Scoliosis is a spinal malformation characterized by lateral curvature and vertebral rotation.

To understand scoliosis, you must first learn what a healthy spine looks like. Your spine is divided into four sections:

• Cervical spine: This is the beginning of your neck, which starts at the base of your head. It has seven tiny spinal bones (called vertebrae) that are labeled C1 through C7 by physicians (the "C" means cervical). The levels of the vertebrae are indicated by the numbers one through seven. C1 is closest to your head, while C7 is closest to your chest.
• Thoracic spine: T1 through T12 are the names of the 12 vertebrae in your mid-back (the "T" means thoracic). The thoracic spine's vertebrae attach to your ribs, making this section of your spine particularly rigid and stable. The thoracic spine does not move as much as the rest of your spine.
• Lumbar spine: You have five vertebrae in your low back, designated L1 to L5 (the "L" means lumbar). These are your biggest and strongest vertebrae, bearing the majority of your body's weight. The lumbar vertebrae are also your final "real" vertebrae; your vertebrae are fused below this area. L5 may potentially be fused with a portion of your sacrum.
• Sacrum and coccyx: The sacrum is made up of five vertebrae that normally fuse together by maturity to create one bone. The coccyx, often known as your tail bone, is made up of four (occasionally five) fused vertebrae.

What is Scoliosis?

Scoliosis is described as a departure from the normal vertical line of the spine that consists of a lateral curvature with vertebral rotation inside the curve. For scoliosis to be evaluated, the posterior-anterior radiograph should show at least 10° of spinal angulation coupled with vertebral rotation.

The majority of scoliosis cases addressed by general practitioners will be idiopathic (without an evident etiology), and this will be the primary emphasis of this study.

Etiology

Scoliosis causes vary and are roughly categorized as congenital, neuromuscular, syndrome-related, idiopathic, and spinal curvature owing to secondary causes. Congenital scoliosis is caused by a vertebral defect that causes a mechanical departure from normal spinal alignment.

Scoliosis can be caused by neurological disorders (for example, cerebral palsy or paralysis), muscular abnormalities (for example, Duchenne muscular dystrophy), or other syndromes (eg, Marfan syndrome and neurofibromatosis).

Idiopathic scoliosis is a diagnosis made after all other types of scoliosis have been ruled out. As of now, there is no known etiology of idiopathic scoliosis. Hormonal reasons, asymmetric development, muscular imbalance, and hereditary variables are among theories. A family member with scoliosis affects about 30% of AIS cases.

Significant lateral deviation of the spine can occur with little or no rotation of the spine and without bone deformities on rare occasions. Scoliosis in these situations can be caused by pain, spinal cord anomalies, tumors (both intraspinal and extraspinal), and infection.

Epidemiology

The prevalence of AIS ranges between 1% and 3%. Females are preferred, and there is a right-sided curvature. The curve must be at least 10 degrees in the coronal plane to be considered for scoliosis categorization. Curves measuring greater than 40 degrees have a frequency of around 0.1 percent (those which tend to be those requiring operative intervention).

This disease has a hereditary component, with siblings (seven times more commonly) and offspring (three times more frequently) of scoliosis sufferers having a greater frequency. Adults suffering from idiopathic scoliosis should be aware that their children should be thoroughly checked. 

Types of Scoliosis

Congenital scoliosis is caused by skeletal anomalies of the spine at birth. These abnormalities, which can occur at several levels, are caused by a failure of formation or a failure of segmentation (or both) during vertebral development. Because these spinal abnormalities occur in utero, they are frequently seen on fetal ultrasonography.

Organ systems that develop at the same gestational stage (fifth to sixth week) may also show abnormalities in up to 60% of instances. As a result, it is critical to discover related abnormalities by a complete evaluation of the neurological, cardiovascular, and genitourinary systems, which includes a thorough neurological and cardiac physical examination, an abdomen ultrasound, and an echocardiography.

Treatment is determined on the patient's age, the advancement of the curve, and the location and kind of abnormality. Surgical treatment options include in situ fusion and excision with deformity correction.

Scoliosis has been linked to neurological disorders, muscle anomalies, and worldwide diseases. In addition to scoliosis, this extensive list of diagnoses would generally include other indications, symptoms, and physical manifestations.

These various diagnoses are often treated in tertiary care centers with specialized competence in the management of patients with complicated multisystem disorders. The caregiver who treats these individuals should be conversant with the diseases' nonspinal symptoms.

List of syndromes and neuromuscular conditions associated with scoliosis:

• Cerebral palsy
• Charcot-Marie-Tooth disease
• Poliomyelitis
• Spinal muscular atrophy
• Arthrogryposis
• Duchenne muscular dystrophy
• Congenital hypotonia
• Neurofibromatosis
• Paralysis
• Marfan syndrome
• Ehlers-Danlos syndrome
• Myelomeningocele
• Osteogenesis imperfecta
• Achondroplasia

Scoliosis Symptoms 

Patients usually have a spinal deformity or, most commonly, chest wall and back asymmetry. The most visible symptom of spinal curvature is posterior chest wall prominence, which can be seen by the patient, their parents, or through school or physician screening programs.

Adolescent females with more severe scoliosis may perceive a change in their breast sizes. Shoulder asymmetry and total posture imbalance in the coronal plane are two more possible body features.

The degree of the curvature determines the severity of the symptoms of scoliosis. In mild situations, symptoms may be mainly cosmetic, such as:

• Visible difference in hip and shoulder height
• One or both hips are raised or noticeably high
• Uneven shoulders one or both shoulder blades may stick out
• The Head is not centered right above the pelvis
• Asymmetry between rib cage heights on either side.
• Waistline appears uneven
• Changes in the look or texture of the skin that covers the spine, such as dimples, hairy areas, or color anomalies.
• The entire body leans toward one side

More serious cases of scoliosis may cause:

• Scoliosis back pain
• Inability to stand upright
• Leg pain, numbness, and/or weakness 
• Height loss in adults
• Bowel or bladder dysfunction in more severe cases

Back discomfort is not uncommon, even if it is not the primary complaint. One-quarter of individuals with adolescent idiopathic scoliosis (AIS) complain of back discomfort. Idiopathic scoliosis patients may have back discomfort and, more especially, posterior chest wall pain on the side of the rib prominence. Lower back discomfort is prevalent in adolescents, whether they have scoliosis or not.

Back pain without damage that is severe and unrelenting is cause for worry and should be examined with, at the very least, a full examination and radiographs since a more specific diagnosis may exist. Acute back discomfort with fever, for example, should be checked for spinal infections.

Back discomfort that is limited to one place, is worse at night, and improves considerably with nonsteroidal anti-inflammatory medications might be an indication of a spine tumor, such as an osteoid osteoma.

In the case of any spinal disease, the health care practitioner must keep an eye out for neurological issues. A thorough neurological history should include questions about weakness, sensory changes, balance, gait, and coordination issues, as well as bowel and bladder issues such as incontinence. Significant changes in these parameters may indicate intraspinal diseases such as syringomyelia (central spinal cord dilation), a tethered cord, or a tumor.

The likelihood of curve advancement in idiopathic scoliosis, and hence its treatment and prognosis, is determined by the amount of spinal growth that remains. Simple height measurements are the most dependable technique of measuring development. As a result, the main physician frequently has this information from their yearly checkups. It is also necessary to consider other indicators of growth and maturity, such as indications of puberty, the start of menarche, and breast development.

Patients who are tall, have long fingers and have a large arm span to height ratio should be evaluated for further symptoms of Marfan syndrome (such as cardiac abnormalities). Patients who have joint and skin hyperlaxity, as well as scoliosis, may require further testing for a connective tissue disorder such as Ehlers-Danlos syndrome.

A neurological condition such as Charcot-Marie-Tooth disease or a spinal cord anomaly such as a tumor may be associated with high-arched or cavus feet. A hairy patch or skin dimpling in the back may indicate a spinal dysraphism such as myelomeningocele, whereas café-au-lait patches or axillary freckles imply neurofibromatosis.

Diagnosis of Scoliosis

A standing posterior-anterior radiograph should be performed if scoliosis is suspected. If feasible, these films are taken on a three-foot cassette. Further plain radiograph imaging is outside the scope of a screening test and should be evaluated by the orthopedic surgeon.

On the radiographs, pay close attention to the vertebral bodies. There should be two pedicles at each level, and the spine should rotate, with the tip of the curve rotating the greatest. Remember that true scoliosis is a rotational deformity as well as a coronal plane deformity.

Other causes of a scoliotic curve without rotation include bone tumors (osteoid osteoma), intraspinal disease (syringomyelia and masses), and nerve root irritation.

A lateral radiograph of the spine, including the lumbosacral region, should be obtained if back pain is present to look for vertebral abnormalities associated with diagnoses such as spondylolysis (an idiopathic fracture of the posterior elements of the vertebral body), spondylolisthesis (a slipping forward of one vertebral body on the adjacent one), infection, or bony destruction.

A bone scan or magnetic resonance imaging (MRI) examination may be recommended for individuals with scoliosis and back discomfort. These imaging modalities go beyond screening tests and are often obtained by treating surgeons.

Although this is somewhat debatable, most individuals with AIS do not require an MRI. Some treatment centers will automatically order an MRI for each scoliosis patient. An MRI, on the other hand, is more likely to be beneficial for patients less than 10 years of age at presentation (juvenile and infantile scoliosis), those with left thoracic curvature, and those with a neurological problem. 

Screening 

Whether or not symptoms are evident, your child's physician will usually perform a scoliosis screening at the yearly check-up. Furthermore, several states require schools to check kids for scoliosis on a yearly basis.

During this sort of regular test, practitioners check for any asymmetries in shoulder blade prominence, which means if one shoulder blade stands out more than the other, as well as shoulder and hip height. You should be able to draw a horizontal line across the tops of your shoulders and another across your waist if your spine is normal; if you have scoliosis, those lines will be diagonal.

Scoliosis treatment

Natural history studies of people with idiopathic scoliosis after skeletal maturity discovered that curves less than 30° do not develop, but most curves higher than 50° do.

The rate of advancement is around 1° each year. Cor pulmonale and right heart failure are more common in patients with severe thoracic curvature (greater than 90° to 100°). Long-term investigations of AIS patients, however, have not revealed a higher death rate. Severe scoliosis (greater than 90°) can impair pulmonary function.

 Back pain is widespread in the general population, making it challenging to conduct studies on back pain in scoliosis. According to certain research, people with AIS had a slightly greater risk of back discomfort. Scoliosis has also been identified as a risk factor for psychological problems and risky behavior. However, no research has been conducted to compare the frequencies of back pain and self-image in treated and untreated scoliosis patients.

Pain Management

In addition to physical therapy and regular exercise, as previously noted, there are a number of alternative non-surgical pain treatment techniques, such as:

• Non-steroidal anti-inflammatory medication (NSAID’s)
• Massage
• Injections, such as nerve blocks, epidural steroid injections, and radiofrequency
• Nerve ablation. Candidates for injectable treatment are often people who have degenerative disc degeneration.

Scoliosis therapy is determined by the kind of scoliosis, the degree of the curve, the number of years of growth remaining, and the patient's perception of the form of their back. The treatment of individuals with congenital, neuromuscular, and syndrome-associated scoliosis, as well as those with idiopathic scoliosis under the age of ten, is fraught with controversy. These individuals should be treated in specialist institutions; their care is outside the scope of this study.

Observation, bracing, and surgery are all possibilities for AIS therapy. While many additional aspects must be addressed, the overall objective is to maintain curves at maturity around 50°. Observation is usually advised for young individuals with curves of less than 25°.

Orthotic treatment is advised for immature individuals with progressive curves ranging from 25° to 50°. There are several braces available with variable documented results (Milwaukee brace, Boston brace, and Charleston bending brace). Compliance and wearing time appear to have a role in bracing effectiveness.

Bracing, on the other hand, does not permanently fix or rectify the curvature but rather attempts to keep it from deteriorating. While orthotic treatment is the gold standard for progressing scoliosis, the scientific evidence is inconclusive. A prospective, randomized experiment is presently being conducted to investigate the efficacy of bracing.

For curves larger than 45° in immature children and curves greater than 50° in adult patients, surgical treatment of idiopathic scoliosis is considered. The trunk deformities and balance are also taken into account in the decision-making process.

The long-term effects of an untreated patient with 55° of scoliosis at maturity remain unknown. As a result, the patient must be dissatisfied with the curvature of their back in order to undertake a major and possibly risky surgical correction of scoliotic deformity less than 60°.

Scoliosis Surgery

Surgery is often performed around adolescence, although modern methods enable effective correction to be achieved as late as early adulthood. The aims of surgical therapy are to stop the development of the disease and to enhance spinal alignment and balance. While preserving sagittal alignment, the hips and shoulders should be level, and the head should be above the sacrum. The spine is stabilized with a mixture of rods, hooks, screws, and wires, and it is united with bone graft either from the patient, a cadaver or artificially.

Depending on the curve type, age, and surgeon choice, strategies include fusion with and without instrumentation from the anterior, posterior, or both. Correction and fusion procedures evolve rapidly; long-term results for the most recent approaches have yet to be produced. However, in a 20-year follow-up period, good outcomes were observed using older technologies.

Given these treatment criteria, primary care physicians should send any kid with an unusual curve of more than 10° to a specialist, especially children less than 10 years old, those with left thoracic curves, those with neurological problems, or those experiencing considerable discomfort.

A kid over the age of 10 who has not attained skeletal maturity can be referred at any time, but especially when the curve approaches 20° to 25°. Because normal scoliosis seldom develops faster than 1° each month, a referral should be made within three to six months. Within one month, atypical scoliosis should be detected.

Differential Diagnosis

It is critical to rule out other reasons for scoliosis, such as neurologic disorders, neuromuscular diseases, congenital or syndromic abnormalities.

Prognosis

Patients with teenage idiopathic scoliosis who remain untreated into adulthood can experience a rate of advancement of 0.5 to 1 degree per year after they have achieved a 50-degree coronal angle. Furthermore, in general, curves in adults are significantly stiffer and more inflexible than those in adolescence, necessitating more forceful and intrusive surgical procedures.

Long-term studies show that individuals with scoliosis have a greater risk of arthritis and a negative view of their body image, regardless of therapy. Furthermore, if the surgical repair includes chest wall invasion, discomfort and reduced lung function may occur.

Complications

Deformity progression is one of the complications of untreated scoliosis. Back discomfort, lumbar radiculopathy, cosmetic issues, nerve damage, and even cardiac and pulmonary limitation might result from this. Untreated individuals with a coronal plane curve of greater than 80 degrees may have increasing shortness of breath.

Surgical problems are less common than in adult spinal deformity surgery, although they still occur. One national data collection estimated post-surgical brain damage to be 0.9 percent, respiratory problems to be 2.8 percent, cardiac complications to be 0.8 percent, infection to be 0.5 percent, and gastrointestinal complications to be 2.7 percent. Delayed infections in hardware are also quite prevalent.

Surgeon competence and volume of operation are also key determinants in surgical results and cost.

To ensure that you get a comprehensive picture and understand everything regarding Scoliosis, we invited Doctor Bae who is a leading doctor at Wooridul Hospital in Gangnam to address any questions you may have from an experienced point of view.

Interview

1. What is the difference between stenosis and scoliosis?

Stenosis refers to a disease in which the passage of nerves is blocked, and scoliosis refers to a disease in which the bones bend. So many patients with stenosis do not have scoliosis. However, in the case of scoliosis where the bone is curved, the nerve pathway that passes through the bone gets blocked so stenosis will necessarily follow.

2. Depending on the severity of scoliosis, what kind of treatments can be done?

If we have to divide scoliosis into categories, there are adolescent scoliosis that occurs during adolescence, middle school and high school, and congenital scoliosis that occurs a little earlier than that. The most common is scoliosis that occurs in adolescence, and there is also degenerative scoliosis that occurs after the age of 50-60. In the case of adolescent scoliosis, early detection is very important, and if the angle of scoliosis exceeds 15 degrees before it exceeds 20 degrees 30 degrees, it can be brought back to normal through appropriate exercise. If the curvature of more than 20 degrees has progressed, it is important to actively use braces to prevent it from further progressing to 30 degrees or 50 degrees that require surgery.

Degenerative scoliosis that occurs with age is more common in people who work a lot in the field, have a bad posture, or do a lot of labor that requires lifting heavy things. So if you think you fall under such a risk, you should exercise properly and try not to strain your back.

3. For the symptoms, can we say that they’re the same as in the case of stenosis?

Especially in the case of degenerative scoliosis, it is always accompanied by symptoms of stenosis. So among scoliosis patients, if you say that the legs pull more and hurts more than the back, the part where the nerve is compressed in the scoliosis is much larger, so you need to focus on that part and treat it. If you have scoliosis and you have severe back pain as well as pain in your legs, the bent bone is much larger, so surgery to straighten the bone is more important.

4. Are there any points that should be considered in the case of surgery, or in the case of a patient who needs surgery?

It is most important when determining the patient's basic physical condition - how old he is, how hard his bones are, and whether there are other medical complications such as high blood pressure or diabetes. And it is important to calculate how much treatment goals are achieved and how many complications are there, accordingly. For example, if the patient is suffering from severe pain from elsewhere, there is no need for surgery to fix the screw on the back to straighten the back. But if the patient is unable to perform daily activities due to severe back pain, screw fixation must be considered in order to straighten the back.

However, if these patients are very old, have weak bones, or have severe diabetes or high blood pressure, and so many complications from surgery are expected, then other types of non-surgical treatment may be considered to reduce the pain and also to reduce the scope of surgery as much as possible.

5. For the prevention of scoliosis, is there any workout that you can suggest for people to do?

Scoliosis can be diagnosed very early. Therefore, it is most necessary to make the diagnosis as early as possible. Once diagnosed as scoliosis, it is more important than other stenosis or herniated disc patients to strengthen the back muscles to prevent it. So proper walking, swimming, and indoor cycling, along with special exercises to strengthen the waist and core muscles, are ways to prevent the disease from progressing.

6. On the other side, what should be avoided not to get scoliosis?

The worst thing is bad posture, but the bad posture you think of in everyday life is actually not a big problem. However, rural grandmothers who live in the countryside, who work in the fields for a long time or who have to lift heavy objects repeatedly while doing labor, doing repetitive work with a bad posture is the best way for this scoliosis to progress. So if these people can't avoid work, they need to at least wear something like a back brace to relieve some of the stress in their muscles.

Conclusion 

Scoliosis is a spine deviation characterized by lateral curvature and vertebral rotation. While scoliosis is associated with a variety of diseases, the great majority of individuals seen are idiopathic. To rule out non idiopathic causes of scoliosis, a comprehensive history, physical examination, and radiographs should be performed. Idiopathic scoliosis therapy is individualized based on age, curve magnitude, and risk of development, and involves observation, orthotic care, and surgical correction.

Surgery is suggested for symptomatic patients with significant deformity, but the patient must be educated about the serious consequences of scoliosis. Nurses should encourage incentive spirometry after surgery to prevent atelectasis. Although surgery can improve function and appearance, a large proportion of patients experience persistent pain or other neurological deficits, which can decrease their quality of life.

Overall, the results of surgery are unsatisfactory; surgery is frequently linked with severe consequences that are worse than scoliosis itself. Furthermore, as a result of the spinal deformity, many individuals have low self-esteem and stay isolated and reclusive. The interprofessional team should take precautions to avoid offering intrusive therapies that are more likely to cause damage than good; the objective is to improve quality of life.

There are difficulties in managing bracing with this population. Furthermore, the research found that higher compliance with bracing techniques resulted in better results. Adherence necessitates substantial participation from both the patient and the patient's support network. Furthermore, extensive parental education is necessary regarding operating risk, operative planning, and the goal of the surgical intervention.