Scoliosis- Adolescent Idiopathic Scoliosis

Scoliosis is a condition that refers to the sideways curving of the spine. There are several types of scoliosis and it can occur throughout childhood. Congenital, neuromuscular and adolescent idiopathic scoliosis are the broad categories. The most common type of scoliosis is adolescent idiopathic scoliosis.

What is the spine in the first place? The spine is the collective term for a group of bones that connect your head to your pelvis. Each bone is called a vertebra. Depending on the site of these vertebrae they are grouped into named regions. It is made up of four such regions. A. Cervical (7 neck bones), B. Thoracic (12 Chest bones) C. Lumbar (5 low back) and D. Sacrum/coccyx.

The spine is naturally curved front to back when looked at from the side. Two curves are C shaped (cervical and lumbar) and these are joined by a reverse c shaped curve at the thoracic area and sacrum. These balanced curves allow us to stand up straight and walk. If any of these curves become too big or too small then our spine balance is disrupted and we look for ways to compensate. Example of this are “hunchback” when the thoracic kyphosis is too great or sway back when the lumbar lordosis is too great.

When the spine is viewed from the back it should be straight.

Vertebrae: These bones perform important functions they are made up of a number of parts but the important components are the vertebral body at the front and the vertebral canal at the back which transports the spinal cord from the brain to the lumbar area.

Discs: The bones are separated by shock absorbers. These are known as intervertebral discs. The disc itself has two parts a strong outer layer (annulus fibrosis) and a jelly like middle (nucleus pulposus). This allows for freedom of movement but keeps the spine strong.

What is Scoliosis? In a person with scoliosis the vertebrae instead of being straight are rotated or twisted. This can give the appearance of a C or S shape of the patient’s spine when viewed from behind.

Often, the curve is noticed as the child goes through a large growth spurt as this tends to increase the rotation of the vertebrae and progression can be rapid.

Adolescent Idiopathic Scoliosis (AIS) - what is it? AIS can occur at any stage of the adolescent period. It commonly manifests from age 10 onwards. It is often a small curve that is unnoticed by both child and parent but may be picked up incidentally during medical examinations or on x- rays take for chest infections/abdominal pain. Both males and females can be affected but in AIS girls are more likely to develop a curve that requires medical intervention

There has been no absolutely definitive cause for AIS identified to date despite much research into the area. Genetics plays some role in the process with data from some large research groups based in the United States of America demonstrating a 30% family history of scoliosis in patients with AIS.

What to look out for: Small curves are unnoticeable. Curves can occur in any part of the spine but the thoracic spine – where the ribcage sits - is the most common site. The most frequent physical findings are:

Uneven shoulders heights Uneven shoulder blades Uneven pelvis-waistline Uneven hips Prominent ribs on one side over the other

What to expect from a doctors visit? Please bring shorts to the doctors visit. Girls should wear a bra/bikini top to ensure modesty is maintained while allowing the doctor see as much of the back as possible. Long hair should be tied up.

The examination will be an in depth analysis of the child from head to toe. The first component of the examination is to look for subtle signs on the skin that may hint to the doctor that there is an underlying cause of the scoliosis and that it may not just be a AIS. The spine mobility will then be tested. A special test called the Adams forward bend test is used to unmask a subtle curve. A full examination of the nerves, leg length discrepancy etc will be carried out.

X-rays: X-rays allow for measurement of the curve size and help to guide treatment. Interestingly scoliosis diagnosis is only made on x-ray when the curve is greater than 10 degrees in size.

Treatment: The treatment for scoliosis and specifically AIS is always in a state of flux. There are many issues to be considered when making a treatment plan with the patient/family being at the center and the orthopaedic doctor providing information and making recommendations.

Variables consist of the location of the curve, the size of it, the age and growth potential of the patient. Depending on the outcome of all of the above considerations there are essentially three ways to manage the scoliosis 1- Surveillance or observation - watch and wait 2- Use a brace 3- Surgery

Surveillance: Most curves do not require any form of treatment other than serial examination and x-rays through the growth period. Once fully grown this will cease and life continues as normal with no further input for the scoliosis

Brace: There is some evidence that brace treatment can be of some benefit to a particular subgroup of scoliosis curves. It may help decrease the severity of a curve and may eliminate the need for surgery in this group. However, the use of braces has multiple forms and each has to be individually discussed with your surgeon

Surgery: Surgery is generally recommended for those patients with a curve greater than 50 degrees or if the spine is significantly unbalanced (i.e. head is no longer situated over the pelvis) The aim of surgery is to prevent the curve from getting worse by performing a spine fusion. Correction of part of the curve is a secondary goal and happens as a consequence of the fusion procedure.

Surgical Risks:

Bleeding: During surgery some patients can lose enough blood to require a blood transfusion.

Infection: a deep infection after spine surgery is a rare event but when it does occur is a significant burden to the patient. It can require multiple operations and months of antibiotics to control the infection

Pseudarthrosis: if the spine fusion does not occur fully an area of non-healing can occur. This can become painful and may lead to the rods breaking.

Nerve injury: it is possible to injury nerves and spinal cord during this operation. During the operation special monitoring of nerve function takes place to minimize the risk.

Blood clots: after any surgery there is a risk of blood clots forming. These can travel to the lungs and cause difficulty with oxygen getting into the blood. This is a rare complication but early movement and hydration is encouraged to minimize the risk.