SCOLIOSIS

 

 

Scoliosis is a three dimensional deformity of the spine that involves rotation of the vertebral bodies. This is associated with changes in both the frontal (coronal) and lateral (sagittal) planes. There is typically a S-shaped bend when viewed from the back, and there is often a loss of the normal sagittal curvature when viewed from the side.

To the patient or parent, the first noticeable change is the emergence of a prominence over the thoracic spine or the asymmetry of the breast/chest area. This is due to the spinal rotation, which forces the ribs with it and causes the asymmetry.

When the scoliosis deformity progresses one of the shoulders may drop. A crease in the flank area may occur which often is perceived as one of the hips “sticking out”. The pelvis may also become oblique.

 
CAUSES

There are many types of scoliosis. They may occur from birth and called congenital. This is due to a failure of the vertebrae to form normally, which results in abnormal or asymmetrical growth. Often this type of scoliosis is associated with other birth defects such as heart or kidney problems. It usually manifests at an early age and needs close attention and investigation.

The commonest group of scoliosis is the so-called “Idiopathic” scoliosis. Although it can occur at any age, it usually presents in children from 10-12 years old, as they start their rapid growth phase. There is no known cause. It is more common in girls. They are typically tall, slim and have lax joint ligaments (“double jointed”).

Other causes include any conditions that affect the neurological system, ie the brain, spinal cord and nerves to the muscles. Conditions such as Cerebral palsy, spinal cord injuries (paralysis), polio would fall into this group. Certain muscle weakening conditions also cause scoliosis. These would include Duchenne’s muscular dystrophy, Smooth Muscular Atrophy and other rather conditions.

Many rare syndromes are associated with scoliosis, such as Marfan’s.

NATURAL HISTORY

Not all scoliosis requires intervention. Some cases are mild and do not progress. This is dependent on the type and the age of presentation. Generally scoliosis at an early age implies that it will progress. This is due to the amount of growth remaining in the patient.

ASSESSMENT

The scoliosis is assessed by the doctor both clinically and radiologically.
Clinically the patient’s history is taken in an effort to establish a specific cause.

 
 
On examination, the balance of the spine is assessed in terms of level shoulders and pelvis, and the position of the spine is palpated. The Adam’s forward bending test is used to unmask a mild curve.
 
 

 
 
 
The whole spine is X-rayed on one film with the patient erect. Here the deformity is measured using the Cobb angle, which allows serial comparisons.
 

MANAGEMENT

Should the curve be small (<20 degrees) and the cause benign, the patient would generally be observed.

Should there be serial progression or a larger curve (20 - 40 degrees) bracing may be considered appropriate. This is often difficult in the SA environment as unless the brace is worn 20 out 24 hours it is unlikely to assist. There is a low compliance rate in warm climates.

Should the curve show progression and be assessed as likely to reach 60 degrees or already be greater then 60 degrees, surgery may be indicated. Much depends on patients physical maturity status.

Should surgery be performed it can be done through the chest or abdomen or from behind.

OUTCOME

Should the curve be less than 40 degrees by the time the patient is physically mature, it is unlikely to progress in adult life. If greater than 60 degrees, it may progress at a rate of one degree per year for the rest of life.

Although the deformity is largely a cosmetic issue, curves greater than 100 degrees significantly affect morbidity rates.

Surgery is successful in correcting and controlling the curve. However the patient is exposed to peri-operative complications of infection (2%), neurological injury (0.3%) and non-union (5%).

The scoliosis is assessed by the doctor both clinically and radiologically
Surgery is successful in correcting and controlling the curve

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