rod, developed in the 1960s by Dr Paul Harrington. This long rod operated on a ratchet system, being attached by outward-facing hooks to the spine at the top and bottom of the curvature. As it was cranked out, it would distract, or straighten the curve. This system was relatively unstable in the early stages of healing, so it was still necessary to wear a cast for several months after surgery.

It also became apparent during the 1980s, as the first long term outcome data became available, that use of the Harrington for long fusions extending into the lumbar region caused problems, specifically flatback, where the loss of lumbarlordosiscauses the spine to become unbalanced.

Modern spinal systems such as Luque, CD HORIZON, USS and Synergy involve a combination of rods, screws, hooks and wires fixing the spine and can apply stronger, safer forces to the spine than the Harrington rod.

Recently types of scoliosis surgery have been trialled that aim to control a curve aggressively and delay necessary spinal fusion to allow the spine to grow to full length. These include growth rodsthat are extended with the spine every few months, and VEPTRor ?titanium rib? ? a metal ribcage implant, sometimes used in conjunction with a spinal implant, that pushes apart the ribs on the concave side of the curve, distracting the curve straighter without fusion. Like bracing, these are usually only effective on growing immature skeletons.

Finally, vertebral staplingis a potential alternative to fusion altogether. Staples are driven into the convex side of a curve to retard the growth of that side of the spine, allowing the other side to grow and differentially straighten the curve.

Prognosis

The prognosis of scoliosis depends on the progression of the condition. Since the best outcome is the disruption or arrest of the natural history of the scoliosis, prognosis is contingent on the likelihood of progression – a factor assessed with the assignment of a Risser stage and grade. The general rules of progression are that larger curves carry a higher risk of progression than smaller curves, and that thoracic and double primary curves carry a higher risk of progression than single lumbar or thoracolumbar curves.

See also

• Kyphosis
• Lordosis

External links

Information pages

• Scoliosis in Children: A Complex Disorder
• Understanding idiopathic scoliosis
• Scoliosis
• Scoliosis in Children and Adolescents
• Scoliosis Research SocietyAssociation of surgeons and researchers committed to scoliosis treatment through education, research, and advocacy. Includes information for patients.

Support sites

• National Scoliosis Foundation of America
• Scoliosis Support - for people with scoliosis, kyphosis and lordosis
• SpineKIDS | dedicated to children and parents dealing with scoliosisca:Escoliosi

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This article is licensed under the GNU Free Documentation License.
It uses material from the http://en.wikipedia.org/wiki/Scoliosis Wikipedia article Scoliosis.