Scoliosis Research Institute :
Ronald Blackman M.D. (English version)
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Scoliosis is the medical term for curvature of the spine. This paper
deals primarily with the surgical treatment of scoliosis. Xray pictures
of scoliosis before and after treatment are shown. The thumbnail
pictures of scoliosis can be enlarged by clicking on them.
Scoliosis occurs in approximately
2% of women and less than 1/2% of men. It usually starts in the early
teens or pre-teens and may gradually progress as rapid growth occurs.
Once rapid growth (puberty) is over then mild curves often do not change
while severe curves nearly always progress.
There is a fine line between the
term scoliosis and a very mild curve in a normal spine. Curves are
measured in degrees. Persons with a curve of ten degrees or less are
often thought to have just an asymmetry of the spine - but in children
who end up with significant curves we have to consider that they started
with a straight spine so even a ten degree curve can progress to a fifty
degree curve and a significant deformity, if there is enough growing
time remaining. Persons with curves measuring under thirty degrees
entering adulthood are considered having a mild curve while those over
60 degrees are considered severe.
There are several different "warning signs" to look for to
help determine if you or someone you love has scoliosis. Should you
notice any one or more of these signs, you should schedule an exam with
- Shoulders are
different heights one shoulder blade is more prominent than the
- Head is not
centered directly above the pelvis
- Appearance of a
raised, prominent hip
- Rib cages are at
- Uneven waist
- Changes in look
or texture of skin overlying the spine (dimples, hairy patches, color
- Leaning of
entire body to one side
standard exam that is often used by pediatricians and in initial school
screenings is called the Adam's Forward Bend Test. Most schools test
children in the fifth or sixth grade, and the Adam's
Forward Bend Test can be administered easily by school nurses or
parent volunteers. For this test, the patient is asked to lean forward
with his or her feet together and bend 90 degrees at the waist. The
examiner can then easily view from this angle any asymmetry of the trunk
or any abnormal spinal curvatures. It should be noted that this is a
simple screening test that can detect potential problems, but cannot
determine accurately the exact severity of the deformity.
suspected, scoliosis is usually confirmed with an x-ray, spinal
radiograph, CT scan, MRI or bone scan of the spine. The curve is then
measured by the Cobb
Method and is discussed in terms of degrees. Generally speaking,
a curve is considered significant if it is greater than 25 to 30
degrees. Curves exceeding 45 to 50 degrees are considered severe and
often require more aggressive treatment.
following is a list of questions your physician/orthopaedic specialist
- At what age was the spinal
deformity first noted? This information is important in determining
the prognosis and severity of the scoliosis.
- Who first
noted the problem? Parent? Teacher? Physician?
- What is the patient's
prenatal history? Did the child experience any problems while still
in his or her mother's womb? Was there anything unusual about the
Did the patient meet normal
developmental milestones? Walking? Talking?
Is there a family history of
scoliosis or other spinal problems? You are 20 percent more likely
to develop scoliosis if someone in your family also has scoliosis.
Is the patient experiencing any
back pain? Generally speaking, scoliosis in children and adolescents
is not painful. If pain exists, further tests should be conducted for
tumors, herniated discs or other abnormalities.
The test for scoliosis screening is simple. Most parents are
capable of doing the screening test with a high degree of accuracy. The
standard test for scoliosis is termed the Adam's
Forward Bend Test. Kids are asked to bend over at the waist as
if they were touching their toes. The examiner gets their eyes level
with the back and looks for one side being higher than the other, or any
asymmetry of the back. Even parents with no medical training can detect
relatively small curves if they look carefully.
screening is so easy, then why do kids show up with large curves on
their first visits to the orthopedic surgeon? The simple answer is that
most of the kids at risk are at a stage of their development where they
have become modest, private people. It is surprisingly difficult to
detect scoliosis under the standard loose clothing that teenagers wear
currently. We encourage all parents to look at their adolescent
children's backs periodically during their growth spurts, in a setting
where they are comfortable. If you suspect scoliosis, then we would
recommend further evaluation by your physician.
evaluation by your physician will begin with a simple physical exam. If
scoliosis is suspected, it is confirmed by taking an x-ray. Make sure
that the x-ray that is taken is adequate for initial evaluation of
scoliosis. This should be an x-ray that includes the entire spine and
the top of the pelvis, taken in the standing position. Once the x-ray is
taken, it is important to ask your physician the following questions:
- Do I have
- What does my
- Can you tell if
I still have growth to go?
- Do I need to see
a specialist about this or is it safe to wait a while?
Questions about Scoliosis Screening:
I have to get undressed in front of other kids?
No. The examiner will need to look at your back. This does involve
pulling up your shirt from behind and bending over, but not completely
undressing. Most examiners will be sensitive to your modesty. Boys are
usually screened in a different location from girls for privacy reasons.
No. This is a painless test.
will I know if my test is "positive"?
If the examiner thinks that you have a curvature of the spine, he or she
will give you a form to take home to your parents. This form usually
includes a recommendation to see your doctor for a closer examination of
your back. The examiner will give you a form to take to your doctor for
him or her to sign and return to school to document that you had an
I have a "positive" test for school screening, does it mean
that I will have to wear a brace or have surgery?
Not necessarily. Only one-fourth of kids with a positive school
screening test end up needing treatment of any kind, so the news that
you get from your doctor is usually good. However, only your doctor can
make this determination. You should definitely not avoid your doctor
because you are fearful that you may require treatment.
The Online Self-Assessment Test
Cobb Diagnostic Test
The cobb method is used to measure the amount of curvature in the spine.
Lines are drawn parallel to the end plates of the vertebral bodies at
the beginning and the end of the curve. A second line is drawn
perpendicular to each of the first lines, and the angle between these
two lines is equal to the Cobb measurement.
is important to realize that the Cobb measurement is never exactly the
same each time the spine is x-rayed since the measurement is affected by
the position of the patient, the way the x-ray is taken, and the way the
lines are drawn. As a result, there is a standard measurement error of 3
to 5 degrees. Therefore, major treatment decisions should not be made
upon single measurements and small changes.
is an example of a right thoracic curve in a 14-year-old female
measuring 47 degrees by the Cobb Method.
Depend on the severity and the age of the person. We can, of course,
make up a long list of treatments; only a few have actually been shown
to affect the outcome of scoliosis. Numerous studies have failed to show
any benefit from exercise, manipulation, meditation or drugs. While
exercise is beneficial to maintaining good muscle tone and a healthier
heart and lungs, there is no evidence that it affects, one way or the
other, the curve progression. It may help in reducing discomfort.
1. Do nothing. The decision to do nothing may be a
reasonable decision depending on the age of the person and the predicted
outcome. If the person is a teen or pre-teen and the prediction is that
this curve will worsen then doing nothing may not be appropriate.
Increasing curves usually give an increase in the deformity. That is the
chest twists throwing the shoulder blade off in back causing a rib hump
and the chest in front rotates as well causing unevenness to the
breasts. At the same time the hips at the waist become more uneven. So
doing nothing in the teen years may be disastrous.
On the other hand, if the person
has reached maturity ( physical at least!) then if the curve is mild,
below forty degrees, it may not increase any more. So not doing anything
may be okay.
appropriate for small curves, curves that are at low risk of
progression, and those with a natural history that is favorable at the
completion of growth. These decisions are based on the expected natural
history of a given curve. For example, if your child is diagnosed with a
curve of 25 to 40 degrees and has completed growth (i.e., boys older
than 17, girls older than 15), then observation is appropriate.
Statistically, these curves are at low risk of progression and are not
likely to cause problems in adulthood. Follow-up x-ray once per year for
several years would then confirm that the curve is not progressing after
completion of growth. As an adult, an x-ray every five years, or if
there are symptoms, is sufficient.
14-year-old female presented from school screening with a 14-degree
right thoracic scoliosis. She had begun menstrual periods over a year
ago and was risser 3 in terms of skeletal maturity. The doctor's
recommendation was observation, since the likelihood that her curve
would progress was low.
is a three-year-old male with a complex pattern of congenital anomalies
of the spine, including multiple hemi-vertebra and a failure of
segmentation on the convex side of the curve. This curve has a
significant risk of further progression. However, no intervention was
recommended at this point.
2. Wear a brace. Bracing has been shown to be an
effective method to prevent curves from getting worse. From a practical
aspect though this treatment is reserved for children and adolescents in
whom the prediction of a rapid increase in the curve needs to be
thwarted. A brace worn 16 or more hours per day has been shown to be
effective in preventing 90% or more of the curves from getting worse.
Unfortunately, a brace worn 23 hours per day and worn properly does not
guarantee that the curve will not continue to increase. Still, in curves
that are mild i.e. between 20 and 35 degrees a brace may be quite
In adults, the curve may progress
slowly over the years, bracing is not a practical solution to prevent
curves from increasing. Mild curves under 30 degrees do not usually
progress; severe curves over 60 degrees usually progress and scoliosis
between 30 and 60 degrees may or may not progress.
It must be remembered that a
brace for a teenager is not an easy treatment. The brace is hot, hard,
uncomfortable, ugly and while it normally can't be seen under the
clothes definitely makes a teenager more selfconscious.
We tend to use a brace for 23
hours per day. Using it part time seems to create problems of when to
put it on, when to take it off, and for how long; whereas if it becomes
part of the routine it becomes a standard function. Additionally, logic
supported by data shows that the more the brace is on the better the
chance of maintaining correction.
NOTE HOWEVER THAT A BRACE USUALLY
DOES NOT CORRECT A CURVE. AT BEST IT WILL STOP IT FROM WORSENING.
There are numerous anecdotes from
many kinds of practitioners, including ourselves, who have seen curves
straighten both spontaneously and while using a brace. In medicine there
are always exceptions.
The inset shows such an exception
of a teenager in a brace for 18 months.
On the left is an X-ray of the person
before starting brace treatment.
On the right is the same person
18 months after wearing a brace
23 hours per day.
braces are used to prevent further spinal deformity in children with
curve magnitudes within the range of 25 to 40 degrees. If these children
already have curvatures of these magnitudes and still have a substantial
amount of skeletal growth left, then bracing is a viable option. It is
important to note, however, that the intent of bracing is to prevent
further deformity it is not to correct the existing curvature or to
make the curve disappear.
are several different types of braces used by adolescents with
scoliosis. The Milwaukee Brace is quite common and is used particularly
for high thoracic curves. The brace extends from the neck to the pelvis
and consists of a plastic pelvic girdle and a neck ring connected by
metal bars in the front and the back of the brace. Pressure pads push
against the patient's curve to prevent further deformity. The metal bars
help extend the length of the torso, and the neck ring keeps the head
centered over the pelvis.
types of braces include the TLSO (thoracic-lumbar-sacral orthosis)
braces. These braces are also called "low-profile" or
"underarm" braces. They are not as large or bulky as the
Milwaukee Brace, as the TLSO braces use plastic materials shaped to fit
the patient's body.
Boston Brace covers from below the breast to the beginning of the pelvic
area in the front and from below the scapulae to the tailbone in the
back. The brace's design forces the lumbar area to flex, which pushes in
the abdomen and flattens the posterior lumbar curve. Pressure pads are
also placed strategically along the curve.
bracing option is the Charleston Bending Brace. This brace is molded to
conform to the patient's body while he or she is bent against the curve
(towards the rounded-out portion of the curve). This brace is worn only
at night while the patient is sleeping, thus "overcorrecting"
the curve for eight hours per day.
studies support the use of bracing in adolescents with curves at risk of
progression, specialists disagree about what the appropriate indications
for bracing are, what the best type of brace is and how long the brace
should be worn. Nonetheless, according to several large bracing studies,
using a brace is successful in stopping curve progression in about 80
percent of children with scoliosis.
a short period of adjustment is normal for teenagers wearing braces for
scoliosis, many studies show that these young people live very normal
lives. They can participate in athletic functions and are able to easily
interact socially, regardless of which type of brace they wear.
is a 13-year-old female who presented with a 30 degree lumbar scoliosis.
She is skeletally immature, (Risser 0), and therefore at significant
risk of progression with growth. She was placed in a scoliosis brace and
demonstrates an in-brace correction of ~70 percent. Initial brace
correction should be 50 percent or greater.
3. SURGERY: For those persons who already have a
significant curve with a significant deformity surgery can reduce the
curve and significantly reduce the deformity. Usually surgery is
reserved for teen and pre-teens who already have a curve around 40
degrees or more. In our practice we tend to be more aggressive than many
in doing surgery around 40 degrees while there are many excellent
surgeons who defer to 45 or 50 degrees. In the adult age range the
reasons for doing surgery are less well defined but include an
increasing discomfort or pain in a curve that appears to have increased.
For many women the deformity in the hip line and the increasing
discomfort combine to make surgery a reasonable option. Many persons
note the increasing deformity in the chest coupled with an increase in
the rib hump. For those persons surgery can ( not always and certainly
not guaranteed) reduce the deformity and the discomfort or pain.
Surgery however is a big deal and
not to be undertaken lightly. We invariably use metal rods or screws to
help straighten and hold the spine in the corrected position.
There are three major types of
curves each with their own method of correction. However, what we do may
not be what someone else would do. Surgeons base their procedures on
many different factors including their experience with techniques and
The usual scoliosis curve is a
thoracic curve ( i.e. at the level of the chest.) In these curves the
procedure is a posterior spinal fusion. A fusion is a procedure where
the individual bones are made solid each to the one above and below.
Typically 10 or more segments are included. In order to first get as
much correction of the curve, multiple hooks or wires are attached to
the back of the individual vertebra and then these are connected to one
or two metal rods which have been pre-bent to the desired contour. The
correction is done and then little bits of bone are flaked off the back
of the vertebra so that when healing occurs the flakes of bone cross and
become solid. The metal rod hopefully holds the correction until it is
solid approximately in one year.
the curve before surgery
and after surgery with rods in place.
Click on picture to see an
Scoliosis is a three dimensional
problem. It is easy to think of the curves from looking at the back or
the front; but the side view also must be considered. Flattening of the
normal roundness to the side view of the back affects the general look
of the back and the person. One of the aims of surgery is to try to
restore the normal contour of the back from both the front view and the
in the roundness.
We have developed a technique to
assist us in getting a maximum of correction with a minimum of scar and
morbidity. We have developed the use of the endoscope to go into the
chest (similar to the way surgeons take out gallbladders now) in front
where the actual vertebra are and take out the discs in front thus
loosening up the spine so we can get better correction when we do the
fusion in back. This is called ENDOSCOPIC DISCECTOMY SURGERY. Placing
the arrow on this at the bottom of the page will give you a report on
this technique as presented to the North American Spine Society in 1995.
This method goes in through the
chest using three or four small incisions to reach the front of the
spine. Once inside the chest the spine is clearly visible and
"soft" tissues can be cleaned off exposing the spine. The
discs are easily seen and can be removed.
are four views of the spine
as seen through the endoscope.
The views are taken through the chest
Click on this to enlarge the picture.
ANTERIOR APPROACH: For those
curves which present more as a distortion of the waistline or hips going
in through the front of the abdomen can reach the vertebra and using
screws the spine can be exceedingly well corrected ( again not always
though). Going in through the front can often allow us to fuse fewer
vertebra and get better correction. So we "save a level" and
get better motion remaining and usually better correction than
The spine is actually in the
middle of the body and the larger weight bearing part of the vertebra is
in the front. To correct the curve by going in front,the incision is
across the chest in line with a rib and down the front of the abdomen
for a short distance. It sounds like a big approach ( and it is ) but
the actual incision is no longer than the one in back. The chest is
entered and the area of the curve is identified. The discs are removed
so that the curve becomes much more mobile and screws are then placed in
the vertebra and connected together with a metal rod. Bone graft is
placed in the space where the discs were so that later fusion between
each adjacent vertebra will occur.The screws are then compressed
together, shortening the distance on the outside of the curve and so
straightening the curve. Usually fusion occurs in a shorter time than
the posterior method and the number of vertebra fused are usually less.
was a teenager
with an increasing curve
out of balance. Note the
return of the center of gravity.
This is a side view or lateral view. It shows the bodies of the vertebra
with the screws and rod in place. Note the slight sway back which is
built into the correction.
And for those who have a double
curve then often a combination of any of the above may be needed. That
is, we may just go in from the back and fuse a long segment of the
curves or we may go in from the front and fuse the lower curve and
correct it and then fuse from the back or we may do all three
procedures, to try to get the maximum correction possible.
female was diagnosed with scoliosis at age 12. Despite bracing, her
curve progressed to 55 degrees. Surgery was chosen because her curve was
still at risk of further progression with growth and her long-term
natural history was unfavorable. Posterior spinal instrumentation and
fusion produced an excellent correction of her curve.
are different techniques and methods used today for scoliosis surgery.
The most frequently performed surgery for adolescent idiopathic
scoliosis involves posterior
with instrumentation and bone
grafting. This kind of surgery is performed through the patient's
back while the patient lies on his or her stomach. Two common
instrumentation techniques are called Cotrel-Dubousset (CD)
instrumentation (rod rotation technique) and COLORADO instrumentation
(translation technique). During these types of surgery, the surgeon
attaches a metal rod to each side of the patient's spine by using hooks
attached to the vertebral bodies. Then, the surgeon fuses the spine with
a piece of bone from the patient's hip (a bone graft). The bone grows in
between the vertebrae and holds them together and straight. This process
is called spinal fusion. The metal rods attached to the spine ensure
that the backbone remains straight while the spinal fusion takes place.
operation usually takes several hours. With recent advances in
technology, most people with idiopathic scoliosis are released within a
week of surgery and do not require post-operative bracing. Most patients
are able to return to school or work in two to four weeks after the
surgery and are able to resume all pre-operative activities within four
to six months.
surgery option for scoliosis is an anterior
approach, which means that the surgery is conducted through the chest
walls instead of entering through the patient's back. The patient lies
on his or her side during the surgery. During this procedure, the
surgeon makes incisions in the patient's side, deflates the lung and
removes a rib in order to reach the spine. This approach allows the
surgeon to operate higher up in the spine than through posterior
approaches, and studies have shown favorable results with this type of
surgery. Video-assisted thoracoscopic surgery allows surgeons to enhance
their vision of the spine and to conduct a less invasive surgery than
with an open procedure. The anterior spinal approach has several
advantages: better cosmetic results, quicker patient rehabilitation,
improved spine mobilization, and fusion of fewer segments. Most patients
require bracing for several months after this surgery.
My doctor told me not to worry
about my scoliosis. What should I do?
If you are concerned about the
diagnosis given to you, you should feel free to seek a second opinion.
Can you tell me what is the best
treatment for Scoliosis?
The treatment prescribed for
scoliosis, kyphosis or lordosis varies with the individual patient.
Severity and location of the curve, age, potential for further growth
and general health of the patient all must be taken into account. A mild
curvature (up to 20 degrees) generally needs only periodic observation
to watch for signs of further progression. Bracing is the usual
treatment for children and adolescent with curves of 25-40 degrees, and
in other special circumstances.
I have a mild scoliosis
curvature. Should I be concerned?
Four out of five people with
scoliosis have curves of less than 20 degrees. Such curves are usually
unnoticable to the untrained eye and are no cause for concern, provided
they show no sign of further progression. However, in growing children
and adolescents, mild curvatures can worsen quite rapidly (10 degrees or
more in a few months ). Therefore, for this age group, frequent checkups
by a primary care physician or orthopedist is well advised.
Will you please send me a
description of exercises to help my scoliosis?
Orthopedists tell us that
exercise alone will not prevent a curvature from progressing. Exercises
are prescribed in conjunction with brace treatment to maintain muscle
tone while the torso is immobilized by the brace. These exercises are
prescribed individually according to the age of the patient and the
location and degree of the curvature.
Do you think a chiropractor could
help my scoliosis?
Moderate and major curvatures:
We do not know of any long-term study which shows that chiropractic
treatment can stop a moderate (over 25 degrees) or major curve (over 40
degrees) from progressing in the bone growing years. It has been our
experience that chiropractors who are knowledgeable about the
development of idiopathic scoliosis in children will refer young
patients with such curvatures to an orthopedist for a second opinion.
It is still not clear whether spinal manipulation is effective in
controling minor curves (under 20 degrees). Chiropractors do tell us
that they have had success but they have not sent us controlled research
data to support these claims. On the other hand, the data collected by
orthopedists shows that without any form of treatment, 4 out of 5 minor
curvatures will not progress beyond 20 degrees. For this reason,
orthopedists no longer treat such minor curvatures but they do recommend
periodic observation, especially in growing children.
Will scoliosis affect my ability
to have children?
According to a recent study,
pregnancy and delivery are rarely affected by scoliosis. Pregnant women
are no more prone to progression than non-pregnant women. Any adult,
male or female, with an untreated major curvature may experience a
progression after skeletal maturity. The tendency to develop idiopathic
scoliosis is inherited, so children of a scoliotic parent may be at
greater risk than the general population. Early detection and treatment,
however, should prevent problems.
When I was younger my scoliosis
didn't bother me. Now, I am having pain. What should I do?
If you are in pain or suspect a
possible progression of your scoliosis curvature, a professional opinion
should be obtained.
I have enclosed all the
particulars concerning my scoliosis condition. What do you think would
be the best treatment for me?
As lay persons, we are not in the
postion to give medical opinions. Each individual case of scoliosis,
like fingerprints, is different. Your physician or orthopedic spine
specialist is the person to consult.
I am preparing a science project
on scoliosis and would like to recieve information. Can you send me
x-rays and braces to illustrate my report?
We are pleased about interest in
scoliosis and hope our material will be of assistance. You are in the
position to educate many people around you and, of course, this is one
of our goals. We do not have braces or x-rays available. Our
publication, "Resources Available for Patients and Parents",
should lead you to further sources of information.
How can I get in touch others who
are dealing with spinal curvatures
The Foundation maintains lists of
support groups and pen pal services. Please call or write to request
Due to scoliosis I lost my job
and my insurance. Now I realize treatment is available for adults. Where
can I find funds?
There may be funds available
through Medicare or the Social Security Administration if you qualify.
We are not aware of other help available.
Can the National Scoliosis help
me with my medical expenses?
The National Scoliosis Foundation
raises money for educational purposes and materials to assist postural
screening programs in grades five through ten. We don't have funds
availible for patient expenses. For information on free medical care for
children 18 and under, call the Shriner's Hospital toll free at (800)
I have been told that there are
college scholarships available for scoliosis patients. Whom do I contact
The National Scoliosis Foundation
does not have funds or knowledge about such scholarships.