Adolescent Idiopathic Scoliosis

• The spine or backbone is made up of 24 individual bones called vertebrae that are separated by discs (cushions). These disc act like shock absorbers and make the spine flexible.
• There are 4 regions of the spine
• Cervical (neck) - seven vertebrae,
• Thoracic (chest) - 12 vertebrae
• Lumbar (low back) - 5 vertebrae
• Sacrum (tail bone) - 5 fused vertebra below the mobile lumbar spine.
• The spinal cord is the main nerve that connects your brain with the rest of your body. The spinal cord is protected inside the spinal column. Smaller nerves project out of the spinal cord and exit out of the spinal column through spaces between each vertebrae.

• The spine is as straight as an arrow when seen from the front or the back.
• Scoliosis is a sideways curvature of the spine, either to the right or left.
• About 10% of normal population can have very small curves (<10 degrees). These have no negative effects on health or function.
• Scoliosis is defined as a curve greater than ten degrees.
• The most common curve pattern is a right thoracic curve.

• Scoliosis can result from a number of underlying conditions.
• The most common form is called "idiopathic", which means "unknown cause."
• Scientists have found some genes that occur more frequently in idiopathic scoliosis. Whether these genes directly cause scoliosis is unknown. As scientist gather more information, it is becoming clearer that idiopathic scoliosis has some genetic basis.

• No, it does not!

• Idiopathic scoliosis is categorized by the age at which it begins of develop.
• Each category has a unique treatment and challenges associated with its treatment.
• Types
• Infantile (0-3 y)
• Juvenile (4-10y)
• Adolescent (>10y)

• Idiopathic scoliosis is thought to be present in 2-3 percent of adolescents.
• However, only 1 in 500 of these will require active treatment
• Only 1 in 5000 have curves that progress to the degree where surgery is recommended.
• Girls and boys are equally affected by small degrees of scoliosis.
• Girls, however, are 8x times more likely than boys to develop progressive curves.

There are a number of things that one might notice:

• One shoulder higher than the other
• One shoulder blade (scapula) more prominent
• One hip higher than the other
• One leg appears longer
• Asymmetry of the waist
• Trunk and ribcage shifted to one side
• Head not centered over middle of hips
• Clothing hangs unevenly & when child bends forward at the waist, one side appears higher

Some of these signs of scoliosis may be very hard to see, especially to the untrained observer.

• Parents
• Child her/himself
• Family members
• Pediatrician
• Family Doctor
• Incidentally on Xrays done for other purpose.

• It is not uncommon for someone other than a parent or a child to notice scoliosis.
• Changes to the body occur rapidly during pre-adolescence and adolescence.
• Children typically become more private about their bodies, so parents often don’t see their children in situations where it is easily noticed.
• The early changes in body shape that result from scoliosis may be subtle, and there may be little outward deformity despite a significant curve.
• In addition, scoliosis is not a typically painful condition so patients may not notice they have it.

• In USA, some states mandate that all children in public schools are screened for scoliosis.
• India does not have a school screening program.

• When there is concern for scoliosis, the first step is an evaluation by one’s doctor. He or she will do a complete exam and might refer you to a specialist with expertise in scoliosis.
• And X-ray is required to confirm the suspicion of scoliosis.
• Ideally, the X-ray should be done at a hospital that routinely treats scoliosis. X-rays for scoliosis are always done in the standing position. The entire spine must be visible on a single photographs. Multiple X-rays of different regions of the spine on separate films are not useful.
• MRIs and CT scans should not be done unless request by a spine specialist who is going to treat your child's scoliosis.

• Scoliosis either looks like a C-shaped curve (singe curve) or an S-shaped curve (double curve) on an Xray.
• The curve can develop in the upper thoracic spine, middle thoracic spine, or in the lumbar spine.
• The direction of the curve can be to the right or left.

• The size of the curve is measured on an X-ray in degrees.
• This measurement is called the Cobb angle.

• The spine specialist may ask for an MRI if the curve pattern is unusual or if s/he suspects spinal cord anomalies
• Some might require MRI before planning surgery.

• We cannot say with certainty how a particular curve will behave.
• However, we can estimate the risk of progression by looking at number of factors.
• The greatest risk for progression is at the time of puberty or the adolescent growth spurt.
• Larger curves tends to be progressive.
• Therefore, current size and the amount of growth remaining are used to predict risk of curve progression.

• Scoliosis can be treated non-operatively or operatively, depending on how large the curve is and how much growth is remaining.
• Nonoperative options include observation, which means a scoliosis specialist will periodically check the curve for progression. In addition, your child may or may not be asked to wear a brace.
• Operative treatment (surgery) may be considered if the curve is significant and will likely continue to progress after growth is finished.

• Observation means that the patient will be regularly checked by the scoliosis specialist, who will perform an exam and take x-rays every four to twelve months.
• The frequency of visits is based on your child's stage of growth.

There are a few different scenarios for curves in the 20-40 degree range:

1. If the curve is less than 40 degree and the growth of your child is finished (no change in serial height measurements), then there is little risk for the curve to continue progress in adulthood. So the doctor may not recommend any treatment.
2. If the curve is less then 40-45 degree, but the child is still growing, bracing may be considered.