Scoliosis is the word derived from Greek word "Scolio" means S shape. Scoliosis is caused by lateral (left or right side) bend of more than 10 degrees of vertebral column. Scoliosis may be associated with lordosis (posterior or backward bend) or kyphosis (anterior or front bend). Scoliosis of 10 to 15 degrees is often not diagnosed during routine examination. Scoliosis is an abnormal curvature of vertebral column. Over 60% of body weight is transmitted through vertebral column to pelvis and legs. Weight transfer through vertebral column affects gait and posture in patients suffering with scoliosis. Epidemiology studies suggest 2 to 3% of teenagers suffer with scoliosis and scoliosis is more common among females. Less than 1% patients suffer with severe (more than 40 degree) curvature.
Skeletal Deformity in Scoliosis
Scoliosis is an abnormal curvature of lumbar vertebral column.
Deformity is Graded as Follows1-
- Mild Scoliosis- There will be curvature of spine of 10 to 15 degrees.
- Moderate Scoliosis- Spinal curvature of 15 to 30 degrees.
- Severe Scoliosis- Spinal curvature of 30 degrees and more.
Classification of Scoliosis
- Infantile Scoliosis is diagnosed between age of birth and 3 years.
- Infantile scoliosis is 1% of all scoliosis diagnosed every year.
- Infantile scoliosis is thought to be caused by intrauterine abnormal molding and bending of spine.
- Genetic causes have been evaluated and solid genetic correlations were not found2.
- Juvenile Scoliosis is diagnosed between the ages of 4 and 10.
- 10% to 15% of all scoliosis are diagnosed as Juvenile scoliosis.
- Juvenile scoliosis is more common with male children of less than 7 years of age.
- Juvenile scoliosis is more common among female children between age 7 and 10.
Adolescent scoliosis is diagnosed between the ages of 10 and 18.
Most of the patients are diagnosed as having idiopathic scoliosis.
Adolescent Scoliosis is often diagnosed during routine examination at school and early treatment has prevented severity of the disease in majority of cases.
- Scoliosis is diagnosed as adult scoliosis when abnormal bend in vertebral column (spine) is found after age of 18 years.
- In few cases severe bend is observed in an adult patient. Most of these patients were either not seen by the physician or early diagnosis of scoliosis was ignored.
- Scoliosis in elderly is mostly cause by degenerative disease of spine (vertebral column).
- Elderly scoliosis is often caused by osteoporosis in female patients.
Types of Scoliosis and Its Causes
Idiopathic Scoliosis (70%)
- Idiopathic Scoliosis Caused By Genetic Disorder (30%)-
- Approximately 30% of the idiopathic scoliosis is caused by genetic abnormalities.
- Research has suggested genetic variation in patients suffering with scoliosis, but specific gene has not been identified.
- Scoliosis is associated with several genetic disorder of bones malformation, bone metabolism and connective tissue disorder.
- Idiopathic Scoliosis Caused By Environmental Abnormalities (35 to 40%)
- Cause is unknown (idiopathic).
- Scoliosis was thought to be caused by:
- Diet deficiency
- Mental abuse and stress
- Intake of toxins and chemicals by contamination of drinking water.
- Idiopathic Scoliosis Caused By Genetic Disorder (30%)-
Congenital Scoliosis (20%)
Associated Scoliosis (10%)
Neurological Disorder Causing Scoliosis
- Cerebral Palsy
- Muscular atrophy of spinal muscles.
- Familial Dysautonomia
- Freedreich's Ataxia
Musculoskeletal Disorder Causing Scoliosis
- Ehlers-Danlos Syndrome
- Charcot- Marie Tooth Disease
- Prader-Willi Syndrome
- Osteogenesis Imperfect Muscular Dystrophy
- Marphan's Syndrome.
Symptoms and Signs of Scoliosis
Chronic Pain in Scoliosis
Origin of Pain in Scoliosis- Pain originates from following anatomical structures-
- Facet Joint- Thoracic and lumbar vertebrae
- Disk disease of thoracic and lumber spinal column
- Pinch or irritation of spinal nerve of thoracic and lumbar spine causes pain in scoliosis.
Signs and Symptoms of Radicular Pain in Scoliosis- Chronic pain is distributed in lower back and leg. Cause of pain is as follows-
- Irritation and
- Pinched nerve at foramina
Signs and Symptoms of Radiculopathy in Scoliosis- Radiculopathy is a radicular pain associated with following symptoms-
- Weakness in lower extremity (leg)
Symptoms of Backache in Scoliosis- Causes of backache in scoliosis is as follows-
- Muscle spasm of paravertebral muscles.
- Facet joint arthropathy.
Shortness of Breath (Dyspnea) as a Symptoms of Scoliosis
Patient suffering from scoliosis complaints of shortness of breath (dyspnea). Scoliosis causes bend in thoracic and lumbar spine. Bend of thoracic spine in moderate to severe scoliosis compresses lung and decreases lung capacity thus causing shortness of breath.
Effect of Decreased Lung Capacity Causes-
- Hypoxia- Low oxygen concentration in blood.
- Dyspnea- Patient complaints of shortness of breath.
Palpitation as a Symptom of Scoliosis
Patient suffering from Scoliosis often complains of palpitation (feeling of heart beats). Symptoms are observed after rapid movement of upper body or sitting in one place for prolonged period as during travelling.
Causes of Palpitation in Patients Suffering from Scoliosis are as follows-
- Severe scoliosis lifts diaphragm into chest.
- Diaphragm contracts and relaxes with each breath. Upward lift of diaphragm helps to drive air out of lung and also in scoliosis pushes against heart resulting in decreased blood flow out of heart.
Tachycardia as a Symptom of Scoliosis
- Tachycardia is an increase in heart rate
- Cause of tachycardia is same as palpitation.
Uneven Musculature-A Prominent Sign of Scoliosis
Scoliosis is an abnormal curvature causing some muscles to be overworked than compared to others.
- Prominent back muscles
- Atrophied back muscles
Uneven Skeletal Curvature
Examination of chest, middle, and lower back indicates following skeletal abnormalities-
- Abnormal hump or curvature of spine over middle back.
- Prominence of ribs on side, which is curved out.
Investigations to Diagnose Scoliosis
Scoliometer4 for Scoliosis
Scoliometer is an instrument used to measure degree of curve in patients suffering with scoliosis. Scoliometer also measures trunk rotation.
X-Ray for Scoliosis
- Weight bearing full spine AP (Antero-Posterior) and lateral X-Ray is taken.
- X-Ray helps to diagnose Scoliosis and associated kyphosis and lordosis.
- X-Ray is repeated every 6 month in children between 12 and 18 years.
MRI (Magnetic Resonance Imaging) for Scoliosis
Blood Examination for Scoliosis
- Check genetic abnormalities
Genetic Testing for Scoliosis
- DNA associated with scoliosis has been identified by several scientific researches but routine test is yet not freely available.
- Close to 50 Gene Markers have been identified and cross-matched with parents.
Treatment of Scoliosis
- Infantile and adolescent scoliosis is closely observed.
- X-Ray and clinical examinations are performed every 4 to 6 months to observe the progress of Scoliosis.
- Aggressive physical therapy for scoliosis is advised when necessary.
Physical Therapy (PT) For Scoliosis5,6
- Early physical therapy is advised to strengthen back muscles and prevent rapid exaggeration of curvature of spine or scoliosis.
- Physical therapy plan differs with severity of scoliosis. Mild and moderate scoliosis may be treated on and often with physical therapy for pain and to prevent exaggeration of curvature of spine. Severe scoliosis is often aggressively treated with physical therapy.
- Postural Training for Scoliosis- Physical therapist will add postural training to tolerate prolonged sitting, standing, and sleeping positions.
- Positioning Support- Patient suffering from Scoliosis or curvature of spine is encouraged to use bed sheets, pillows and rolls to support back and leg to maintain proper weight distribution during lying down in supine (lying on back) or lateral (on side) position.
Schroth Approach of Physical Therapy (PT) to Reverse Scoliosis-
Schroth approach of selective physical therapy for scoliosis is considered as effective treatment for reversal of scoliosis.
Results observed as follows.
- After four to six weeks of PT for scoliosis- 10% of the treated scoliosis patient showed reversal of most of the curvature of mild and moderate scoliosis.
- After one year of PT- 30% of the patient show reversal of most of the scoliosis.
- Remaining 60% of the Scoliosis patient may not respond.
Occupational Therapy for Scoliosis
Therapist will evaluate daily activities, optimum need of manual work and posture during table work.
- Posture- Therapist will evaluate the correct posture to complete the task during manual work or table work.
- Assessment- Therapist will assess the tolerance of manual and table work to optimum duration.
- Evaluation- Therapist will evaluate Scoliosis patient periodically and intervene if symptoms are exaggerated and anatomical deformity has worsened.
- Intervention- Occupational Therapist will advise to change the job or change the hours of work so that the scoliosis patient is able to cope with it. Therapist may demand to eliminate manual work.
- Support- Therapist may modify treatment and advise to use braces for the patient suffering from Scoliosis. Occupational Therapist may prescribe an equipment to support activities like cane or walker.
Chiropractic Treatment for Scoliosis
- Over the last several years chiropractic manipulation for scoliosis has advanced to prevent any injuries and also to assist improvement of facet joint movement of vertebral column.
- Regular visit to neighbourhood chiropractor has been instrumental in maintaining daily exercise and muscle strengthening which prevents further enhancing of curvature of spine or Scoliosis.
Casting to Treat Scoliosis
- Casting is mostly used to treat progressive infantile scoliosis and juvenile scoliosis.
- Casting is applied as either plaster jacket or braces.
- Infantile idiopathic scoliosis is often treated with multiple frequent series of plaster casts.
- Casting for scoliosis is also often combined with corrective traction.
- Corrective traction helps to straighten soft vertebral column.
Braces To Correct Scoliosis-
- Bracing is often used for long-term treatment of Scoliosis. Scoliosis brace prevents exaggeration of curvature of spine.
- Bracing for scoliosis is more effective in adolescent while bone growth is not yet complete.
- Research and cases published in scientific journals suggest scoliosis curve of 40 degree can be reduced to 10 to 18 degree by use of Scoliosis braces and traction.
- Scoliosis Brace is also useful to reduce pain by maintaining straight spine. Near normal position of spine is achieved by reducing curvature of spine. Reduction of spinal curvature helps to remove stress, pressure and pinch of muscle, facet joint, disc and nerve.
- Braces for Scoliosis are advised if spinal column is curved more than 25 degrees.
- A recent advance in creating braces involves CAD system and various measurement of spine using MRI and X-Ray.
Surgery for Scoliosis
- Surgery for scoliosis is indicated if curvature is greater than 45 degree as suggested by Society on Scoliosis Orthopedic and Rehabilitation Treatment (SOSORT).
- Surgery to correct scoliosis is performed by Spine Surgeons. Spine surgeons are specialized in orthopedic or neuro surgery.
Types of Spinal Fusion with Instrumentation Surgery for Scoliosis-
Anterior Fusion for Scoliosis
- Incision is made on lateral side of the chest
- The metal rods are placed at the lateral side of vertebrae.
Posterior Fusion for Scoliosis
- Incision is over the spine of thoracic and lumbar vertebrae.
- The metal rods are placed at the back of the vertebrae in each side of spinous process.
- Auto or allo bone grafts are used to correct the gap created between vertebrae following straightening of the spine.
- Auto Bone Graft is a bone taken from elsewhere in the body of the same patient.
- Allograft is bone of donor.
- Autografts or Allografts are used to correct the gap between the vertebrae and disc.
- The position of the spine and vertebral column maintained in straight position either by using a fix cast for 6 to 8 weeks or placing a rod to hold the straight position.
- The metal rods are placed at the side of vertebrae.
Use of Cast after Surgery to Correct Scoliosis-
Advantages of Cast for Scoliosis
- Eliminates need of rod to maintain straight position of spine after surgery.
- Surgery time is shorter
- Less bleeding
Disadvantage of Cast for Scoliosis
- Prolonged cast is not tolerated by patient
- Inadequate and improper cast may caused breakage and bend of fusion of bone graft
- Recurrence of scoliosis is possible.
- Restricts activities and poor quality of life during cast is in place.
Placement of Rods during Surgery to Correct Scoliosis-
Advantages of Placing Rods to Correct Scoliosis-
- Eliminates need of cast
- Patient can be mobilized sooner
- Recurrence of scoliosis is very rare.
- Prolong cast is not tolerated by patient
Disadvantages of Placing Rods to Correct Scoliosis--
- Surgery time is longer
- Profuse bleeding and post hematoma is often seen
- Rods may break.
Scoliosis Surgical Complications
- Soft tissue Injury
- Soft tissue inflammation
- Breathing Impairment
- Nerve Injury
Post Treatment Prognosis for Scoliosis
- Post surgery the scoliosis patient experiences improvement in breathing
- Scoliosis patient experiences less pain after treatment with braces, physical therapy and surgery
- Improved range of activities after use of braces, cast, physical therapy and surgery.
- Improved tolerance to activities after treatment with cast, braces, physical therapy and surgery.
Prognosis of Scoliosis if not Treated-
- Difficulties of breathing and complaining of dyspnea (shortness of breath)
- Pain intensity increases as scoliosis gets worse.
- Dependent on pain medication and muscle relaxants.
- Range of activities are restricted
- Tolerance of any activity is decreased
Articles On Other Postural Deformities:
- Lordosis: Its Causes, Symptoms, Treatment, Exercises
- Lumbar Lordosis or Lumbar Swayback: 5 Simple Corrective Exercises
- Kyphosis: Its Causes, Symptoms, Treatment, Taping
1. Morphological changes in scoliosis during growth. Study in the human spine,
Duart Clemente J, Llombart Blanco R, Beguiristain Gurpide JL.
2. The search for idiopathic scoliosis genes
Ogilvie JW, Braun J, Argyle V, Nelson L, Meade M, Ward K (2006).
Spine 31 (6): 679–881.
Rev Esp Cir Ortop Traumatol. 2012 Nov-Dec;56(6):432-8.
3. The pathogenesis of adolescent idiopathic scoliosis: review of the literature
Kouwenhoven JW, Castelein RM 2008,
Spine 33 (26): 2898–2908
4. Validity and reliability testing of the Scoliometer.
Phys Ther. 1990 Feb;70(2):108-17.
Amendt LE, Ause-Ellias KL, Eybers JL, Wadsworth CT, Nielsen DH, Weinstein SL.
5. Treatment of adolescent idiopathic scoliosis: Systemic Review.
Weiss HR, Goodall D (2008). European Journal of Physical and Rehabilitation Medicine 44 (2): 177–93
6. Exercises reduce the progression rate of adolescent idiopathic scoliosis: results of a comprehensive systematic review of the literature. Negrini S, Fusco C, Minozzi S, Atanasio S, Zaina F, Romano M (2008). Disability and Rehabilitation 30 (10): 772–785.