Scoliosis and Spinal Deformity

The normal spine is straight in the frontal plane, whereas in the sagittal plane it is composed of three curves: a cervical lordosis, a thoracic kyphosis and a lumbar lordosis.

Deviations in normal spinal contours comprise a group of disorders termed spinal deformities of which idiopathic scoliosis is the most common. Spinal deformities are clinically important because they may produce pain, difficulty with sitting or ambulating, neurologic compromise, unacceptable cosmesis and in advanced cases cardiopulmonary compromise. Each type of spinal deformity is associated with its own clinical presentation, symptoms and natural history for progression.

Although scoliosis has been defined as lateral curvature of the spine, it is associated with vertebral rotation, which produces the cosmetically unacceptable rub hump. Idiopathic Scoliosis is classified according to the age at onset: infantile, juvenile and adolescent. Scoliosis seen after skeletal maturity is termed adult scoliosis. Progression of idiopathic curves correlates with the magnitude of the curve, the age of presentation and the patient’s menarchal status. Non-idiopathic causes of scoliosis must be determined because of their less predictable, and generally higher risk for progression (e.g. congenital, neurofibromatosis and neuromuscular).

Symptoms and Signs

Significant pain or neurological symptoms are uncommon with idiopathic scoliosis. These findings warrant further investigation to rule out tumor, infection, disc herniation, or other non-idiopathic causes of spinal deformity.

Imaging

Patients referred for evaluation of spinal deformities should obtain standing AP and lateral radiographs including the entire spine (36"x14" film). If treatment is contemplated, bending films in the direction of each curve convexity will help to determine curve flexibility. Curves are measured according to the Cobb Method. The vertebrae, which are maximally tilted into the concavity of the curve, are the end vertebrae. Perpendiculars from their endplates are drawn and the angle between them determines the curve magnitude. Curves should be measured from the same vertebrae during each examination for serial comparison.

Patients presenting with neurological signs or symptoms, left thoracic curves or rapid progression should obtain magnetic resonance scans to rule out intraspinal pathology.

Skeletally immature patients presenting curves less than 20 degrees or for those presenting with curves less than 40 degrees at skeletal maturity should be observed. Adolescent patients should be followed with radiographs at 4-6 month intervals until skeletal maturity.

Curves greater than 20 degrees or progression of greater than 5 degrees should be referred for treatment to a surgeon experienced in the management of patients with spinal deformity.

Growing children with curves measuring 20-40 degrees or documented progression are candidates for brace treatment. Patients with curve apices below T8 can be fitted with polypropylene underarm type braces. Higher curves can only be controlled with a cervico-thoracic-lumbar orthosis (Milwaukee Brace). The goal of bracing is to halt progression. Long-term curve correction is rarely achieved with brace treatment.

The daily duration of brace wear is necessary to halt progression is controversial. Although historically braces have been worn for 23-24 hours per day, recent studies have indicated that limited daily brace wear may be equally effective. Generally, patients should be braced until skeletal maturity and then should be gradually weaned. For bracing instructions, click here.

Surgical Treatment