Louisiana Pain Specialists - Pain Diagnosis and Intervention Experts

By Tarun Jolly, MD, Ryan Cooper

Scoliosis describes a condition in which the spine is abnormally curved and/or rotated to the side¹. The condition has been estimated to effect 2-3% of the U.S. population³. There is some evidence of a genetic component as scoliosis affects as high as 20% of persons whom have a relative also diagnosed with the condition.

Scoliosis is typically found in those aged 10-15 years, although the disorder can be found at any age from infancy to maturity³. It tends to be found in women more than men, and the severity of disease is determined by the extent of spinal curvature and rotation angle; 80% of cases are mild with curves under 20 degrees.

The etiology, or causation, of scoliosis has been classified into three main groups¹

• Neuromuscular – resulting from lack of muscle stability and control, due to musculoskeletal or neurologic conditions such as cerebral palsy, muscular dystrophy and more
• Congenital – resulting from an abnormality in spine development present at birth
• Idiopathic – resulting from causes unknown; idiopathic scoliosis is diagnosed when no other cause is apparent, and can occur from infancy through adolescence

The most common symptom of scoliosis tends to be pain and fatigue associated with stress on the spine due to the abnormal curvature, but in severe cases heart and lung problems can develop as well⁴. Depending on the severity, scoliosis may not cause pain at all; particularly in children or teens. If a teen with scoliosis experiences pain, doctors must rule out other possible spinal problems.

Patients with scoliosis typically present in childhood with characteristic findings²

• The shoulders appear to rest at different heights
• The pelvis appears to be tilted to one side
• Back pain exists
• Fatigue exists
• There is external appearance of a sideways, abnormal spinal curvature

Diagnosis of scoliosis can be made by a doctor through a comprehensive history, physical exam and with supplemental imaging. One exam technique is the Adams forward bend test, which has the patient bend forward over legs that are flat to a surface with the knees together. This technique has been demonstrated to be very sensitive in detecting scoliosis as the abnormal curvature becomes very apparent during full flexion¹. Doctors can also use a device known as a scoliometer to measure trunk rotation.

Radiographic imaging is reserved for when a scoliometer reading is suggestive of an abnormal angle that requires treatment, or when the scoliosis is otherwise clinically apparent on physical examination¹. X-Ray imaging is required for a definitive diagnosis of scoliosis as it can indicate the type and severity of the scoliosis, as well as the potential for further degeneration. For cases in which there is evidence of neurological deficit or rapid degenerative progression, magnetic resonance imaging (MRI) can be used to better visualize soft tissues such as nerves. Computed tomography (CT) imaging is also useful if a doctor suspects infection or bone tumor involvement.

Patients diagnosed with scoliosis have a variety of treatment options available, the choice of which is dependent upon the severity of disease (as measured by curvature angle) and the stage of growth for younger patients⁵. Growing patients are at risk for progression of disease. Common treatment courses include observation, bracing and surgery^{4, 5}:

• Simple observation is adequate if curvature angles measure less than 20 degrees, and patients should be followed every 6-12 months with physical exams and radiographs as needed. For younger patients still growing, increases in curvature of 5 degrees or more between follow-ups may indicate a need for more aggressive treatment
• Bracing is the first step for progressive scoliosis with patients who have growth remaining, and is typically reserved for curvatures between 20 – 50 degrees. While a brace will not cure or reverse damage already caused, it has been shown to be effective in halting further progression of the scoliosis. In mild cases, easily disguised under-arm braces can be used, but occasionally braces extending to the chin are necessary. These braces are worn all day, each day until growth has stopped
• Surgery is reserved for the most extreme cases (angles greater than 50) and for those patients with significant growth remaining. The procedure used most often is the posterior spinal fusion, which attaches adjacent vertebrae together and restricts their mobility- effectively halting progression of the condition. In many cases, the fusion can also reduce existing outward curvature

Physical therapy, chiropractic treatment and many other alternative therapies are not effective with this condition⁵. Some alternative treatments may be effective, notably osteopathic manipulation and shoe lifts for those experiencing neuromuscular scoliosis secondary to differing leg lengths. Louisiana Pain Specialists can assist patients in identifying scoliosis and selecting an appropriate course of treatment.

The prognosis for scoliosis patients with treatment is generally favorable. Prevention is important too; with children, a pediatrician should perform an examination to rule out existing or developing scoliosis. When detected and diagnosed early enough, measures can be taken to halt further degeneration and correct any damage. It’s important to note, that even with treatment via bracing and surgery, additional curving of the spine may occur with time⁵. It is also important to note that scoliosis presents a particular hardship for younger patients, especially with bracing, which increases risks for negative self-image and suicidal ideation.

REFERENCES

1 Scherl, S. Clinical features; evaluation; and diagnosis of adolescent idiopathic scoliosis. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011.

2 Nidus Information Services 2010: Scoliosis. Patient Handouts page. MD Consult Web site, Core Collection. Available at www.mdconsult.com.ezproxy2.library.arizona.edu. Accessed May 1, 2011.

3 Nidus Information Services 2010: Scoliosis. Patient Handouts page. MD Consult Web site, Core Collection. Available at www.mdconsult.com.ezproxy2.library.arizona.edu. Accessed May 1, 2011.

4 Mayo Clinic 2009. Scoliosis. Available at www.mayoclinic.com/health/scoliosis. Accessed May 2, 2011

5 Scherl, S. Treatment and prognosis of adolescent idiopathic scoliosis. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2010.