Scoliosis is a condition that involves complex lateral and rotational curvature and deformity of the spine. It is typically classified as congenital (caused by vertebral anomalies present at birth), idiopathic (sub-classified as infantile, juvenile, adolescent, or adult according to when onset occurred) or as having developed as a secondary symptom of another condition, such as cerebral palsy or spinal muscular atrophy.
Everyone’s spine has natural curves. These curves round our shoulders and make our lower back curve slightly inward. But some people have spines that also curve from side to side. Unlike poor posture, these curves can’t be corrected simply by learning to stand up straight.
In scoliosis, the spine curves to the side when viewed from the front, and each vertebra also twists on the next one in a corkscrew fashion.
Scoliosis affects girls twice as often as it affects boys. About three to five of 1,000 people are affected. Scoliosis usually occurs in those older than 10 years, but the condition can be seen in infants.

Causes

In 80 to 85 percent of people, the cause of scoliosis is unknown; this is called idiopathic scoliosis. Before concluding that a person has idiopathic scoliosis, the doctor looks for other possible causes, such as injury or infection. Causes of curves are classified as either nonstructural or structural.
Nonstructural (functional) scoliosis–A structurally normal spine that appears curved. This is a temporary, changing curve. It is caused by an underlying condition such as a difference in leg length, muscle spasms, or inflammatory conditions such as appendicitis.
Structural scoliosis–A fixed curve that doctors treat case by case. Sometimes structural scoliosis is one part of a syndrome or disease, such as Marfan’s syndrome, an inherited connective tissue disorder. In other cases, it occurs by itself. Structural scoliosis can be caused by neuromuscular diseases (such as cerebral palsy, poliomyelitis, or muscular dystrophy), birth defects (such as hemivertebra, in which one side of a vertebra fails to form normally before birth), injury, certain infections, tumors (such as those caused by neurofibromatosis, a birth defect sometimes associated with benign tumors on the spinal column), metabolic diseases, connective tissue disorders, rheumatic diseases, or unknown factors (idiopathic scoliosis).

Risk factors

The cause of most scoliosis is unknown (idiopathic). Scoliosis is often first noticed just before and during adolescence, during a growth spurt. Growth is the biggest risk factor for worsening of an existing curve.
Although infantile idiopathic scoliosis is more common in boys, the other forms — congenital, juvenile (ages 3 to 10) and adolescent (older than 10) — are more common in girls.
Other than growth, risk factors that make it more likely that a scoliosis curve will get worse include:

Sex

Curves in girls are more likely to worsen than curves in boys.

Age

The younger the child when scoliosis appears, the greater the chance the curve will worsen.

Angle of the curve

The greater the curve angle, the higher the likelihood that it will worsen.

Location

Curves in the middle to lower spine are less likely to progress than those in the upper spine.

Spinal problems at birth

Children who are born with scoliosis (congenital scoliosis) may have rapid progression of the curve.

Treatment

In planning treatment for each child, an orthopedist will carefully consider a variety of factors, including the history of scoliosis in the family, the age at which the curve began, the curve’s location and severity of the curve.
Most spine curves in children with scoliosis will remain small and need only to be watched by an orthopedist for any sign of progression. If a curve does progress, an orthopedic brace can be used to prevent it from getting worse. Children undergoing treatment with orthopedic braces can continue to participate in the full range of physical and social activities.
Electrical muscle stimulation, exercise programs, and manipulation have not been found to be effective treatments for scoliosis.
If a scoliotic curve is severe when it is first seen, or if treatment with a brace does not control the curve, surgery may be necessary. In these cases, surgery has been found to be a highly effective and safe treatment.
The decision to treat scoliosis is not always clear. While there are guidelines for mild, moderate and severe curves, there is a range in which you may have a choice among treatments. Treatment decisions depend on your child’s age, how much he or she is likely to grow and the degree and pattern of the curve.

Symptoms:

These symptoms are only those associated with the spine being curved:

  • Your head may be off center.
  • You may walk with a rolling gait.
  • The opposite sides of the body may not appear level.
  • You may experience back pain or tire easily during activities that require excessive trunk (chest and belly) movement.
  • One shoulder blade that appears more prominent than the other.
  • Uneven waist.
  • One hip higher than the other.
  • Leaning to one side.
  • As scoliosis curves get worse, the spine will also rotate or twist, in addition to curving side to side. This causes the ribs on one side of the body to stick out farther than on the other side. Severe scoliosis can cause back pain and difficulty breathing.

Scoliosis surgery

Surgery for scoliosis is only recommended for patients with curves that are greater than 40 to 45 degrees and continuing to progress, and for most patients with curves that are greater than 50 degrees. The main objective of scoliosis surgery is to fuse the spine so that the curve will not continue to progress into adulthood.
Only more severe curvatures (greater than 50 degrees) are likely to progress in adulthood.
Surgery is usually done to prevent one or more of the following problems that can occur with more severe scoliosis:

• Decreased lung function
• Back Pain

Appearance Surgery is generally done when it is safest: before these problems develop. It is therefore recommended for those patients that the surgeon feels could later develop the problems listed above.

The surgery itself has two parts:

  1. Straightening the spine with rigid rods.
  2. Adding bone graft to the curved area of the spine to fuse it in the correct position previously obtained by the rods. “Graft” refers to pieces of bone taken from other areas of the patient’s body (i.e. usually from the pelvis) or the bone bank. The fusion prevents the spine from curving more.

After surgery, the patient is noticeably straighter, but not completely. Likewise, the x-ray usually looks better, but is not perfect. The curve that does remain, however, is not normally a problem.

Potential risks and complications with scoliosis surgery

The most concerning risk with scoliosis surgery is paraplegia. It is very rare (about 1 in 1,000 to 1 in 10,000 chance) but is a devastating complication. To help manage this risk, the spinal cord can be monitored during surgery through one of two methods:

  • Somatosensory Evoked Potentials: This test involves small electrical impulses that are given in the legs and then read in the brain. If there is the development of slowing of the signals during surgery this can indicate compromise to the spinal cord or its blood supply. Another way to monitor the cord is with Motor Evoked Potentials, and often both are used throughout a surgery.
  • Stagnara wake up test: This test involves waking the patient during the surgery and asking them to move their feet. The patient does not feel any pain during this procedure and will not remember it afterwards.

Another risk with scoliosis surgery is excessive blood loss. There is a lot of muscle stripping and exposed area during the surgery. With proper technique the blood loss can usually be kept to a reasonable amount and blood transfusions are rarely needed. As a precaution, many surgeons will ask the patient to donate his or her own blood prior to surgery (autologous blood donation), which can then be given back to the patient after the surgery. Also, during scoliosis surgery the patient’s blood can be collected and transfused back to the patient.

Other potential risks and complications include:

  • The rods breaking or the hooks or screws dislodging (although with modern instrumentation systems, this type of hardware failure is quite uncommon)
  • Infection (less than 1%)
  • Cerebrospinal fluid leak (rare)
  • Failure of the spine to fuse (about 1 to 5%)
  • Continued progression of the curve after surger

Braces

A brace is often used to prevent further progression of moderate curves of (24 to 40 degrees). It is important to note that a brace will almost never reverse an existing curve and is only used to stop progression. One study reported overall success rates of around 74%, but results vary widely depending on the length of time the brace is worn, the type of brace, and the severity of the curve. The great majority of subjects in any scoliosis study are girls. Limited data suggest that in boys compliance rates are low and braces are not effective at all.

Sources: Hopkins Medicine, Spine Health, Healyhscout

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