Overview

Scoliosis is a three-dimensional deformity of the spine characterized by a sideways curvature that typically appears as an "S" or "C" shape when viewed from behind. This condition affects approximately 2-3% of the population, or an estimated 6 to 9 million people in the United States.

The condition can develop at any age, but it most commonly begins during the growth spurt just before puberty, typically between ages 10 and 15. While both boys and girls develop mild scoliosis at about the same rate, girls are more likely to have curves that worsen and require treatment.

Most cases of scoliosis are mild and require only monitoring. However, severe scoliosis can be disabling. An especially severe spinal curve can reduce the amount of space within the chest, making it difficult for the lungs to function properly. Children who have mild scoliosis are monitored closely, usually with X-rays, to see if the curve is getting worse.

Key Points

  • Scoliosis affects 2-3% of the population
  • Most commonly develops between ages 10-15
  • Girls are 8 times more likely to progress to a curve requiring treatment
  • 80% of scoliosis cases are idiopathic (unknown cause)
  • Early detection and treatment can prevent progression

Symptoms

The signs and symptoms of scoliosis can vary depending on the severity of the curve. Many people with mild scoliosis have no symptoms at all, while others may experience noticeable changes in their appearance or physical discomfort.

Common Symptoms

Visible Signs

  • Uneven shoulders (one shoulder blade more prominent)
  • Uneven waist or hips
  • One hip higher than the other
  • Ribs sticking out more on one side
  • Prominence of the ribs on one side when bending forward
  • Entire body leaning to one side
  • Uneven leg lengths

Severe Cases May Include

  • Breathing problems due to reduced lung capacity
  • Cardiovascular issues from chest cavity changes
  • Chronic pain that affects daily activities
  • Neurological symptoms if nerves are compressed

Causes

The exact cause of scoliosis remains unknown in about 80% of cases, which are termed "idiopathic scoliosis." Researchers continue to study genetic and environmental factors that may contribute to the development of spinal curves.

Types and Causes

1. Idiopathic Scoliosis (80% of cases)

  • Infantile: Develops before age 3
  • Juvenile: Develops between ages 3-10
  • Adolescent: Develops between ages 10-18 (most common)

2. Congenital Scoliosis

Caused by abnormal vertebral development in the womb, resulting in malformed or fused vertebrae.

3. Neuromuscular Scoliosis

Associated with neurological or muscular conditions such as:

  • Cerebral palsy
  • Muscular dystrophy
  • Spinal muscular atrophy
  • Spina bifida

4. Degenerative Scoliosis

Develops in adults due to wear and tear of the spine, disc degeneration, or osteoporosis.

5. Other Causes

  • Injuries or infections of the spine
  • Tumors
  • Genetic conditions like Marfan syndrome or Ehlers-Danlos syndrome

Risk Factors

Several factors can increase the likelihood of developing scoliosis or experiencing curve progression:

Primary Risk Factors

  • Age: Risk increases during growth spurts, particularly just before puberty
  • Sex: Girls are 8 times more likely to have progressive curves requiring treatment
  • Family History: Scoliosis tends to run in families, though most children with scoliosis don't have a family history
  • Curve Pattern: S-shaped curves and thoracic curves are more likely to progress
  • Curve Magnitude: Larger curves are more likely to worsen over time

Factors Affecting Progression

  • Remaining growth potential (younger age at diagnosis)
  • Initial curve size (curves over 25-30 degrees more likely to progress)
  • Location of curve (thoracic curves progress more than lumbar)
  • Sex (females more likely to experience progression)

Diagnosis

Early detection of scoliosis is crucial for effective management. Diagnosis typically involves a combination of physical examination and imaging studies.

Physical Examination

Adam's Forward Bend Test

The most common screening test where the patient bends forward at the waist while the examiner looks for:

  • Rib prominence on one side
  • Shoulder blade asymmetry
  • Waist asymmetry
  • Hip elevation

Scoliometer Measurement

A device used during the forward bend test to measure the angle of trunk rotation. Readings of 7 degrees or more typically warrant further evaluation.

Imaging Studies

X-rays

  • Standing posteroanterior and lateral views
  • Used to measure the Cobb angle (degree of curvature)
  • Helps determine skeletal maturity (Risser sign)

MRI

Recommended when:

  • Neurological symptoms are present
  • Unusual curve patterns are detected
  • Rapid progression occurs
  • Planning for surgery

CT Scan

Used for detailed bone imaging, particularly in complex cases or surgical planning.

Curve Classification

  • Mild: 10-25 degrees
  • Moderate: 25-40 degrees
  • Severe: 40-50 degrees
  • Very Severe: Over 50 degrees

Treatment Options

Treatment for scoliosis depends on several factors including the severity of the curve, the patient's age, and the likelihood of progression. The goal is to prevent curve progression and maintain quality of life.

1. Observation

For mild curves (less than 25 degrees) in growing children:

  • Regular check-ups every 4-6 months
  • X-rays to monitor progression
  • No active treatment unless progression occurs

2. Bracing

For moderate curves (25-40 degrees) in growing children:

Types of Braces

  • Boston Brace: Most common, worn 16-23 hours daily
  • Milwaukee Brace: For high thoracic curves
  • Charleston Bending Brace: Nighttime wear only

Bracing effectiveness depends on compliance and is designed to prevent progression, not correct existing curves.

3. Physical Therapy

Specific exercises and techniques:

  • Schroth method - specialized three-dimensional exercises
  • Core strengthening
  • Posture training
  • Breathing exercises
  • Pain management techniques

4. Surgery

Considered for severe curves (over 40-50 degrees) or progressive curves despite bracing:

Spinal Fusion

  • Most common surgical treatment
  • Involves fusing vertebrae together
  • Uses metal rods, hooks, screws, or wires
  • Recovery time: 6-12 months

Growing Rods

  • For young children with severe scoliosis
  • Adjustable rods that can be lengthened
  • Allows continued growth

Vertebral Body Tethering (VBT)

  • Newer, less invasive technique
  • Uses flexible cord instead of rigid fusion
  • Preserves spine flexibility

5. Alternative Treatments

While not proven to stop progression, these may help with symptoms:

  • Chiropractic care
  • Massage therapy
  • Acupuncture
  • Yoga and Pilates

Prevention

While idiopathic scoliosis cannot be prevented, early detection and appropriate treatment can prevent progression and complications. Here are key preventive strategies:

Screening Programs

  • School-based screening (though controversial)
  • Regular pediatric check-ups
  • Family awareness if there's a history of scoliosis

Lifestyle Modifications

  • Maintain good posture
  • Regular exercise to strengthen core muscles
  • Balanced nutrition for bone health
  • Avoid one-sided activities or carrying heavy bags on one shoulder

For Those Diagnosed

  • Comply with prescribed treatment (especially bracing)
  • Attend all follow-up appointments
  • Perform prescribed exercises regularly
  • Monitor for progression signs

When to See a Doctor

Early intervention is key to managing scoliosis effectively. Consult a healthcare provider if you notice:

Visual Signs

  • Uneven shoulders or shoulder blades
  • Prominent ribs on one side
  • Uneven waist or hips
  • Body leaning to one side
  • Clothes not fitting properly

Physical Symptoms

  • Persistent back pain
  • Difficulty breathing
  • Reduced physical endurance
  • Numbness, weakness, or pain in legs

Urgent Medical Attention

Seek immediate care for:

  • Severe, sudden back pain
  • Loss of bowel or bladder control
  • Progressive weakness in legs
  • Difficulty breathing

Related Conditions

Several conditions may be associated with or mistaken for scoliosis:

Spinal Conditions

  • Kyphosis: Forward rounding of the back
  • Lordosis: Inward curve of the lower back
  • Spondylolisthesis: Vertebral slippage
  • Spinal stenosis: Narrowing of spinal canal

Associated Syndromes

  • Marfan syndrome
  • Ehlers-Danlos syndrome
  • Neurofibromatosis
  • Osteogenesis imperfecta

Neuromuscular Conditions

  • Cerebral palsy
  • Muscular dystrophy
  • Spinal muscular atrophy
  • Spina bifida

References

  1. Weinstein SL, Dolan LA, Cheng JC, et al. Adolescent idiopathic scoliosis. Lancet. 2008;371(9623):1527-1537.
  2. Negrini S, Donzelli S, Aulisa AG, et al. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis Spinal Disord. 2018;13:3.
  3. Konieczny MR, Senyurt H, Krauspe R. Epidemiology of adolescent idiopathic scoliosis. J Child Orthop. 2013;7(1):3-9.
  4. Hresko MT. Clinical practice. Idiopathic scoliosis in adolescents. N Engl J Med. 2013;368(9):834-841.
  5. Sanders JO, Browne RH, McConnell SJ, et al. Maturity assessment and curve progression in girls with idiopathic scoliosis. J Bone Joint Surg Am. 2007;89(1):64-73.