Comprehensive Care Guide on Scoliosis
Scoliosis is an abnormal lateral curvature of the spine that may lead to physical and psychosocial impairments depending on its severity. While many people might think of the spine as straight when viewed from behind, there’s actually a natural curvature that helps with balance and movement. Scoliosis occurs when this curvature becomes excessive or abnormal.
Scoliosis is defined as a lateral curvature with a Cobb angle of greater than 10 degrees. The condition often begins in childhood or adolescence and may not be recognized prior to adulthood, or it can develop de novo during adulthood.
Types of Scoliosis
Adult scoliosis is one aspect of adult spinal deformity (ASD), which also includes kyphosis and spondylolisthesis. These entities can affect the cervical, thoracic and lumbar spine as well as the pelvis.
The main types of scoliosis include:
- Adolescent Idiopathic Scoliosis (AIS): The most common form, affecting 1-3% of adolescents in the U.S. The term “idiopathic” indicates that the cause is unknown.
- Adult Degenerative Scoliosis: The most common causes of adult scoliosis are de novo scoliosis (scoliosis associated with degenerative changes in patients with no previous history of scoliosis) and progression of adolescent idiopathic, congenital, or early-onset scoliosis.
- Congenital Scoliosis: Present at birth due to vertebral anomalies.
- Neuromuscular Scoliosis: Associated with conditions affecting the neuromuscular system, such as cerebral palsy or muscular dystrophy.
- Syndromic Scoliosis: Associated with specific genetic syndromes like Marfan syndrome or Ehlers-Danlos syndrome.
Epidemiology
The overall prevalence of adult spinal deformity (ASD) is 32 percent and increases with age, with estimates ranging from 8 percent in adults age 25 to 74 and increasing to 68 percent among adults ≥50 years. Many individuals have mild forms of scoliosis that may not cause symptoms.
For adolescent idiopathic scoliosis specifically, it affects 1-3% of adolescents in the U.S., making it the most common form of scoliosis.
Causes and Risk Factors
The etiology of scoliosis varies depending on the type:
Adolescent Idiopathic Scoliosis
Genetic factors are thought to play a role. Recent research indicates a multifactorial etiology, involving genetic, hormonal, and environmental factors. Epigenetic research has identified DNA methylation and non-coding RNAs as potential biomarkers.
Adult Degenerative Scoliosis
Usually begins with asymmetric degeneration of the intervertebral disc and facet joints, leading to unbalanced loading of the spine. Asymmetric loading can cause ongoing damage and curve progression.
Secondary Scoliosis
Less commonly secondary to underlying medical conditions including neurologic conditions such as stroke and Parkinson disease, posttraumatic paralysis, fracture(s), or spinal surgery.
Risk factors for curve progression include:
- Cobb angle >30 degrees or curves 20 to 30 degrees with severe rotation
- Lumbar curves (progress more rapidly than thoracic curves)
- History of decompression laminectomy without spinal fusion
- Osteoporosis, especially with known vertebral fracture
Clinical Presentation
Patients with spinal deformity are often asymptomatic, although others may have significant symptoms. When symptoms are present, they typically include:
- Back pain (in up to 90 percent of patients)
- Postural imbalance with difficulties standing and walking
- Symptoms of spinal stenosis in approximately 50 to 89 percent of patients
- Neurogenic claudication (pain, sensory loss, and/or weakness affecting the legs)
- Radiculopathy (pain, numbness, tingling, or weakness that radiates into the legs)
Psychosocial concerns about posture and appearance, worries about future curve progression and depressive mood (e.g., decreased height, change in posture, asymmetry, change in fit of clothing) may also be present.
Diagnosis
The diagnosis of scoliosis involves a comprehensive evaluation:
Physical Examination
Key elements of the physical examination include:
Inspection of the standing patient from behind to observe for lateral curvature of the spine with thoracic or lumbar asymmetry, head not centered over the sacrum, asymmetry in shoulder or scapulae height, waistline, or distance that the arms hang from the trunk.
The Adam’s forward bend test is crucial: The test evaluates the rotational component of scoliosis by observing the patient from the back while they bend forward at the waist until the spine is parallel to the floor. Thoracic (rib) or lumbar (loin) prominence on one side is a sign of scoliosis.
Radiographic Evaluation
Radiographs are required to confirm the diagnosis of scoliosis, evaluate the etiology, determine the curve pattern, measure the magnitude of the curve (Cobb angle), evaluate the extent of degenerative changes, and assess sagittal balance.
The initial radiographic evaluation includes standing posteroanterior (PA) and lateral views of the spine on a 36-inch digital cassette. Standing radiographs are required because lying down eliminates the effect of gravity, reduces the magnitude of the curve, and limits the ability to assess coronal and sagittal balance.
The Cobb angle is the standard measurement used to quantify the severity of scoliosis:
The Cobb angle is formed by intersecting a line parallel to the superior end plate of the most tilted cephalad vertebra in a specific curve, with the line parallel to the inferior end plate of the most tilted caudad vertebra of the curve.
Advanced Imaging
MRI of the spine is indicated in patients with spinal deformity and clinical or radiographic findings suggestive of intraspinal pathology or patients who are experiencing neurologic symptoms. MRI may be superior to computed tomography (CT) for evaluating intervertebral disc herniations and spinal stenosis.
CT of the spine is useful in evaluating the bony anatomy (e.g., fractures such as spondylolysis, severity of disc degeneration and disc instability, and osteophytes in the spinal foramen) and the integrity of spinal fusion and hardware from previous surgery.
Diagnostic Images
Treatment Options
Treatment for scoliosis is individualized based on the patient’s age, curve severity, symptoms, and risk of progression. The main options include:
Observation & Conservative Management
For mild curves or asymptomatic patients, observation may be appropriate. Initial treatment with conservative measures is appropriate for patients without “red flag” findings or progressive neurologic deficits.
May include:
- Lightweight lumbar brace
- Anti-inflammatory medications
- Regular low-impact exercise
- Weight management
- Physical therapy (Schroth technique)
Bracing
Bracing is primarily recommended for growing children and adolescents with curves between 20° and 40°. For adults, bracing generally doesn’t correct the curve but may help with pain management.
Types of braces:
- Soft bracing for support & pain relief
- Firm orthoses (Rigo-Chêneau brace)
Surgical Intervention
Surgical intervention can be performed both to prevent potential long-term effects and to treat existing problems. The goals are to improve quality of life, posture, and stop progression.
Considered when:
- Meaningful benefit expected
- Poor quality of life
- Conservative therapy fails
- Surgically correctable problem
- Patient medically suitable
Latest Research and Advances
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Epigenetic Biomarkers:
Research has identified DNA methylation and non-coding RNAs as potential biomarkers for AIS, which may help in understanding its pathogenesis and progression.
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Physiotherapeutic Scoliosis-Specific Exercises (PSSE):
Methods like Schroth, SEAS, and BSPTS show promise in reducing the Cobb angle and improving quality of life.
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Screening Recommendations:
The U.S. Preventive Services Task Force (USPSTF) has found insufficient evidence to recommend routine screening for AIS in asymptomatic adolescents, citing potential harms such as unnecessary radiation exposure and overtreatment.
Conclusion
Scoliosis is a complex condition with various causes and presentations. Management is individualized according to etiology, severity of symptoms, and quality of life. Primary care management usually includes conservative treatments, while specialist management may include serial monitoring, injection therapies, and surgical intervention when appropriate.
Early detection, proper monitoring of curve progression, and timely intervention are key to achieving the best outcomes. Ongoing research into genetic and epigenetic factors continues to improve our understanding of this condition and may lead to more targeted treatments in the future.