Idiopathic Scoliosis

Adult

Figure 1: A 20-year old woman

whose curve progressed after
she stopped growing.
Adult Idiopathic Scoliosis
This is a slow increase in curvature that began during teenage years in an otherwise healthy
individual and progressed during adult life. Curves may increase in size 0.5-2° per year (Figure
1). Adolescent curves less than 30° are unlikely to progress significantly into adulthood, while
those over 50° are likely to get bigger. For this reason, it is important to be aware of adult
scoliosis specialists to monitor the curves over time.

Some patients may have had brace treatment during adolescence while others may have never
sought treatment during their teenage years. This can occur in the thoracic (upper) and lumbar
(lower) spine and has the same basic appearance as that seen in teenagers. Physical findings may
include shoulder asymmetry, a rib hump or a prominence of the lower back on the side of the
curvature. These curves can get worse in the older patient due to degeneration of the discs which
results in settling of the vertebrae (spinal segments). Settling of the discs may also cause patients
to lean progressively forward, leading to sagittal imbalance. Additionally, arthritis sets in the
joints of the spine (facets) that leads to the formation of bone spurs. This can result in pain and
stiffness of the back. In more severe cases, patients may also develop shooting pain and
numbness down the legs due to pinched nerves.
Idiopathic Scoliosis

Adolescents

Scoliosis in patients between 10 and 18 years of age is termed adolescent scoliosis. By far the
most common type of scoliosis is one in which the cause is not known. It is called “idiopathic”
or adolescent idiopathic scoliosis (AIS). Although significant ongoing research continues in this
area, including the genetic basis for AIS, there are no identifiable causes for this condition today.
Despite this, we currently have accurate methods to determine the risk for curve progression of
scoliosis and good methods of treatment.

Causes
There are significant efforts being made toward identifying the cause of AIS, but to date there are
no well-accepted causes for this particular type of scoliosis. The vast majority of patients are
otherwise healthy and have no previous medical history. There are many theories about the cause
of AIS including hormonal imbalance, asymmetric growth and muscle imbalance. Approximately
30% of AIS patients have some family history of scoliosis, and therefore there seems to be a
genetic connection. Many Scoliosis Research Society members are working to identify the genes
that cause AIS, and this knowledge continues to expand at a rapid pace. Most likely, there will be
many genes associated with scoliosis and each may be helpful in detecting scoliosis and
determining the risk for progression of the curve. A genetic screening test, called the
ScoliScore™ is available as an adjunct to clinical and x-ray information to determine risk of
progression in Adolescent Idiopathic Scoliosis. It is currently used in Caucasian (North
American, European, Eastern European, Middle Eastern) patients between the ages of 9 and 13
years with a mild scoliotic curve (less than 25 degrees). The stated goal of the test is to determine
the risk that the curve will increase to 40 degrees or more. Thus far independent verification of
the test has not been done.

Symptoms
Adolescent idiopathic scoliosis generally does not result in pain or neurologic symptoms. The
curve of the spine does not put pressure on organs, including the lung or heart, and symptoms
such as shortness of breath are not seen with AIS. When scoliosis begins in adolescence patients
often have some back pain, typically in the low back area. Although it is often associated with
scoliosis, it is generally felt that the curvature does not result in pain. Low back pain is not
uncommon in adolescences in general. Many teens experience back pain due to participating in a
large number of activities without having good core abdominal and back strength, as well as
flexibility of the hamstrings. Adolescent idiopathic scoliosis generally does not result in pain or
neurologic problems. If these symptoms occur, further evaluation and testing may be necessary
to include an MRI.

Adolescents

Physical Findings
There are many visible symptoms associated with adolescent idiopathic scoliosis. One of the
most common is shoulder height asymmetry, in which one shoulder appears higher than the other
(see figure 1A). A shift of the body to the right or the left can occur especially when there is a
single curve in the thoracic (chest-part) or the lumbar (lower back) of the spine without a second
curve to help balance the patient. This is often seen as some waistline asymmetry in which one
hip appears to be higher than the other and may result in one leg appearing taller than the other
(see figure 1B). A prominence on the back or a rib hump secondary to the rotational aspect of the
scoliosis is the most visible sign of scoliosis (see figures 1C and 1D).

Patients with AIS have a normal appearance when viewed from the side. In general, there are no
neurologic abnormalities such as weakness or changes in a patients feeling in the upper or lower
extremities (see figure 1E).
Figure 1:
A) Shoulder asymmetry (note how the left shoulder is higher in the right).
B) Waistline asymmetry and the body shifted to the right.
C&D) Rib prominence tends to correlate with the size of the curve.
E) Patients typically look normal when viewed from the side.

Adolescents

Imaging Evaluation

Figure 1: A) AP radiograph, B) Lateral radiograph, C) Cobb method

The typical radiographic images that are obtained to define scoliosis include a standing X-ray of
the entire spine looking both from the back (see Figure 1A), as well as from the side (see Figure
1B). These radiographs are often done with lead shields to protect the patient while allowing for
a clear view of the spine. Your physician will be able to measure the radiographs to determine
your curves magnitude, which is measured in degrees using the Cobb method (see Figure 1C). A
straight spine has a curve of 0º, any curve greater than 10º is considered scoliosis. Between 0º
and 10º is considered “postural asymmetry” which is not true scoliosis. The way a patient stands
at the time of an X-ray or many other factors can cause a slight curvature. The lateral radiograph
is used to determine the thoracic kyphosis (or roundback appearance) and the amount of lumbar
lordosis (swayback).

Further radiographs can be performed to determine the flexibility of the curvature (how much it
straightens). These flexibility radiographs can be done several ways. X-rays can be taken in
which the patient lays on the table and bends to the right and then to the left (see Figure 2).
Traction films are taken with the patient's arms and legs pulled to stretch the spine out. A
fulcrum- bend radiograph is taken with a padded roll placed at the apex of the curve to improve
the curve correction. These radiographs are most often taken in the planning of surgical
treatments.

Figure 2: Flexibility radiographs

Adolescents

Treatment
Treatment of adolescent idiopathic scoliosis falls into three main categories: observation, bracing
and surgery. The treatment recommended is based on the risk of curve progression. In general,
AIS curves progress during the rapid growth period of the patient. While most curves slow their
progression significantly at the time of skeletal maturity, some, especially curves greater than
60o, continue to progress during adulthood.
Since scoliosis gets larger during rapid growth, the potential for growth is evaluated taking into
consideration the patient's age, the status of whether females have had their first menstrual
period, as well as radiographic parameters. In general, girls grow until 14 years of age, while
boys grow until 18 years of age. Girls grow very rapidly until their first menstrual period, and
then their growth generally slows down. Women continue to grow until approximately 2 years
after their first menstrual period.

Figure 1: "Risser Grading System - as the iliac apophysis (growth area) moves from
outside to inside, the child is approaching skeletal maturity.

Non-Operative Treatments

Observation / Alternative Treatment

Observation
Observation is generally for patients whose curves are less than 25-30º who are still growing, or
for curves less than 45º in patients who have completed their growth. Scoliosis surgeons often
wish to observe the scoliosis every few years after patients complete their growth to make sure it
does not progress into adulthood.

Alternative Treatment
Alternative treatments to prevent curve progression or prevent further curve progression such as
chiropractic medicine, physical therapy, yoga, etc. have not demonstrated any scientific value in
the treatment of scoliosis. However, these and other methods can be utilized if they provide some
physical benefit to the patient such as core strengthening, symptom relief, etc. These should not,
however, be utilized to formally treat the curvature in hopes of improving the scoliosis.

Bracing

Figure 1: The X-ray and brace of a young woman with

scoliosis. A T-shirt is usually worn beneath the brace.
The brace is usually custom-made to provide appropriate
correction.
Bracing is recommended for patients with curves that measure between 25o and 40o during their
growth phase. The goal is to prevent the curve from getting bigger. This is accomplished by
correcting the curve while the patient is in the brace so that the curve does not progress with
time. Growth plates on the vertebrae are more likely to grow symmetrically if they have equal
pressure over their surface as the child grows. Straighter spines equalize pressure better than
curved spines. Once the brace is discontinued, the goal is to maintain the curve at the magnitude
present when the brace was started. Even if slight curve progression occurs despite wearing the
brace, surgical treatment is not necessary as long as the curve remains below 45o at the end of
growth. There are several types of braces available but all of them work in the same fashion. All
braces are worn under the clothes and cannot be seen by others. Bracing is most effective when it
is worn more than 20-22 hours per day. Your physician will often recommend removing the
brace for bathing and sports.
Figure 2: X-rays before and after brace placement
showing correction of the thoracic and lumbar
curves.

Surgical Treatment
Figure 1: A) Front and side X-rays of a patient with adolescent idiopathic scoliosis in her
thoracic spine. B) Post-surgical correction through a posterior approach using two rods
and pedicle screws.
Surgical treatment is recommended for patients whose curves are greater than 45o while still
growing, or are continuing to progress greater than 45o when growth stopped. The goal of
surgical treatment is two-fold: first, to prevent curve progression and secondly to obtain some
curve correction. Surgical treatment today utilizes metal implants that are attached to the spine,
and then connected to a single rod or two rods. Implants are used to correct the spine and hold
the spine in the corrected position until the instrumented segments fuse as one bone. The surgery
can be performed from the back of the spine (posterior approach) (Figure 1) through a straight
incision along the midline of the back or through the front of the spine (anterior approach)
(Figure 2). Although there are advantages and disadvantages to both approaches, the posterior
approach is utilized most often in the treatment of AIS and can be utilized for all curve types.
The anterior approach is an option when a single thoracic curve or a single lumbar curve is being
treated. Many factors go into the decision as to the surgical approach and your doctor will review
the options and choose the best approach for you.

Following surgical treatment, no external bracing or casts are used. The hospital stay is generally
between 3 and 6 days. The patient can perform regular daily activities and generally returns to
school in 3-4 weeks. Depending on the activities of the patient, full participation is allowed
between 3 and 6 months after surgery. Most children will not need pain medications 10-14 days
after surgery.

Figure 2: A) Front and side X-rays of a patient with adolescent idiopathic scoliosis in her
thoracic and lumbar spine. B) Post-operative xrays showing instrumentation placed via an
anterior (side) approach.

http://www.srs.org/patient_and_family/scoliosis/idiopathic/adolescents/physical_findings.htm
7 December 2013