Adolescent idiopathic scoliosis
What is adolescent idiopathic scoliosis?
The word “idiopathic” means that the cause of this form of scoliosis is unknown. Adolescent idiopathic scoliosis affects children between 10 and 18 years old. This form of scoliosis affects girls more than boys. In fact, girls are treated 10 times more often than boys.
What causes adolescent idiopathic scoliosis?
There are many theories as to why this type of scoliosis develops, but the root of the condition has yet to be discovered. Some of the theories include:
- Genetics: Scoliosis appears to run in certain families, so it may be hereditary.
- Growth: Curves progress rapidly during growth spurts, perhaps showing a tie to hormonal causes.
- Structural and biomechanical changes: Some studies have shown increased muscular activity around the spinal curves. Differences in leg lengths have also been noted in adolescents with idiopathic scoliosis. But there is no clear evidence that this type of change causes scoliosis; it may simply be a secondary result.
- Central nervous system changes: Because some forms of scoliosis are associated with central nervous system disorders, a lot of research has been focused on this topic. But so far such disorders have not been proven as the root of idiopathic scoliosis.
- Equilibrium and Postural Mechanisms: Idiopathic scoliosis could be related to factors that affect body alignment. If a child has problems with posture, balance, and body symmetry, it could affect the way the spine is positioned. If the problems are chronic, it may disrupt the way the spine and muscles develop.
In many cases of adolescent scoliosis, the child will not even notice the problem. Because the majority of scoliosis patients do not suffer any physical pain from this disorder, it is often not discovered until the curves have progressed to become more obvious. In fact, if the child is suffering from severe back pain, a diagnosis other than idiopathic scoliosis must be considered.
Though the spine may curve sideways, in minor cases the curves are not obvious until the person bends over. Many schools currently screen young students for scoliosis, so referrals often come from school health workers. Parents or physical education instructors are also frequently the first to notice signs of scoliosis in a child. Signs of scoliosis may include the following abnormalities in appearance:
- One shoulder or hip may be higher than the other.
- One shoulder blade may be higher and stick out farther than the other.
- These deformities are more noticeable when bending over.
- A "rib hump" may occur, which is a hump on the back that sticks up when bending the spine forward. This occurs because the spine and ribs also rotate as the curve develops.
- One arm hangs longer than the other because of a tilt in the upper body.
The waist may appear asymmetric.
If the patient's curve is minor (less than 15-20 degrees), the doctor will likely choose to monitor the curve for progression. The patient will normally have X-rays taken every four to six months during rapid growth years, and then once a year.
Physical therapy and exercise
Adolescents with scoliosis may work with a physical therapist. A well-rounded rehabilitation program assists in calming pain and inflammation, improving mobility and strength, and helping with daily activities. Adolescents with idiopathic scoliosis should be encouraged to continue their normal activities, including sports.
Bracing is usually considered with curves between 25 and 40 degrees—particularly if the patient is still growing and the curve is likely to get bigger. It is important that the patient wear the brace daily for the number of hours prescribed by the doctor. Scoliosis often affects more than one area of the spine. A brace can be used to support all the curved areas that need to be protected from progression.
Surgery is generally only considered in patients who have continual pain, difficulty breathing, significant disfigurement, or a steadily worsening curve angle. After skeletal maturity occurs, curves that are less than 30 degrees tend not to progress and, therefore, do not require surgery. Curves above 100 degrees are rare, but they can be life threatening if the spine twists the body to the point it puts pressure on the heart and lungs. If a curve is 45 degrees or more, surgery is more likely to be considered. The main surgery for scoliosis is spinal fusion with instrumentation. Nearly all surgeries will use some type of rods in order to help straighten the spine.
The surgeon may use a posterior approach, which involves going into the spine through the back, or an anterior approach, which is performed from the front or side. The operation can be performed from both the front and the back (a combined approach). The choice depends upon the flexibility of the spine, the location and degree of the curve, and whether there is pressure on any of the nerve roots. The age of the patient is a factor in deciding which type of surgery is used. Patients whose spines are immature are more likely to require combined anterior and posterior fusion.
An incision is made in the chest or flank, and the intervertebral discs are removed in the area of the curve to make it flexible. Screws can be placed in the vertebrae, and then connected by a metal rod. A bone graft is put in place of the discs that were removed so that the vertebra sitting next to each other will fuse together. The screws attaching the metal rod are tightened down, straightening the curve.
This approach is done through the back. Anchors are attached to the spine in the form of hooks, screws, or wires. These anchors are attached to spinal rods that straighten the spine. Bone grafting is done to fuse all instrumented vertebrae.
Combined Anterior/Posterior Approach
This surgery is actually two operations-one through the front, and the other through the back. The two operations may be staged on separate days or as part of one longer surgery. Staged procedures require one to two additional days in the hospital compared to a single surgical procedure.