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Scoliosis - A Guide

Scoliosis is an abnormal curvature of the spine to one side.
In people with the condition, the spine bends either to the left or right.
The curvature in the spine can vary from being slight to severe.

Introduction
Symptoms
Causes
Diagnosing scoliosis
Treating scoliosis
Complications
Self-help

Introduction

The bend in the spine due to scoliosis can occur at any point along the spine, from the top to the bottom. However, the most common regions to be affected by scoliosis are:

  • the chest area (thoracic scoliosis)
  • the lower part of the back (lumbar scoliosis)

In about 80% of scoliosis cases, the cause is unknown. This is known as idiopathic.



Who is affected by scoliosis?

In the UK, scoliosis affects three to four children out of every 1,000. The condition can develop at any time during childhood and adolescence (the teenage years). Scoliosis is more common in girls than boys and often occurs at the start of adolescence.

Outlook

Treatment is not required in about 90% of cases of scoliosis because the condition corrects itself as the child grows.

Most of the remaining 10% of cases can be successfully treated using a back brace to prevent further curvature. Approximately 3 out of every 1,000 children with scoliosis will need surgical treatment.

Scoliosis is usually not serious, but treatment is essential. Left untreated, the curvature of the spine can get worse and cause damage to the spine, chest, pelvis, heart and lungs.

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Symptoms of scoliosis

In children, the symptoms of scoliosis can include:

  • one shoulder being higher than the other
  • one shoulder blade being higher and more prominent than the other
  • one hip being more prominent than the other
  • clothes not hanging properly
  • the child may lean to one side

In babies, the symptoms of scoliosis can include:

  • a bulge on one side of the baby’s chest or back
  • the baby may be consistently lying curved to one side

If your child is in a wheelchair, they may have a tendency to lean to one side. This could be a symptom of scoliosis because sitting can become more difficult as the curve in the spine progresses.

Take your child to see your GP if you notice any of the symptoms above. Scoliosis can often develop gradually without the child realising and it does not usually cause any pain.

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Causes of scoliosis

Idiopathic scoliosis

In approximately 80% of cases of scoliosis, the cause is unknown (idiopathic). However, researchers have discovered that in about 30% of adolescent idiopathic scoliosis cases, the child has some family history of the condition. This suggests that there may be a genetic link to the condition.

Neuromuscular conditions

Most of the remaining cases of scoliosis are caused by neuromuscular conditions (conditions that affect the nerves and muscles), such as muscular dystrophy or cerebral palsy.

These conditions can result in children being unable to walk and finding it difficult to remain upright, both of which can prevent their spine from developing normally.

Congenital scoliosis

Scoliosis that is present at birth is called congenital scoliosis. Congenital scoliosis is rare. It occurs as a result of malformations of the spine that are caused by the bones in the spine developing abnormally in the womb .It can occur in children who have rare birth defects.

Scoliosis cannot be caused by bad posture, exercise, diet or using backpacks or satchels.

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Diagnosing scoliosis

Scoliosis is usually diagnosed with a physical examination of the spine, ribs, hips and shoulders.

The initial diagnosis is often made by a GP or school nurse, who will then refer your child to an orthopaedic specialist (a specialist in conditions that involve the skeleton, particularly the spine and the surrounding joints and ligaments).

X-rays and MRI scan

The orthopaedic specialist will take an X-ray to confirm the diagnosis of scoliosis. The X-ray images will also help to determine the shape, direction, location and angle of the curve.

If the curvature of the spine is severe or if the symptoms of scoliosis are unusual (for example, if your child has back pain), a magnetic resonance imaging (MRI) scan may be recommended.

MRI scans use a magnetic field and radio waves to build up a picture of the inside of your body. The MRI scans will highlight any underlying neurological conditions (conditions that affect the nerves and muscles).

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Treating scoliosis

If your child has scoliosis, the treatment they receive will depend on their age, the extent of the curvature of their spine and how well their lungs work. There are four treatment options:

  • observation
  • casting
  • bracing
  • surgery

The different treatment options are described in more detail below.

Observation

Treatment for scoliosis is often unnecessary because most cases are not severe and the condition often corrects itself as the child grows.

However, X-rays will need to be taken every six months so that the progress of the curvature can be carefully monitored.

Casting

In early cases of scoliosis, your child's spine may need to be guided back into its normal position as they continue to grow. This can be achieved by using a brace, made of plaster of Paris, which is attached to the outside of your child's body.

Your child will have to wear the cast constantly, without removing it. However, it will need to be changed regularly to allow for your child's growth and development. Due to the specific way that a cast is made, your child should be referred to a scoliosis specialist if a cast is required.

If your child is under two years of age, the cast will be changed under an anaesthetic every two to three months to straighten the spine. However, it is likely that your child may need to use a removable brace after the casting treatment.

Bracing

If the curve of your child's spine is more severe (with an angle of more than 20 degrees), a brace will be required. A brace cannot cure scoliosis or correct the curve, but it can stop the curve from getting worse.

The brace will need to be carefully fitted to your child's spine.To do this, a cast of your child's spine will need to be taken. This can be done on an outpatient basis, which means that your child will not have to stay overnight in hospital. Instead, they will have one or more appointments at a hospital or clinic.

It is usually recommended that the brace is worn for 23 hours a day, and that it is only removed for baths and showers. The brace should not interfere with normal everyday activity and can be worn during most non-contact sports. However, it is recommended that the brace is removed during contact sports.

It is important for children who wear braces to take regular exercise. This will help improve muscle tone and body strength, and will help make wearing the brace more comfortable.

The brace will have to be worn for as long as your child's body is still growing. Boys typically stop growing at around 17 years of age and girls typically stop growing at around 15 years of age.

Surgery

If your child's scoliosis is severe (if their spine has a curve of more than 50 degrees), they may require surgery and will be referred to a specialist unit.

Surgery can help prevent damage to the heart and lungs, as well as helping to alleviate back pain and the abnormal development of your child's body.

Spinal fusion surgery is a complicated technique where the spine is straightened using metal hooks and rods, before being fused into place using bone grafts. It should only be carried out by experts this type of surgery.

The surgery will take four to eight hours. After surgery, your child will be transferred to an intensive care unit (ICU), where they will be given intravenous fluid (administered through a vein) and pain relief. Most children are well enough to leave intensive care after 24 hours, although they will often need to spend another7 to 10 days in hospital.

After the operation, most childrencan return to school after four to six weeks andcan play sports about a year after having surgery. Some children may need to wear a back brace to support their spine, which can usually be removed after six months.

After having spinal fusion surgery, your child will need to return every six months to have the rods lengthened by approximately 1cm to keep up with their growth. This is usually an outpatient procedure that is performed through a small incision (cut). A brace will need to be worn to protect the rods. The rods will be removed during surgery when your child is older and their spine has grown.

Risks of spinal fusion surgery

There are a number of risks associated with spinal fusion surgery. It will not be recommended for your child unless the surgeon feels the benefits outweigh the risks. It is important that parents and children understand the risks of spinal fusion surgery so that they can make an informed decision about treatment.

The known risks of spinal fusion surgery are described below:

  • Rod displacement.In around 5% of people who have surgery, one of the rods used to straighten the spine will move from its correct position. This should not cause any discomfort, but additional surgery may be required to return the rod to its correct position.
  • Pseudarthrosis occurs when one or more of the bones used to fuse the spine into place fails to graft properly. Pseudarthrosis happens in around 1-5% of cases. It can cause mild discomfort and, in some people, can also cause some loss of the correction of the curvature of the spine. Further surgery will be needed to regraft the relevant bones.
  • Infection. Around 1-2% of people develop an infection after surgery. However, this can usually be easily treated with antibiotics.
  • Nerve damage. In very rare cases (in about one or two cases in every 1,000), spinal fusion surgery will cause damage to the nerves in the spine. The results of this nerve damage can be relatively mild (a feeling of numbness in one or both legs), or it can be more severe and cause a loss of all lower bodily functions (paraplegia). To minimise this risk, a neurologist (a specialist in conditions of the nervous system) will be present during spinal fusion surgery to monitor the nerves and prevent any damage to them.

Additional therapies

A number of additional therapies may be helpful in correcting scoliosis. These include:

  • osteopathy: manipulation of the muscles, nerves and joints
  • physiotherapy: massage and manipulation to help improve general health and wellbeing
  • reflexology: a therapy where certain areas of the body, such as the soles of the feet, are massaged to help improve general health
  • acupuncture: a traditional Chinese treatment that involves sticking needles into certain points of the bodyto improve health
  • electronic stimulation of the nerves in the back

It is important to note that there is little evidence to show that these additional therapies are effective in treating scoliosis. Physiotherapy can be beneficial, but only when it is used in combination with a back brace.

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Complications

Complications of scoliosis are rare if the condition is treated. However, if scoliosis is left untreated, it can cause serious complications, such as those outlined below.

Kyphosis

If a severe case of scoliosis is left untreated, it can cause the upper spine to twist, resulting in a rounded or hunched back. This condition, known as kyphosis, will also cause back pain. Kyphosis will need similar treatment to scoliosis, such as bracing and possibly spinal fusion surgery.

Lung and heart problems

In severe cases of scoliosis (where the curve is 70 degrees or more), the rib cage can be pushed against the heart and lungs, causing breathing problems and making it difficult for the heart to pump blood around the body.

In very severe cases of scoliosis (where the curve is 100 degrees or more), the rib cage will push harder against the heart and lungs, causing physical damage.

Strain or damage to the heart and lungs increases the chances of lung infections developing, such as pneumonia and heart failure.

Back problems

Adults who had scoliosis when they were children are more likely to develop chronic (long-term) back pain than others. People who have scoliosis that is untreated are also more at risk of developing arthritis in their spine.

Problems in later life

Other possible problems thatcould develop later in life if a child's scoliosis is not treated include:

  • social isolation
  • limited job opportunities
  • lower marriage rates

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Self-help

Adolescence is a difficult time for teenagers. The changes to a teenager's body can often make them feel awkward and self-conscious. Having to wear a back brace can make adolescence an even more difficult time as it can affect body image, self-esteem and overall quality of life.

Modern back braces are designed to be unobtrusive and are practically impossible to see under loose-fitting clothing. However, your child may still worry that they look different or unusual.

Some ways to help improve your child's self-image are described below.

Communication

Encouraging your child to communicate with other teenagers who have scoliosis can help improve their confidence and reduce feelings that they are alone with their condition.

There are several support groups, such as Scoliosis Association UK, that provide information and support for people with scoliosis. Some also have online message boards, so that teenagers from across the world can compare experiences, share tips and exchange messages of encouragement.

Exercise

Not only will regular exercise make wearing a back brace more comfortable, but it is also a proven method of increasing self-esteem and improving children's feelings about their body.

Reassurance

Reassure your child that they will not have to wear a back brace forever. Once treatment has been completed, there is no reason why your child cannot live a normal, active life.



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