Scoliosis — spinal curvature

About spinal curvature

Look at the image below. Viewed from the side, a healthy spine has forward-backward curves. Viewed from behind (or in front), it is a perfectly straight, vertical line. We speak of scoliosis when the spine is not vertical or straight when seen from the back but deviates sideways, the shoulders and hips are not level with the horizontal, and the spine deviates from the vertical.

About 3–5% of adolescents have spinal curvature, but in most cases the deviation is mild. It becomes a problem if the deformity progresses rather than settles as the child grows. Neglected scoliosis can even worsen to the point of disability. In severe cases it can deform the chest, which can restrict lung expansion and hinder proper breathing.

Changes can be tracked by regular X-rays taken at intervals, so scoliosis requires repeated follow-up checks.

Symptoms of scoliosis

Signs and symptoms of spinal curvature may include:

• the shoulder line tilts, the shoulders are not at the same height;
• one shoulder appears more forward;
• the waistline tilts to one side, the edges of the pelvic bones are at different heights;
• one hip joint appears more forward.

The spinal column can not only curve sideways but also rotate or twist. In such cases the ribs on one side may protrude more than on the other.

When should you see a doctor?

If you notice any of the above signs or symptoms in your child, consult an orthopaedic specialist. Mild curvature is usually painless, so the child may not report it and you might not notice it. It is common for teachers or coaches to be the ones who detect and inform you about your child’s scoliosis.

Causes of spinal curvature

In most cases the underlying cause of scoliosis is unknown.

In some families the condition appears across generations, so heredity may play a role.

Less common causes include conditions that cause paralysis or muscle wasting. Congenital abnormalities affecting the development of the spinal bones, as well as spinal injuries or infections, can also trigger scoliosis.

Risk factors

• Age. Symptoms typically appear during puberty when growth accelerates.
• Sex. Mild scoliosis occurs in boys and girls at similar rates. However, girls have a higher risk that the curve will worsen or will require some form of treatment.
• Family history. Some families have multiple generations affected by spinal curvature. Nevertheless, in most cases the child's parents are not affected.

Possible consequences

Scoliosis most often does not constitute an illness and does not require treatment. In other cases it can cause complications that require intervention.

• Back problems. Adults who had a curvature diagnosed in childhood are more likely to suffer chronic back pain.
• Lung and heart impairment. Severe spinal curvature can deform the chest and the ribs can press on the lungs and heart, making normal breathing and circulation difficult.
• Worsening scoliosis causes increasingly visible and perceptible changes to the body — the heights of the hips and shoulders differ, the ribs protrude on one side, and the waist and trunk tilt to the side. Your specialist will initially take a detailed medical history and may ask about recent growth changes. During the physical exam your child will be asked to stand straight and then bend forward at the waist with the arms hanging freely; this helps check whether one side of the rib cage protrudes more than the other.

Making the diagnosis

The doctor will ask about the child’s recent growth pattern. During the physical exam they observe the position, alignment and motion of the shoulders, hips, rib cage and spinal column while standing and bending forward.

A neurological exam may be performed to look for muscle weakness, sensory disturbances, numbness or abnormal reflexes.

Simple two-view X-rays can confirm the diagnosis of scoliosis and show the severity of the spinal curve.

Further tests are indicated if there is suspicion that an underlying condition — for example a tumor, inflammation, etc. — is causing the scoliosis. In such cases additional imaging, such as MRI, may be requested.

Treatment considerations for scoliosis

Most children with scoliosis do not need either a brace or surgery. However, regular monitoring is required to detect any adverse changes during growth.

Different recommendations apply for mild, moderate and severe scoliosis, but therapy must always be individualized. Several factors must be taken into account.

• Child’s sex. Girls are more likely than boys to experience progression of the curve.
• Severity of the curve. Larger initial curves are more likely to progress.
• Curve pattern. Double curves, i.e. those that deviate both sideways and forward with rotation (S-shaped scoliosis), are more likely to worsen than simple single curves that only bend sideways (C-shaped scoliosis).
• Location of the curve. Curves in the middle, thoracic region of the spine are much more likely to worsen than those in the upper or lower segments.
• Maturity. Once bone growth has stopped, the likelihood of progression decreases. This also means that braces are primarily useful for children whose bones are still growing.

Physiotherapy – the basis of treatment

Daily individual physiotherapy is the most important element of treatment. It helps strengthen the muscles that support the spine and can correct the curvature or at least prevent further worsening.

A physiotherapist teaches the exercises to both the child and the parent and periodically checks progress. However, the exercises must be performed individually and daily. Willpower and perseverance are required, and parents must support their child, because only regular exercise will have an effect.

Wearing a brace

For moderate scoliosis in children whose bones are still growing, wearing a brace may be recommended. Wearing it does not cure or straighten the scoliosis, but generally prevents further progression.

Bracing can be uncomfortable and visibly noticeable for a child or adolescent. Parents can ask classmates, friends and teachers to help the child cope with the difficulties of wearing a brace.

Most common braces are made of plastic and are shaped to the body. They fit almost invisibly under clothing thanks to cutouts around the rib cage, lower back, hips and under the arms.

Most braces must be worn day and night. In fact, the more hours spent in the brace, the more effective it is. Children who wear braces can usually participate in most everyday activities; only a few sports or activities are restricted or contraindicated. If necessary, the brace may be removed for sports or other physical activities.

It is important to know that while a brace provides support, it does not meaningfully strengthen the spinal-supporting muscles!

Brace use should be stopped once bone growth has ceased.

Surgical solution

In severe scoliosis, doctors may recommend surgery to reduce the spinal curve or prevent harmful effects.

The most common type of surgery is spondylodesis, or 'spinal fusion'. During the operation surgeons fuse two or more vertebrae in the spinal column so they cannot move independently. Bone grafts or bone-like material are placed between the vertebrae. The spine is straightened and held in place with metal rods, screws and wires.

Today there are also implantable devices whose length can be adjusted over time. That is, the length of the rod supporting the spine can be increased as the child grows.

Spinal surgery is not without risk; possible complications include bleeding, infection, pain or even nerve injury. Therefore it is performed only for solid indications.

Posture-correcting exercise

Posture-correcting physiotherapy is the most widely accepted treatment for spinal curvature. I note that this therapy requires more repetition than the number of sessions the national health insurance reimburses. Clinic-based sessions serve to teach and help the child master the necessary movements and exercises. However, if you do not have the child continue the exercises at home daily — and especially if the child does not understand how important daily repetition is — then even the few prescribed sessions are essentially pointless. Muscles cannot be strengthened in 10–12 days (if they could, why would athletes train for years for the Olympics?). The effectiveness of posture-correcting exercise depends not only on strengthening the back and abdominal muscles but on making all muscles responsible for posture sufficiently strong and stretchable. When this is achieved, biomechanically correct posture develops. In that state the load on the spine is minimal, and you can thereby protect the spine from adult complications such as degenerative disc disease.

I note that numerous scientific studies support the effectiveness of yoga in strengthening the deep back muscles. Although you will find many spine-strengthening yoga courses on various forums, among domestic instructors I consider Gergely Medvegy one of the most authentic. Here you can find his online spinal therapy yoga course.

Electrical muscle stimulation (EMS)

Numerous studies have examined whether muscle stimulation offers a solution for spinal curvature. According to the latest studies, its use is beneficial, but stimulation treatment does not "straighten" the deformity. Its main advantages are relief of tension-related pain, reduction of muscle stiffness and improvement of basic muscle strength.