Scoliosis is the curving of the spine to the side due to a twist. Types of scoliosis include idiopathic scoliosis, congenital scoliosis, or neuromuscular scoliosis.

Scoliosis

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Syed Intisar Hussain

Overview

Scoliosis refers to an abnormal curvature of the spinal cord greater than 10 degrees, as seen on an X-ray. The condition is mostly diagnosed during the early years. 
&nbsp;

The spine&#39;s normal curves can be observed at the cervical, thoracic, and lumbar regions &ndash; different segments of the spinal cord &ndash; in the sagittal plane. These naturally occurring curves help to position the head over the pelvis and act as a shock absorber to reduce some of the mechanical stress when the person moves.

Scoliosis can also be defined as a spinal curvature in the coronal or frontal plane. The curvature degree can be evaluated on the coronal plane, making scoliosis a more complex, three-dimensional problem that includes the planes mentioned below<a href="#accordion">[5]</a>:

<ul>
	<li>Coronal plane</li>
	<li>Sagittal plane</li>
	<li>Axial plane 
	&nbsp;</li>
</ul>

While the coronal plane is a vertical plane from head to foot and parallel to shoulders, the sagittal plane is a demarcation between the right and left halves of the body. Lastly, the axial plane is parallel to the ground&rsquo;s plane at a 90&deg; angle to the coronal and sagittal planes. 
Scoliosis affects 2-3% of the entire population, or around 6-9 million people residing in the USA. While scoliosis is likely to develop in infancy or early childhood, the primary age of onset is 10-15 years old, with no predilection to any gender. 
&nbsp;

Each year, 600,000 visits to a private physician&rsquo;s office are due to scoliosis alone, and shockingly 30,000 children are given a brace while 38,000 patients have to undergo spinal fusion surgery<a href="#accordion">[5]</a>.

The exact cause of idiopathic scoliosis remains unknown; however, it is presumed that it is multifactorial. It is also assumed that close relatives of people with idiopathic scoliosis are at more risk of having it. The gender distribution of idiopathic scoliosis is not perfectly understood.

The prognosis depends on the severity of the scoliosis and the patient&rsquo;s age. According to clinical observations, there is an equal ratio of male to female infants being affected by infantile scoliosis; however, girls get affected more as their age increases, so much so that the gender ratio after the age of 10 is around 6:1<a href="#accordion">[4]</a>.

A similar development is observed based on the severity of curvature: boys have mild scoliosis compared to girls, even though the ratio of girls to boys with spinal curvatures greater than 20&deg; is 5:1, and it increases to 10:1 in children whose spinal curvature exceeds 30&deg;<a href="#accordion">[4]</a>. 
&nbsp;

There are two major categories of scoliosis<a href="#accordion">[1]</a>:

<ol>
	<li>Structural Scoliosis: Structural scoliosis is the most common variant of scoliosis. It usually includes rotation of the spinal cord along with the side-to-side curvature of the spine. This variant of scoliosis affects the spine&rsquo;s structure and is a permanent condition until it is treated. 
	&nbsp;</li>
	<li>Nonstructural Scoliosis: Non-structural scoliosis is also known as functional scoliosis as it results from a temporary cause and involves only a side-to-side curvature of the spine. There is no spinal rotation involved in this type of scoliosis. The spine&rsquo;s structure is still normal. 
	&nbsp;</li>
</ol>

According to clinical assessments, in the case of a nonstructural variant of scoliosis, bending forward or lying down will lead the scoliosis curve to go away while held in that position. However, structural scoliosis is considered a much more serious condition as it does not straighten out on its own and has the potential to develop into a spinal deformity. 
&nbsp;

Structural scoliosis is further categorized into:

<ul>
	<li>Idiopathic Scoliosis: Idiopathic scoliosis is responsible for almost 8 out of 10 cases of scoliosis1. This variant is clinically evident during adolescent years, but it can also occur during early childhood. As the name suggests, the actual cause is currently unknown. However, a few researches indicate that genetics might be a major factor. 
	&nbsp;</li>
	<li>Degenerative Scoliosis: Degenerative scoliosis is referred to as adult scoliosis. It is a relatively common condition that happens in the later years of life as the joints in the spine wear off. It&rsquo;s a side-to-side spinal curvature, which is completely different from standard adolescent scoliosis. 
	The degenerative scoliosis curve will develop as a slight &ldquo;C&rdquo; shape forms on one side of the lumbar spine. Symptomatic degenerative scoliosis exhibits sciatica, a pain ranging from dull backache to unbearable pain sensations down the leg, making walking impossible.</li>
	<li>Neuromuscular Scoliosis: Also known as myopathic scoliosis, this condition usually affects people who are unable to walk because of a neuromuscular condition, such as muscular dystrophy, spina bifida, and cerebral palsy. 
	&nbsp;</li>
	<li>Congenital Scoliosis: Congenital scoliosis affects the fetus inside the mother&rsquo;s womb and is clinically evident during the infantile years. It is a rare condition, which affects 1 in every 10,000 babies due to malformations in the baby&rsquo;s vertebrae1. Mostly, this type of scoliosis requires surgery to treat the patient. 
	It&rsquo;s highly unlikely that scoliosis develops from a spinal tumor. 
	&nbsp;</li>
</ul>

<h5>Types Of Curves</h5>

A normal spine will appear to be straight when viewed from behind. In scoliosis, the spine will appear like a C or S, such that the individual will look as if they are learning on one side. Scoliosis can occur on either side of the spine &ndash; left, right, and mid and lower regions of the spine. 
&nbsp;

A scoliosis curve can be categorized into four types:

<ol>
	<li>Right Lumbar Curve: The curve starts and ends in the lower back, bending to the right.</li>
	<li>Right Thoracic Curve: The curve develops in the upper back, bending to the right side.</li>
	<li>Double Major Curve: There are two curves simultaneously &ndash; a left lumbar curve and a right thoracic curve. This shows little to no deformity because they balance out the effect of the other individual curve.</li>
	<li>Right Thoracolumbar Curve: The curve starts in the upper back region but ends in the lower back, bending to the right. 
	Other rare types of curves include triple curves and left thoracic curves. 
	&nbsp;</li>
</ol>

Signs and Symptoms

Children aged 8-11 years, who are diagnosed with any type of scoliosis, reportedly experience pain, numbness, and a left-curving thoracic spine. The healthcare practitioner will order some diagnostic tests, including an MRI, to rule out any possibility of a spinal tumor or any other lesions that can lead to scoliosis. 
&nbsp;

A mild scoliosis curve is often easy to miss. It can be brought to attention if:

<ul>
	<li>Someone observes the patient in a bathing suit, for instance, or while changing when their back is bare. The parent or teacher can notice the sideways curvature and get it checked by a doctor early on.</li>
	<li>Another person or the patient becomes aware of how their clothes hang unevenly from their shoulders. 
	&nbsp;</li>
</ul>

When the curve progresses from mild to moderate (and severe), it will cause pain and the deformity is more prominent. Besides twisting, the spine curves to one side in scoliosis. As a result, the muscles or bones on that side of the body stick out noticeably further as compared to the other side. The most commonly reported symptoms of scoliosis are listed below; however, it should be kept in mind that it is a very individualistic experience<a href="#accordion">[6]</a>.

<ul>
	<li>Uneven shoulders</li>
	<li>Head not centrally aligned with the rest of the body</li>
	<li>Asymmetrical hip position while walking, causing one hand to brush against one hip while the other doesn&rsquo;t touch it</li>
	<li>Uneven waist</li>
	<li>A difference in the way the arms hang beside the body while standing straight</li>
	<li>A difference at one side of the back when bending forward</li>
	<li>One side of the rib cage jutting out 
	&nbsp;</li>
</ul>

Other signs of scoliosis can be:

<ul>
	<li>Muscles tire easily because of all the extra effort to maintain balance</li>
	<li>The range of motion becomes limited due to spinal twisting</li>
	<li>The rib cage can tighten and make it difficult to breathe due to spinal twist</li>
	<li>The rib cage twisting and tightening can also cause cardiovascular problems</li>
	<li>Local inflammation and spasms around strained back muscles; can lead to degeneration of intervertebral discs and pain</li>
	<li>Stress caused by social encounters&nbsp; 
	&nbsp;</li>
</ul>

Symptoms related to idiopathic scoliosis include:

<ul>
	<li>Back pain</li>
	<li>Leg pain</li>
	<li>Changes in bowel and bladder habits 
	&nbsp;</li>
</ul>

Anyone experiencing such symptoms should immediately approach their medical practitioner to find the cause of the symptoms. 
&nbsp;

NOTE: The symptoms of scoliosis can be misleading as the condition often looks like other spinal deformities, spinal injuries, or infections. Therefore, it is crucial to diagnose the condition correctly. 
&nbsp;

Currently, there are no screening tests available for scoliosis. 
&nbsp;

Diagnosis

Diagnosing scoliosis as soon as possible is extremely crucial for a treatment plan to work effectively. The medical practitioner will take a complete history of the patient&rsquo;s health, a physical exam, and an X-ray, which is the primary diagnostic modality for scoliosis.

The physical exam entails observing the child standing and then bending forward with their arms loosely by their side. If the rib cage is protruding at one side, it can hint at scoliosis. 
&nbsp;

It will also include a neurological exam checking numbness, muscle weakness, and abnormal reflexes present in the patient.

To establish a diagnosis, the healthcare practitioner measures the degree of spinal curvature according to the individual&rsquo;s X-ray report. However, other imaging studies can also be ordered by the doctors<a href="#accordion">[5]</a>: 
&nbsp;

<ul>
	<li>
	<h5>MRI</h5>
	</li>
</ul>

A magnetic resonance image is a diagnostic modality that uses large magnets and a computer to make detailed images of the organs and structures in the body. It&rsquo;s used if the doctor suspects that scoliosis is caused due to an underlying condition like spinal cord abnormality. 
&nbsp;

<ul>
	<li>
	<h5>CT Scan</h5>
	</li>
</ul>

Computerized tomography is another imaging tool that uses X-rays and a computer to develop horizontal or axial images (termed slices) of the body. A CT scan has the potential to produce detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are much more detailed compared to standard X-rays. 
&nbsp;

Treatment

While making a treatment plan for scoliosis, the aim is to stop the development of the curve and do everything to prevent deformity. 
&nbsp;

<ul>
	<li>Curve Less Than 20&deg; &ndash; As hard as it sounds, the healthcare practitioner might just wait and watch to see if the curve is aggravating or not. They will order an X-ray every 4-6 months to see its progress. 
	&nbsp;</li>
	<li>Curve Is 20-50&deg; &ndash; If the patient is a developing child, a technique called bracing is recommended. An external torso brace, or TLSO, is prescribed for a fixed number of hours (13-16 hours a day) to apply pressure to the growing spine and prevent the aggravation of scoliosis. 
	It&rsquo;s usually made out of plastic, according to the individual&rsquo;s body shape, and can be worn under clothes. It fits snugly around the lower back, hips, arms, and rib cage. The purpose of a back brace is not to reverse the curve, only to keep the condition from worsening. 
	&nbsp;</li>
	<li>Curve Is More Than 50&deg; &ndash; Surgical intervention is advised if the patient is a child and has severe scoliosis. The preferred surgical option these days is posterior spinal fusion, insertion of one or two expanding rods, and vertebral body tethering. Spinal surgery is risky and only a last resort as it can cause infection, bleeding, and nerve damage. 
	Treatment for degenerative scoliosis usually involves pain management through medications, physical therapy, and avoiding strenuous activities. However, when these nonsurgical treatment options don&rsquo;t work and pain starts to affect the quality of life, then surgery may be recommended. 
	&nbsp;</li>
</ul>

NOTE: According to studies, soft braces, dietary supplements, chiropractic manipulation, and electrical stimulation of muscles do not correct the curve<a href="#accordion">[8]</a>. 
&nbsp;

Scoliosis usually presents as a milder form of the disorder. However, it may sometimes cause complications, which include<a href="#accordion">[3]</a>:

<ul>
	<li>Breathing Problems: If it develops into severe scoliosis, the rib cage may push against the lungs, making it hard to breathe. 
	&nbsp;</li>
	<li>Back Problems: If it develops at a younger age, there is a possibility the patient experiences chronic back pain while growing up. This happens especially in cases where curves are large and left untreated. 
	&nbsp;</li>
	<li>Appearance: Scoliosis may make the body look uneven or disproportionate, including hips or shoulders. This can cause <a href="https://merisehat.pk/disease/depression">depression </a>and <a href="https://merisehat.pk/disease/anxiety">anxiety</a>. Counseling or joining support groups help. 
	&nbsp;</li>
	<li>Age-Related Risks: Scoliosis surgery can trigger other age-related issues, especially if the patient is 65 and older and has a weak heart or fragile bones. 
	&nbsp;</li>
	<li>Permanent Leg Weakness: If a nerve root becomes impinged, through severe bending of the spine or narrowing of the spinal canal, it can cause sciatic pain, which can cause further serious issues, like lack of control of bowel/bladder functions and permanent leg weakness. 
	&nbsp;</li>
	<li>Death: It is unlikely, but a possibility that people suffering from scoliosis and not have access to surgical intervention. 
	&nbsp;</li>
</ul>

Risk factors that can cause scoliosis include<a href="#accordion">[3]</a>:

<ul>
	<li>Age: Signs and symptoms essentially become clinically evident in adolescence.</li>
	<li>Sex: Even though boys and girls develop mild scoliosis at around the same rate, girls carry a greater risk of the curve worsening that may require intervention.</li>
	<li>Family History. Scoliosis runs in families; however, most children with scoliosis are not seen to have a family history of the disease. 
	&nbsp;</li>
</ul>

Unfortunately, there is no preventive measure available currently for scoliosis. There are many factors responsible for scoliosis, including childhood injuries, carrying heavy backpacks, poor posture, and being overweight or obese. However, these reasons aren&rsquo;t confirmed to cause scoliosis.

The patient is advised to practice good posture by doing exercises that help strengthen their back muscles. Remember, yoga or Pilates will not prevent scoliosis<a href="#accordion">[2]</a>. 
&nbsp;

There is one type of scoliosis, though, which can occasionally be prevented, i.e., adult scoliosis caused by <a href="https://merisehat.pk/disease/osteoporosis-80">osteoporosis</a>. Osteoporosis makes the bone weak and brittle, which in turn can lead to an abnormal curving of the spinal cord. Good nutrition along with regular exercise can reduce the risk of getting osteoporosis, thereby, keeping the individual from developing scoliosis. 
&nbsp;

NOTE: Adults should regularly examine their child&rsquo;s spine and talk to a doctor if they&rsquo;re concerned about any deformity. 
&nbsp;

An important development in addressing scoliosis is the establishment of genetic testing<a href="#accordion">[7]</a>.

In recent times, there has been drastic progress in targeting the genes, which mutate and might correlate with scoliosis. Even though the exact cause of the most common type of scoliosis in children remains unknown, there is a first-generation commercial genetic test at our disposal now that allows health practitioners to successfully identify children at low, intermediate, and severe risk for curve development. The information which is retrieved by the help of this test helps the healthcare providers to offer relevant preventive care. 
&nbsp;

As these genetic tests are improving with time, it is quite hopeful that intervention will improve as well and include non-operative treatment modalities as well. 
&nbsp;

Key Points

<ul>
	<li>Scoliosis refers to an unusual sideways curvature of the spinal cord.</li>
	<li>The spine&#39;s normal curves can be observed at the cervical, thoracic and lumbar regions &ndash; different segments of the spinal cord &ndash; in the sagittal plane.</li>
	<li>Scoliosis can also be defined as a spinal curvature in the coronal or frontal plane.</li>
	<li>It affects 2-3% of the entire population, or around 6-9 million people residing in the United States of America.</li>
	<li>The primary age of onset is 10-15 years old, with no predilection to any gender.</li>
	<li>Women are 8 times more at risk to develop a curvature that needs treatment.</li>
	<li>According to clinical observations, there is an equal ratio of male to female infants being affected by infantile scoliosis. However, girls get affected more as their age increases, so much so that the gender ratio after the age of 10 is around 6:1.</li>
	<li>Structural scoliosis is the most common variant of scoliosis. It usually includes rotation of the spinal cord along with the side-to-side curvature of the spine.</li>
	<li>Nonstructural scoliosis is also known as functional scoliosis, as it results from a temporary cause and only involves a side-to-side curvature of the spine.</li>
	<li>Idiopathic scoliosis is responsible for almost 8 out of 10 cases of scoliosis.</li>
	<li>Degenerative scoliosis is essentially adult scoliosis.</li>
	<li>Neuromuscular scoliosis usually affects people who are unable to walk because of a neuromuscular condition, such as muscular dystrophy.</li>
	<li>Congenital scoliosis affects the fetus inside the mother&rsquo;s womb and is clinically evident during the infantile years.</li>
	<li>The symptoms of scoliosis may be misleading as the condition looks like other spinal deformities.</li>
	<li>The actual cause of scoliosis remains unknown. However, doctors believe that hereditary factors might be at play because the disorder is seen to occasionally run in families.</li>
	<li>Currently, there are no screening tests available for scoliosis.</li>
	<li>Diagnosing scoliosis as soon as possible is extremely crucial as it is needed for a treatment plan to work effectively.</li>
	<li>The medical practitioner will take a complete history of the patient&rsquo;s health, a physical exam, and an X-ray, which is the primary diagnostic modality for scoliosis.</li>
	<li>A treatment plan aims to stop the development of the curve and do everything to prevent deformity.</li>
	<li>Bracing is recommended if the patient is a developing child with scoliosis curves between 20 and 50&deg;.</li>
	<li>Surgical intervention is advised if the patient is a child and has severe scoliosis or a curve that has progressed to more than 50&deg;.</li>
	<li>Complications of severe scoliosis include breathing problems, depression, and anxiety.</li>
	<li>There is one type of scoliosis, though, which can occasionally be prevented i.e., adult scoliosis caused by osteoporosis.</li>
	<li>Good nutrition along with regular exercise can reduce the risk of getting osteoporosis, which keeps the individual from developing scoliosis.</li>
	<li>&nbsp;An important development in addressing scoliosis is the establishment of genetic testing. 
	&nbsp;</li>
</ul>

[1] By: Ali Baaj MDP-R. Types of scoliosis. Spine.

[2] Scoliosis prevention: Can you prevent scoliosis or keep it from worsening? SpineNation

[3] Scoliosis. Mayo Clinic.

[4] Trobisch, P., Suess, O., & Schwab, F. (2010). Idiopathic scoliosis. Deutsches Arzteblatt international, 107(49), 875–884. https://doi.org/10.3238/arztebl.2010.0875