Abnormal curvature in the spine is known as scoliosis, and
generally begins just at the onset of puberty and progresses during the period of rapid
growth. Most junior high schools routinely screen for scoliosis because, if caught early,
progressive spine curvature can be prevented. Scoliosis affects girls much more frequently
There are three general causes of scoliosis: congenital, usually related to a problem
with the formation of vertebrae or fused ribs during prenatal development; neuromuscular
(poor muscle control or muscular weakness or paralysis due to diseases like cerebral
palsy, muscular dystrophy, spina bifida and polio); and idiopathic (of unknown cause),
which appears in a previously straight spine.
The idiopathic form in adolescents is the most common and may have a genetic
predisposition. Most cases occur in girls and curves generally worsen during growth
spurts. There are also infantile and juvenile forms that are less common and affect a
similar number of boys and girls.
Scoliosis may be suspected when one shoulder appears to be higher than the other, or the
pelvis appears to be tilted. It is often unnoticeable to an untrained observer, however.
Routine scoliosis screening is now done in junior high school/middle school and many early
cases are detected that previously would have gone undetected until they were more
There may be fatigue in the spine after prolonged sitting or standing. Pain will become
persistent if irritation of ligaments results. The greater the initial curve of the spine,
the greater the chance for progression of the condition after growth is complete. Severe
scoliosis (curves in the spine greater than 100 degrees) may cause breathing (respiratory)
More information about Scoliosis
When viewed from the rear, the spine usually appears perfectly straight. Scoliosis is a
lateral (side-to-side) curve in the spine, usually combined with a rotation of the
vertebrae. (The lateral curvature of scoliosis should not be confused with the normal set
of front-to-back spinal curves visible from the side.) While a small degree of lateral
curvature does not cause any medical problems, larger curves can cause postural imbalance
and lead to muscle fatigue and pain. More severe scoliosis can interfere with breathing
and lead to arthritis of the spine (spondylosis).
Approximately 10% of all adolescents have some degree of scoliosis, though fewer than
1% have curves which require medical attention beyond monitoring. Scoliosis is found in
both boys and girls, but a girl's spinal curve is much more likely to progress than a
boy's. Girls require scoliosis treatment about five times as often. The reason for these
differences is not known.
Symptoms of Scoliosis
- the spine curving abnormally to the side (laterally)
- shoulders and/ or hips appearing uneven
- backache or low back pain
Note: Kyphoscoliosis also involves abnormal front-to-back curvature, with a
"rounded back" appearance.
Four out of five cases of scoliosis are idiopathic, meaning the cause is
unknown. While idiopathic scoliosis tends to run in families, no responsible genes had
been identified as of 1997. Children with idiopathic scoliosis appear to be otherwise
entirely healthy, and have not had any bone or joint disease early in life. Scoliosis is
not caused by poor posture, diet, or carrying a heavy bookbag exclusively on one shoulder.
Idiopathic scoliosis is further classified according to age of onset:
- Infantile. Curvature appears before age three. This type is quite rare in the United
States, but is more common in Europe.
- Juvenile. Curvature appears between ages 3 and 10. This type may be equivalent to the
adolescent type, except for the age of onset.
- Adolescent. Curvature appears between ages of 10 and 13, near the beginning of puberty.
This is the most common type of idiopathic scoliosis.
- Adult. Curvature begins after physical maturation is completed.
Causes are known for three other types of scoliosis:
- Congenital scoliosis is due to congenital birth defects in the spine, often associated
with other organ defects.
- Neuromuscular scoliosis is due to loss of control of the nerves or muscles which support
the spine. The most common causes of this type of scoliosis are cerebral palsy and
- Degenerative scoliosis may be caused by degeneration of the discs which separate the
vertebrae or arthritis in the joints that link them.
Scoliosis causes a noticeable asymmetry in the torso when viewed from the front or
back. The first sign of scoliosis is often seen when a child is wearing a bathing suit or
underwear. A child may appear to be standing with one shoulder higher than the other, or
to have a tilt in the waistline. One shoulder blade may appear more prominent than the
other due to rotation. In girls, one breast may appear higher than the other, or larger if
rotation pushes that side forward.
Curve progression is greatest near the adolescent growth spurt. Scoliosis that begins
early on is more likely to progress significantly than scoliosis that begins later in
More than 30 states have screening programs in schools for adolescent scoliosis,
usually conducted by trained school nurses or gym teachers.
Diagnosis of Scoliosis
Diagnosis for scoliosis is done by an orthopedist. A complete medical history is taken,
including questions about family history of scoliosis. The physical examination includes
determination of pubertal development in adolescents, a neurological exam (which may
reveal a neuromuscular cause), and measurements of trunk asymmetry. Examination of the
trunk is done while the patient is standing, bending over, and lying down, and involves
both visual inspection and use of a simple mechanical device called a scoliometer.
If a curve is detected, one or more x rays will usually be taken to define the curve or
curves more precisely. An x ray is used to document spinal maturity, any pelvic tilt or
hip asymmetry, and the location, extent, and degree of curvature. The curve is defined in
terms of where it begins and ends, in which direction it bends, and by an angle measure
known as the Cobb angle. The Cobb angle is found by projecting lines parallel to the
vertebrae tops at the extremes of the curve; projecting perpendiculars from these lines;
and measuring the angle of intersection. To properly track the progress of scoliosis, it
is important to project from the same points of the spine each time.
Occasionally, magnetic resonance imaging (MRI) is used, primarily to look more closely
at the condition of the spinal cord and nerve roots extending from it if neurological
problems are suspected.
Treatment of Scoliosis
Treatment decisions for scoliosis are based on the degree of curvature, the likelihood
of significant progression, and the presence of pain, if any.
Curves less than 20 degrees are not usually treated, except by regular follow-up for
children who are still growing. Watchful waiting is usually all that is required in
adolescents with curves of 20-30 degrees, or adults with curves up to 40 degrees or
slightly more, as long as there is no pain.
For children or adolescents whose curves progress to 30 degrees, and who have a year or
more of growth left, bracing may be required. Bracing cannot correct curvature, but may be
effective in halting or slowing progression. Bracing is rarely used in adults, except
where pain is significant and surgery is not an option, as in some elderly patients.
Two general styles of braces are used for daytime wear. The Milwaukee brace consists of
metal uprights attached to pads at the hips, rib cage, and neck. The underarm brace uses
rigid plastic to encircle the lower rib cage, abdomen, and hips. Both these brace types
hold the spine in a vertical position. Because it can be worn out of sight beneath
clothing, the underarm brace is better tolerated and often leads to better compliance. A
third style, the Charleston bending brace, is used at night to bend the spine in the
opposite direction. Braces are often prescribed to be worn for 22-23 hours per day, though
some clinicians allow or encourage removal of the brace for exercise.
Bracing may be appropriate for scoliosis due to some types of neuromuscular disease,
including spinal muscular atrophy, before growth is finished. Duchenne muscular dystrophy
is not treated by bracing, since surgery is likely to be required, and since later surgery
is complicated by loss of respiratory capacity.
Surgery for idiopathic scoliosis is usually recommended if:
- The curve has progressed despite bracing
- The curve is greater than 40-50 degrees before growth has stopped in an adolescent
- The curve is greater than 50 degrees and continues to increase in an adult
- There is significant pain.
Orthopedic surgery for neuromuscular scoliosis is often done earlier. The goals of
surgery are to correct the deformity as much as possible, to prevent further deformity,
and to eliminate pain as much as possible. Surgery can usually correct 40-50% of the
curve, and sometimes as much as 80%. Surgery cannot always completely remove pain.
The surgical procedure for scoliosis is called spinal fusion, because the goal
is to straighten the spine as much as possible, and then to fuse the vertebrae together to
prevent further curvature. To achieve fusion, the involved vertebra are first exposed, and
then scraped to promote regrowth. Bone chips are usually used to splint together the
vertebrae to increase the likelihood of fusion. To maintain the proper spinal posture
before fusion occurs, metal rods are inserted alongside the spine, and are attached to the
vertebrae by hooks, screws, or wires. Fusion of the spine makes it rigid and resistant to
further curvature. The metal rods are no longer needed once fusion is complete, but are
rarely removed unless their presence leads to complications.
Spinal fusion leaves the involved portion of the spine permanently stiff and
inflexible. While this leads to some loss of normal motion, most functional activities are
not strongly affected, unless the very lowest portion of the spine (the lumbar region) is
fused. Normal mobility, exercise, and even contact sports are usually all possible after
spinal fusion. Full recovery takes approximately six months.
Alternative treatment for Scoliosis
Although important for general health and strength, exercise has not been shown to
prevent or slow the development of scoliosis. It may help to relieve pain from scoliosis
by helping to maintain range of motion. Good nutrition is also important for general
health, but no specific dietary regimen has been shown to control scoliosis development.
In particular, dietary calcium levels do not influence scoliosis progression.
Chiropractic treatment may relieve pain, but it cannot halt scoliosis development, and
should not be a substitute for conventional treatment of progressing scoliosis.
Acupuncture and acupressure may also help reduce pain and discomfort, but they cannot halt
scoliosis development either.
Prognosis of Scoliosis
The prognosis for a person with scoliosis depends on may factors, including the age at
which scoliosis begins and the treatment received. More importantly, mostly unknown
individual factors affect the likelihood of progression and the severity of the curve.
Most cases of mild adolescent idiopathic scoliosis need no treatment and do not progress.
Untreated severe scoliosis often leads to spondylosis, and may impair breathing.