Scoliosis

Abnormal curvature of the spine in the coronal plane (>10°).

Background/epidemiology

• Scoliosis <10° is not abnormal (considered a normal variation)
  • Around half of patients with AIS (adolescent idiopathic scoliosis- most common form) develop a curvature >70°
• It is estimated to affect 2-3% of the population; 80% is idiopathic
• The most common type is adolescent idiopathic scoliosis (affects between 0.5 and 3% of people, most commonly between the ages 12-14, and, in IAS, is much more common in females (90%)
  • Other common types include
    • Juvenile idiopathic scoliosis (aged between 3 and 10; more common in females; likely to progress/require surgery due to curvature presenting prior to growth spurt at puberty)
    • Infantile idiopathic scoliosis (< age 3; more common in males)
    • Congenital idiopathic scoliosis
    • Neuromuscular and Pathologic Scoliosis (Secondary conditions)
• In older children, curvature is usually to the right.  In infants, left sided curvature is more common.
• As curvature progresses, vertebral bodies rotate towards convexity and spinous processes away from convexity.  In severe cases, this can impair cardiorespiratory function.

Presentation

• May be asymptomatic and detected by chance- note that screening is not routinely offered in the UK (some patients also have a family history)
• Usually present with back (thoracic) pain
• On examination (see back examination)
  • Shoulders/waistline may not be level and/or ribs/scapulae may be more prominent in certain areas
  • Note that the hip usually protrudes on the concave side
  • Adam’s Test
    • Ask the patient to bend forward- a fixed scoliosis becomes more prominent
  • It is important also to look for leg length inequality; any focal neurology (change in reflexes) or any signs of congenital/hereditary conditions e.g. midline skin defects, cafe au lait spots.

Investigations

• XR spine
  • Calculating the Cobb angle (between the uppermost and lowermost vertebra of the primary curvature seen on erect AP XR) is important in deciding management/prognosis

Management

• Exercises
  • Back exercises have very little effect on curvature but can maintain mobility/range of movement and may improve pain
• Bracing
  • Used mainly for curvatures between 20° and 40°, which are well balanced (i.e. have a compensatory secondary curve), and in patients who are growing (in puberty) in which a brace may halt the progression and occasionally improve the deformity
  • Usually not definitive- used mainly to maintain curvature stability in younger patients until adolescence when operative management may be more suitable
• Surgery
  • Spinal fixation (posterior spinal fusion most common) can be used in patients with a curvature of >40°
    • rare but carries risk of neurological complications