Idiopathic Scoliosis

Idiopathic scoliosis is considered in three age groups: Infantile--from birth to three years of age, juvenile--from greater than three years of age through nine years of age and, adolescent from 10-18 years of age. The adolescent type is the most common and represents about 80% of this type of scoliosis. In addition to the amount of spinal deformity, the patient's physiological age is assessed, i.e., is growth completed or is there more potential spinal growth .

Scoliosis is detected by examination of the back. sometimes unequal shoulders helps find it but mostly the bend-over test is most helpful. The picture demonstrates how the child is bent over to touch their knees and the ribs are seen to be unequal in height. They are usually close to 1 inch or more difference. Sometimes the shoulders can be unequal and the back is straight.

In the latter case, potential curve progression is related to the time remaining until maturity. Curve progression is often associated with degenerative intervertebral disc disease and degenerative joint disease of the spine in middle-aged or older patients or may be due to significant previously present undiagnosed or untreated scoliosis.

Idiopathic scoliosis treatment is patient-age dependent. In patients with infantile scoliosis (0-3 years) left-sided curves are commonly seen, particularly in boys and may resolve spontaneously with growth .

Observation treatment is done with repeat evaluation every four to six months. Use of orthoses (braces) and surgery is uncommon. Juvenile idiopathic scoliosis (3-9 year olds) may rapidly progress especially in children over the age of five and may require orthotic (brace) management .

Surgery is indicated if the curve is unable to be controlled by orthotic means. Although surgery in a significantly skeletally immature spine will produce some decrease in ultimate spine height, it is better to have a shorter spine with more normal alignment than a progressive curve where height is lost because of deformity.

The most common of all types of scoliosis is adolescent idiopathic and is seen with equal frequency in boys and girls at low curve magnitudes. Girls, for unknown reasons, have a significantly higher risk for development of curve progression than boys. Pulmonary and cardiac function are not impeded with lumbar curves and significant changes of pulmonary function are not seen in patients with thoracic curves until the curve reaches a level greater than 70° , i.e., a severe curve. This amount of curve and subsequent cardiac and pulmonary changes are often seen later in life in untreated idiopathic infantile and juvenile scoliosis patients and present a threat to life. Patients with adolescents onset idiopathic scoliosis do not usually have such compromise unless severe curves develop. The time of highest risk for curve progression in adolescent idiopathic scoliosis occurs around puberty, i.e., when the growth rate is the fastest. Pulmonary and cardiac function tests which require patient cooperation may be required to assess lung and heart function in some cases of severe scoliosis, especially pre-operatively.

Treatment choice in adolescent idiopathic scoliosis is determined by a complex equation which includes the patient's physiologic (not chronologic) maturity, curve magnitude and location and potential for progression. Thoracic curves are at higher risk for progression than thoracolumbar curves or lumbar curves. Patients whose curves are of consequential magnitude prior to onset of their adolescent growth spurt are at significant risk for curve progression. Treatment options include observation, bracing or surgery. General guidelines include re-evaluation every 4-6 months (often including a PA erect T-L spine radiograph) for patients who are skeletally immature (but still not fully skeletally mature) and have curves less than 25° . In patients who are more skeletally mature with curves less than 45° similar observation should be carried out to assess any evidence of interval change at 6 months.

Brace (orthotic) management of adolescent idiopathic scoliosis is used in children with spinal deformity and curve magnitudes of 25-40° who are skeletally immature and with significant growth remaining. The primary goal of brace management is to stop curve progression. Any amount of curve correction at the end of brace treatment must be considered a "bonus." The orthoses used are usually underarm or higher reaching Milwaukee-type styles . The type of braces and amount of time the braces are worn daily vary according to the orthopaedist's choice .

Brace removal for participation in sports is strongly encouraged. An alternative to full-time brace wear is the use of a night time "bending" brace for management of a single curve. The termination of successful brace use is determined by the achievement of skeletal maturation, usually indicated by the patient not having further changes in height (and no curve progression) and evidence of maturity on skeletal radiographs.

Surgery for idiopathic scoliosis is suggested when curve magnitude is 50° or more in either the previously untreated patient or in one who fails brace treatment. Surgery is undertaken with two goals in mind. The primary one is to prevent spine deformity progression and the secondary one is to diminish spinal deformity. The natural history of idiopathic scoliosis during adulthood is one of continued progression if the curves tend to be more than 50° at the end of growth. The surgical procedure most often used to correct idiopathic adolescent scoliosis is a posterior spinal fusion with instrumentation and bone grafting .

With current instrumentation techniques, post-operative casting and bracing are not required in most idiopathic scoliosis cases. Patients are rapidly ambulatory and usually discharged from hospital within 5-7 days postoperatively with progressive resumption of routine daily activities, including return to school .

There is no scientifically documented role for exercises, manipulation or electrical stimulation in the management of scoliosis.