A Review of Idiopathic Scoliosis
Bambery, 2020
Abstract
Idiopathic scoliosis is long-term, potentially debilitating, spinal deformity. There is no known cure for this condition, however, there are a variety of ways that it can be managed. Diagnoses and treatments vary from case to case and physician to physician. Idiopathic scoliosis is highly unique to each patient, as is the treatment which is custom-tailored for them. In this paper, I will be presenting research on the prevalence of idiopathic scoliosis. Included will be discussion and facts of the anatomy of the disorder, prevalence, treatments, and the effects that it has on the patients.
Etiology
The term “scoliosis” is often heard in elementary schools and pediatrician offices as they frequently screen for the condition. The simplest definition of scoliosis is a curvature of the spine. Like most medical conditions though, scoliosis has a variety of different classifications. A lesser-known component of scoliosis, and other spinal disorders, is that “the spine may also rotate or twist, pulling the ribs along with it to form a multidimensional curve” (Idiopathic Scoliosis: Boston Children’s Hospital 2020). This curvature is unique to every patient and impacts the treatment plan.
The three recognized types of scoliosis are congenital, neuromuscular, and idiopathic. Congenital is the least common type and develops in-utero when the vertebrae of the child fail to form correctly. Neuromuscular scoliosis is a side effect of other musculoskeletal disorders. When these disorders, such as spina bifida and cerebral palsy, weaken the back muscles the spine may be impacted by a lack of muscular support holding its natural shape. The most common type of scoliosis, and the type I am focusing on, is idiopathic scoliosis. This type of scoliosis has no known cause, but genetic patterns are present. There is also no indication that any environmental factors have a significant impact on the presence or severity of scoliosis (Idiopathic Scoliosis: Boston Children’s Hospital 2020).
Prevalence
While scoliosis is considered a common medical condition, it only affects 2-3% of the population or approximately 7 million individuals in the US. Scoliosis can affect people at all stages of life, but most diagnoses are given between 10-15 years of age (National Scoliosis Foundation Early detection). Scoliosis does not discriminate across race and gender, but “girls are eight times more likely than boys to have a curve that will progress to a magnitude that requires treatment” (NSF Early detection). The medical and scientific community continues to research the causes of idiopathic scoliosis and risk factors. Boston Children’s Hospital is a leader in the research and treatment of the condition.
Anatomy of the Disorder
When scoliosis is a significant impediment in one’s life, it is covered under Social Security Disability benefits. This means that if the sufferer’s ability to work is impacted due to their scoliosis, they are eligible to receive benefits for it. When these criteria are met, the condition is considered a disability, at least on legal paper (Social Security Disability Advocates 2020). Whether or not a person identifies their scoliosis as a disability is dependent on their own experience and where on the scoliosis spectrum they fall.
According to Johns Hopkins Medical “The spine is made up of a stack of rectangular-shaped building blocks called vertebrae. When viewed from behind, the spine normally appears straight. However, a spine affected by scoliosis is curved — often appearing like an S or C — with a rotation of the vertebrae. This curvature gives the appearance that the person is leaning to one side” (Johns Hopkins 2020). Severe cases of scoliosis can be noticeable to the naked eye if the sufferer has uneven shoulder height, off-center head placement, and/or uneven hip height which can also cause one leg to appear longer than the other (Johns Hopkins 2020). While the main hallmark of scoliosis is a curvature of the spine >10⁰, there is a variety of other complications that arise due to having scoliosis. According to the Boston Children’s Hospital Orthopedic Center & Spine Division, related complications to scoliosis include thoracic hypokyphosis, lordosis, and vertebral rotation. Thoracic hypokyphosis frequently accompanies idiopathic scoliosis and is a condition where the thoracic spinal region does not maintain the proper curvature perpendicular to the scoliosis curvature. This can look like a reverse hunch in a sufferer. Lordosis is a similar condition that occurs in the lumbar and cervical spine. This will appear as a convexity towards the anterior of the body and is normal to a certain extent but can become problematic at extreme degrees. Vertebral rotation is also common with scoliosis and is defined as a rotation, either clockwise or counterclockwise, of the individual vertebrae. This can often appear as a prominence(s) of the rib cage, which is affected by the rotation (Idiopathic Scoliosis: Boston Children’s Hospital 2020).
Diagnostics
There are a variety of ways to diagnose scoliosis. Two commonly used methods are the Scoliometer and the Adam’s forward bend test. The Scoliometer is an inclinometer that measures rib prominence for angles of concavity and convexity to detect vertebral rotation in the spine (The Scoliosis Authority, 2018). The Adam’s bend test is performed when “the patient takes off his/her t-shirt so that the spine is visible. The patient needs to bend forward, starting at the waist until the back comes in the horizontal plane, with the feet together, arms hanging, and the knees in extension. The palms are held together. The examiner stands at the back of the patient and looks along the horizontal plane of the spine, searching for abnormalities of the spinal curve, like increased or decreased lordosis/ kyphosis, and an asymmetry of the trunk” (Physiopedia – UK, 2020). The Department of Physical Medicine and Rehabilitation at the University of Saskatchewan in Saskatoon, Canada researched the efficacy of both screening methods. They found that “the Scoliometer and Adam’s forward bend tests have adequate interexaminer reliability for the assessment of thoracic curves . . . Because Adam’s forward bend test is more sensitive than the Scoliometer, the authors believe that it remains the best noninvasive clinical test to evaluate scoliosis” (Côté et al 1998, p 802).
The specific degree of spinal curvatures is identified with more precise tests. Frequently, the orthopedic provider will order x-ray imagining of the patient’s spine. This imaging allows them to measure the degrees of curvature. This measurement is colloquially referred to as the Cobb angle and is checked many times throughout treatment to determine any progression, or correction, in the patient’s condition (Baaj, A. 2018).
Another relevant piece of information to obtain from the patient is their bone age or skeletal maturity level. Skeletal maturity is predicted by the amount of bone ossification present on the iliac crest (Jelcick A. 2020). This information is classified using the Risser sign, or scale. “A Risser scale of 0 corresponds to an immature skeleton of someone with a lot of growing left to do, and no ossification is observed along the ilium. As they go through puberty, new bone is laid down until they reach Risser 5, at which point all new bone has fused to the ilium and now appears as one solid bone” (Jelcick A 2020). Knowing the skeletal maturity of a scoliosis patient helps the orthopedic team determine the appropriate treatment. Since interventions vary depending on the amount of growth the patient has left, the Risser scale is significant to the prediction of growth and prognosis.
Treatment of the disorder
Idiopathic scoliosis is treated in ways unique to the patient, and to their physiology. These treatments “involve physiotherapy, corrective braces, and surgical procedures. The value of conservative therapy is disputable; however, the effectiveness of braces in reducing the rate of progression of scoliosis has been confirmed” (Goodall, D., & Weiss, H.-R. 2009). Physiotherapy is used independently or in combination with bracing and surgical procedures. In recent years, physiotherapy has become more intensive and concentrated with positive results (Baaj, 2018). A former Children’s Hospital Patient receiving such treatment commented that “the physiotherapy focuses on isolating and strengthening body muscles to support the spine. Other types of physiotherapy help improve flexibility and the ability to adapt to the brace.” The anonymous patient comments that she has been using a combination of bracing and physiotherapy to achieve positive results.
Bracing has always been a key aspect of scoliosis treatment and a study conducted in 2013 further proved its efficacy in reducing the need for invasive surgery (US Department of Health and Human Services 2013). There are different types of braces for scoliosis and the specialist determines which is most appropriate for the patient. A brace is an orthotic that is worn around the upper body of the patient and provides support and pressure on different areas of the abdomen to hold the spine in a corrected position. Braces have padding in specific areas to push against spinal curvatures, and to de-rotate the vertebrae. Generally, the more significant the curve, the longer the patient will be in the brace. Bracing is usually applied during periods of rapid growth in an effort to correct the spine (Scoliosis Bracing: Boston Children’s Hospital 2020).
Spinal surgery is used only for the most severe cases of scoliosis that are otherwise untreatable. The American Academy of Orthopedic Surgeons, AAOS, says that “The basic idea is to fuse together two or more vertebrae so that they heal into a single, solid bone. This is done to eliminate painful motion or to restore stability to the spine” (AAOS). Generally, the lumbar and cervical vertebrae are where the actual fusion occurs. There are anterior, posterior, and lateral approaches for accessing the spine from different angles. Some minimally invasive procedures have also been developed that allow the surgery to take place through smaller incisions. The type of surgery required is determined by the surgeon based on the degree of curvature (AAOS). To hold the spine in a corrected position, the surgeon will use a bone graft placed between the vertebrae to encourage healing into a solidified, corrected position. Surgeons might also use a combination of plates and screws to secure the graft into the spine and maintain proper positioning. Bone grafts can be obtained from the patient’s pelvic bone or an outside source (AAOS). These sources include demineralized bone materials where the calcium is removed from cadaver bone to make it malleable and combine with other grafts, bone morphogenetic proteins which is a synthetic bone-forming protein that supports solid fusions, and synthetic bone which is created from calcium/phosphate and is similar to natural bone (AAOS). Complications that can occur post-surgery are infection, bleeding, pain at the graft site, recurring symptoms, pseudarthrosis, nerve damage, and/or blood clots.
Post-surgical recovery and rehabilitation can look different for each patient. Pain management drugs may be prescribed by the physician, as well as wearing a brace for stability. While patients may experience reduced mobility in their spine, they should be able to continue most of the activities they enjoyed pre-surgery (AAOS). The rehabilitation process can involve physical therapy which “is typically started from 6 weeks to 3 months after surgery. [The] surgeon will talk with [the patient] about whether physical therapy is needed in [their] situation” (AAOS-Rehabilitation). Also, during rehabilitation, patients learn how to adapt their activities of daily living to keep the spine in place (AAOS-Rehabilitation).
Challenges of Scoliosis
If left untreated, scoliosis can have a range of negative effects on the patient. “Pulmonary symptoms such as shortness of breath, not leading to premature death, may be associated with idiopathic scoliosis. These curves are usually larger, greater than 80° Cobb, or with increased rotation, and usually single thoracic curves. Large double curves may also be associated with shortness of breath” (Asher et al 2006). The National Scoliosis Foundation warns that “Scoliosis, when left untreated, can get worse and may cause chronic back pain, impact heart and lung function and take a toll on self-esteem” (NSF).
There can also be a range of social and emotional consequences related to scoliosis and treatment. The orthotics used to prevent curvature progression are often bulky and uncomfortable. One anonymous scoliosis patient reported that she wore the Original Boston Brace from her freshman through sophomore years of high school. She described the brace as squeezing her lower abdomen so tight that her pelvic area seemed to bulge out, despite her being underweight. She experienced a similar issue with the top half of her body and said that the brace made it painful to wear undergarments and made one of her breasts appear much larger than the other. Being in high school during this time was difficult for her as teenagers are already predisposed to body image issues. She said that she tried to wear bulky clothes to hide the brace, but this was difficult during the hotter months of the year, though she did not report any overheating due to her brace.
This patient’s experience helps highlight some of the social and emotional issues that brace users can experience, especially during the already tumultuous time of adolescence. Similar to the brace causing discomfort and visible effects, scoliosis itself can affect body image and self-esteem. Different forms of scoliosis treatment also seemed to affect the stress levels of patients. Having to wear a brace itself, more so than having the actual condition, caused higher levels of stress in adolescents with scoliosis (Leszczewska 2012).
Conclusion
To summarize, idiopathic scoliosis is a health condition that affects the patient on a variety of levels. The various types of treatments are used to provide a flexible way to manage the condition and prevent it from severely impacting the patient’s life. Research on idiopathic scoliosis, its causes, and innovative forms of treatment is ongoing. Thanks to the dedication of countless doctors, researchers, and patients, scoliosis is a far less intimidating diagnosis than it used to be. Patients can go on and live fulfilling lives which is the goal of any medical treatment. Harvard Medical School and Boston Children’s Hospital are among the leading experts in the world when it comes to scoliosis research and treatment. Their websites and publications are of great help and further reading on idiopathic scoliosis.
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