Explaining Spinal Disorders
- Adolescent Idiopathic Scoliosis
- Adult Degenerative Scoliosis
- Cervical Degenerative Disc Disease
- Cervical Disc Herniation
- Cervical Stenosis
- Vertebral Compression Fractures
- Degenerative Spondylolisthesis
- Isthmic Spondylolisthesis
- Lumbar Degenerative Disc Disease
- Lumbar Disc Herniation
- Lumbar Stenosis
- Neck Sprain (Whiplash) and Strain
- Scoliosis and Deformity
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Spinal Disorders: Adolescent Idiopathic Scoliosis
Adolescent Idiopathic Scoliosis (AIS) is a lateral (side) curvature of the spine. AIS effects 1-3% of children aged 10-16 years. (1) The spine may curve to the left or right. Sometimes AIS starts at puberty, or during an adolescent growth spurt.
Idiopathic means the abnormal curve develops for unknown reasons. Research shows there is a genetic predisposition for some adolescents to develop AIS. Most of these children will be girls and curves may be more progressive.
Signs and Symptoms
Signs and symptoms related to adolescent idiopathic scoliosis include:
- Leg-length difference
- Abnormal gait
- One shoulder higher than the other
- A prominent shoulder blade / rib cage when bending forward
- Visible curvature of the spine to one side
- Uneven hips
- Hemlines or trouser lengths uneven
- Clothing does not fit correctly
- Back pain
It is important to seek treatment for AIS because progressive scoliosis, left untreated, can result in significant deformity. The deformity can cause marked psychological distress and physical disability, especially among adolescent patients. Additionally, the deformity can have serious physical consequences. As the vertebrae (spinal bones) rotate, the rib cage is affected, which in turn can cause heart and lung problems (i.e. shortness of breath). When progressive scoliosis affects the lumbar (low back), spine the pain can be debilitating.
Diagnosis
Our comprehensive diagnostic process includes a medical history, physical and neurological exam, and diagnostic tests.
- Medical history may include questions about the parent’s genealogy. Are there other family members with scoliosis? If so, how did the scoliosis progress and what treatment was provided? The doctor checks for any underlying medical condition that might cause scoliosis. The patient’s age, onset of puberty, and – if female, age at which a young woman has her first period, helps the doctor determine the number of years that remain before the child reaches skeletal maturity. At skeletal maturity curve progression may stop, as long as the curve is less than 40-45 degrees. The curve may continue to progress throughout adulthood, if the curve exceeds 40-45 degrees.
- During the physical and neurological examinations the doctor learns about the patient’s health and general fitness. Both exams provide the doctor with a baseline from which future curve progression can be estimated. A typical examination may include the following:
| Examination | Description |
|---|---|
| Physical assessment | The doctor looks for trunk asymmetry, such as uneven shoulders or hips, humpback, or listing to one side. |
| Cardiopulmonary | Testing heart and lung function. |
| Adam’s Forward Bending Test | The patient bends forward at the waist, with arms extended forward. The doctor looks for asymmetric thoracic prominence, such as a shoulder blade, or a lumbar prominence. |
| Leg length | Both legs are measured to determine if they are of equal length. |
| Plumb line | A plumb line is suspended from the C7 vertebra (neck area) and allowed to hang below the buttocks. The plumb line does not hang between the buttocks if the patient has scoliosis. |
| Range of motion | The doctor evaluates the patient’s ability to perform flexion, extension, bending, and rotation movements. |
| Palpation | The doctor feels the spine for abnormalities. Perhaps the ribs are more prominent on one side. |
| Neurological assessment | Reflexes are tested. The presence of pain, numbness, tingling, extremity weakness or sensation, muscle spasm, and bowel/bladder changes are noted. |
Diagnostic tests include the following:
| Diagnostic Test | Description |
|---|---|
| Scoliometer | A scoliometer measures a rib prominence while the patient bends forward at the waist. |
| X-rays (radiographs) | X-rays may include a standing lateral view of the spine and side bending. |
| Cobb Angle Measurement | A full-length anterior-posterior x-ray is used to calculate curve angle(s). |
| Risser Sign | Using an x-ray, the Risser Sign indicates skeletal maturity by evaluating the iliac crest growth plate; a fan-shaped part of the pelvis. The crest fuses with the pelvis at maturity. |
| Nash-Moe | This technique measures vertebral rotation. Rotation of the vertebral pedicle is measured by dividing the vertebral body into segments. |
| Lenke Classification | Doctors primarily use one of two classification schemes: King-Moe or Lenke. At our practice we usually use the Lenke Classification System. The System helps surgeons determine which spinal levels to instrument and fuse. |
Nonoperative Treatment
Some cases of AIS do not require spine surgery and are treated by observing the curve for progression and bracing.
Small curves (less than 15-20 degrees) are observed for possible progression over a period of time. At this stage, no specific treatment is needed. Larger curves (between 20-40 degrees) require bracing to prevent curve progression.
Some adolescents find wearing a brace 16- to 23-hours every day difficult. Braces can be uncomfortable, unattractive, hot, and make a youngster self-conscious, even though the brace is well-disguised beneath clothing. However, when bracing works and surgery is avoided, the required commitment is worthwhile. A carefully designed exercise program may be recommended.
Unfortunately, some curves do not respond to bracing. Cervicothoracic curves (from the middle of the back up into the neck) and curves greater than 40 degrees tend not to respond well to bracing. Also, older patients who are closer to skeletal maturity may not respond to bracing.
Surgical Treatment
Surgery may be recommended to treat curves greater than 40 degrees.
Scoliosis surgery usually involves spinal instrumentation (i.e. rods, screws) and fusion (bone graft). The goal of surgery is to realign and stabilize the spine. Instrumentation and fusion secure the spine to stop curve progression. Surgery does not cure scoliosis, but helps to correct and manage curve progression to avoid further deformity.
The surgeon may perform surgery through the front (anterior) or back (posterior) of the spine. There are different types of instrumentation, bone graft and graft products, procedures, and minimally invasive techniques.
Conclusion
Left untreated, adolescent idiopathic scoliosis can lead to significant physical deformity, debilitating pain, and psychological distress. However, proper AIS treatment can help prevent curve progression and stabilize the spine while your child grows. Your spine surgeon can discuss the risks and benefits of different treatment options with you, so that both you and your child are well informed.
References:
- Weinstein SL, Dolan LA, Cheng JC, Danielsson A, Morcuende JA. Adolescent idiopathic scoliosis. Lancet. 2008 May 3;371(9623):1527-37.