Scoliosis & Kyphosis

Preface

The Scoliosis Research Society has prepared this booklet to provide patients, and in the case of children, their parents, with a better understanding of scoliosis, its diagnosis and management, using idiopathic scoliosis-the most common type-as a model. This information is intended as a supplement to the information your physician will provide you. Just as no two individuals are exactly alike, no two patients with a spinal deformity are the same. Therefore, your orthopaedic surgeon will be the most important source of information about the management of your particular spinal problem.

It is beyond the scope of this booklet to discuss technical details concerning the surgical correction of scoliosis and kyphosis. Therefore, only a general review of these procedures has been included in the section dealing with surgery.

What are Spinal Deformities?

When the body is viewed from behind, a normal spine appears straight. (Fig. la) However, when a spine with scoliosis is viewed from behind, a lateral or side-to-side curvature may be apparent. (Fig. lb) This gives the appearance of leaning to one side and should not be confused with poor posture. When the trunk is viewed from the side, the spine will demonstrate normal curves. The upper chest area has a normal roundback, or kyphosis, while in the lower spine there is a swayback, or lordosis. (Fig. 2a) Increased roundback in the chest area is correctly called hyperkyphosis while increased swayback is termed hyperlordosis. (Fig. 2b) Changes from normal on a side view frequently accompany scoliosis changes.

What causes Scoliosis?

Eighty-five percent of people with scoliosis have the “idiopathic” type. “Idiopathic” means “no known cause.” It commonly affects adolescents as they complete the last major growth spurt. Idiopathic scoliosis frequently runs in families and may be due to genetic or hereditary influences. Idiopathic scoliosis may appear at any age but most often appears in early adolescence. At this age young people are reluctant to allow their bodies to be seen by parents and other adults. As a result, the Scoliosis Research Society and the American Academy of Orthopaedic Surgeons have endorsed school screening programs to detect scoliosis curves before they may become advanced.

In contrast to idiopathic scoliosis, there are several less common types of scoliosis which do have a known cause. These curves may be due to defects of spinal vertebrae already present at birth (“congenital scoliosis”), disorders of the central nervous system such as cerebral palsy, muscle diseases (muscular dystrophy), disorders of connective tissue (Marfan’s syndrome), and chromosome abnormalities (Down’s syndrome).

Who gets Scoliosis?

In childhood, idiopathic scoliosis occurs in both girls and boys. However, as children enter adolescence, girls are five to eight times more likely to have their curves increase in size and require treatment.

What are the signs of Scoliosis?

One shoulder may be higher than the other.
One scapula (shoulder blade) may be higher or more prominent than the other.
With the arms hanging loosely at the side, there may be more space between the arm and the body on one side.
One hip may appear to be higher or more prominent than the other.
The head is not centered over the pelvis. (Fig. above)
When the patient is examined from the rear and asked to bend forward until the spine is horizontal, one side of the back appears higher than the other.

What should be done?

In ninety percent of cases, scoliotic curves are mild and do not require active treatment. In the growing adolescent, it is very important that the curves be monitored for change by periodic examination and standing X-rays as needed. Increases in spinal deformity require evaluation by an orthopaedic surgeon to determine if brace treatment is required. In a small number of patients, surgical treatment may be needed.

What factors determine treatment?

Age in years.
Bone age (the maturation of bone is not always the same as the chronological age).
Degree of curvature.
Location of curve in the spine.
Status of menses/puberty.
Sex of the patient.
Worsening of curve

What causes abnormal Kyphosis?

Kyphosis (roundback) is commonly used to refer to excessive curvature of the thoracic spine when viewed from the side. Excessive roundback deformity may simply be postural and can often be corrected with exercises and proper posture. A small percentage of patients with kyphosis have more rigid deformities than the postural type, which are associated with wedged vertebrae. This type is called Scheuermann’s kyphosis and is much more difficult to treat than postural kyphosis. Its cause is unknown. Bracing may be recommended for the immature adolescent with Scheuermann’s kyphosis.

Brace treatment for Spinal Deformity

Brace treatment (orthosis) is recommended for increasing scoliosis or kyphosis in the skeletally immature patient. Bracing is recommended for moderate scoliosis or abnormal kyphosis. There are many types of braces, all designed to prevent curves from increasing as the adolescent grows. The orthosis acts as a buttress for the spine to prevent the curve from increasing during active skeletal growth. Braces will not make the spine straight, and cannot always keep a curve from increasing. However, bracing is effective in halting curve progression in a significant percentage of skeletally immature adolescents.

What does successful Brace treatment require?

Early detection while the patient is still growing.
Mild to moderate curvature.
Regular examination by the orthopaedic surgeon.
A well-fitted brace.
A cooperative patient and supportive family.
Maintenance of normal activities, including exercise, dance training, and athletics, with elective time out of the brace for these activities as supervised by the physician.

What happens if the curve requires surgery?

When a young person exhibits a worsening spinal deformity, surgical treatment is indicated to improve the deformity and to prevent increasing deformity in the future. The most common surgical procedure is a posterior spinal fusion with instrumentation and bone graft. The term “instrumentation” refers to a variety of devices such as rods, hooks, wires and screws, which are used to hold the correction of the spine in as normal an alignment as possible while the bone fusion heals. The instrumentation is rarely removed.

A number of factors influence the recommendation for surgery:

The area of the spine involved
Severity of scoliosis
Presence of increased or decreased kyphosis
Pain (rare in adolescents, more common in adults)
Growth remaining
Personal factors.

Operative Considerations

The goal of surgery is to fuse the spine at the optimum degree of safe correction of the deformity. There are always risks that accompany any surgical procedure. These should be discussed with your orthopaedic surgeon. Some important points in planning your surgery are:

A comprehensive preoperative conference
Donating your own blood (if possible)
Good nutritional status before and after surgery
Exercise program before and after surgery
Positive mental attitude

Answers to questions commonly asked

A lack of calcium will not cause scoliosis.
Poor posture does not cause scoliosis.
Carrying a heavy book bag does not cause scoliosis.
Scoliosis is not usually painful in adolescence, but can become so in adulthood.
Braces do not make the spine straight.
Smoking does interfere with bone healing.
The metal implant (spinal instrumentation) does not activate the metal detectors at airports, does not rust, and is not subject to rejection by the body.
Surgery does not interfere with normal childbearing.
Spinal deformities are not contagious.
At present, there is no known prevention for spinal deformities.

Glossary of Medical Terms

Adolescent scoliosis: lateral spinal curvature that appears before the onset of puberty and before skeletal maturity.
Adult scoliosis: scoliosis of any cause which is present after skeletal maturity.
Autograft: any tissue transferred from one site to another in the same individual (iliac bone from the pelvis is commonly used to supplement the fusion mass).
Autologous blood: blood collected from a person for later transfusion to that same person. This technique is often used prior to elective surgery if blood loss is expected to occur. This may avoid the use of bank blood from unknown donors and significantly reduces the risk of acquiring transmitted diseases.
Autotransfusion: the practice and technique of transfusing previously drawn autologous blood back to the same patient.
Cervical spine: that portion of the vertebral column contained in the neck, consisting of seven cervical vertebrae between the skull and the rib cage.
Compensatory curve: in spinal deformity, a secondary curve located above or below the structural curvature, which develops in order to maintain normal body alignment.
Congenital scoliosis: scoliosis due to bony abnormalities of the spine present at birth. These anomalies are classified as failure of vertebral formation and/or failure of segmentation.
Decompensation: in scoliosis, this refers to loss of spinal balance when the thoracic cage is not centered over the pelvis.
Discectomy: removal of all or part of an intervertebral disc (the soft tissue that acts as a shock absorber between the vertebral bodies).
Double curve: two lateral curvatures (scoliosis) in the same spine. Double major curve: describes a scoliosis in which there are two structural curves which are usually of equal size.
Double thoracic curve: a scoliosis with a structural upper thoracic curve, as well as a larger, more deforming lower thoracic curve, and a relatively nonstructural lumbar curve.
Hemivertebra: a congenital anomaly of the spine caused by incomplete development of one side of a vertebra resulting in a wedge shape.
Hysterical scoliosis: a non-structural deformity of the spine that develops as a manifestation of a psychological disorder.
Idiopathic scoliosis: a structural spinal curvature for which cause has not been established.
Inclinometer: an instrument used to measure the angle of thoracic prominence, referred to as angle of trunk rotation (ATR).
Infantile scoliosis: curvature of the spine that develops before three years of age.
Juvenile scoliosis: scoliosis developing between the ages of three and ten years.
Kyphoscoliosis: a structural scoliosis associated with increased roundback.
Kyphosis: a posterior convex angulation of the spine as evaluated on a side view of the spine. Contrast to lordosis.
Lordoscoliosis: a lateral curvature of the spine associated with increased swayback.
Lordosis: an anterior angulation of the spine in the sagittal plane. Contrast to kyphosis.
Lumbar curve: a spinal curvature whose apex is between the first and fourth lumbar vertebrae (also known as lumbar scoliosis).
Lumbosacral: pertaining to the lumbar and sacral regions of the back.
Lumbosacral curve: a lateral curvature with its apex at the fifth lumbar vertebra or below (also known as lumbosacral scoliosis).
Neuromuscular scoliosis: a form of scoliosis caused by a neurologic disorder of the central nervous system or muscle.
Nonstructural curve: description of a spinal curvature or scoliosis that does not have fixed residual deformity.
Pedicle: bony process projecting backward from the body of a vertebra, which connects with the lamina on either side.
Posterior fusion: a technique of stabilizing two or more vertebra by bone grafting.
Primary curve: the first or earliest curve to appear.
Risser sign: used to indicate spinal maturity, this refers to the appearance of a cres-centic line of bone formation which appears across the top of each side of the pelvis.
Sacrum: curved triangular bone at the base of the spine, consisting of five fused vertebrae known as sacral vertebrae. The sacrum articulates with the last lumbar vertebra and laterally with the pelvic bones.
Scoliometer: a proprietary name for an inclinometer used in measuring trunk rotation.
Scoliosis: lateral deviation of the normal vertical line of the spine which, when measured by X-ray, is greater than ten degrees. Scoliosis consists of a lateral curvature of the spine with rotation of the vertebrae within the curve.
Spinal instrumentation: metal implants fixed to the spine to improve spinal deformity while the fusion matures. This includes a wide variety of rods, hooks, wires and screws used in various combinations.
Spondylitis: an inflammatory disease of the spine.
Spondylolisthesis: an anterior displacement of a vertebra on the adjacent lower vertebra.
Structural curve: a segment of the spine that has fixed lateral curvature.
Thoracic curvature: any spinal curvature in which the apex of the curve is between the second and eleventh thoracic vertebrae.
Thoracolumbar curve: any curvature that has its apex at the twelfth thoracic or first lumbar vertebra.
Thoracolumbosacral orthosis (TLSO): a type of brace incorporating the thoracic and lumbar spine.
Vertebral column: the flexible supporting column of vertebrae separated by discs and bound together by ligaments.

Acknowledgements : Scoliosis Research Society

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ASSICON 2014|Scoliosis Research Society|ASSI