Adolescent Idiopathic Scoliosis

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Adolescent idiopathic scoliosis (AIS) is a lateral (side) curvature of the spine. AIS effects 1% to 3% of children aged 10 to 16 years.¹ The spine may curve to the left or right.  Sometimes AIS starts at puberty, or during an adolescent growth spurt.  Idiopathic means the abnormal curve develops for unknown reasons.  Research shows there is a genetic predisposition for some adolescents to develop AIS.  Girls are more likely than boys to develop AIS. AIS is a progressive disorder which means that it worsens with time.

Signs and Symptoms

Signs and symptoms related to AIS include:
 

• Leg-length difference
• Abnormal gait
• One shoulder higher than the other
• A prominent shoulder blade / rib cage when bending forward
• Visible curvature of the spine to one side
• Uneven hips
• Hemlines or trouser lengths uneven
• Clothing does not fit correctly
• Back pain

It is important to seek treatment for AIS because progressive scoliosis, left untreated, can result in significant deformity.  The deformity can cause marked psychological distress and physical disability, especially among adolescents.  Additionally, the deformity can have serious physical consequences. As the vertebrae (spinal bones) rotate, the rib cage is affected, which in turn can cause heart and lung problems (i.e., shortness of breath).  When progressive scoliosis affects the lumbar (low back), spine the pain can be debilitating.

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Diagnosis

An accurate diagnosis of AIS should be sought from a physician with expertise in spinal conditions. This diagnosis may include the following steps.

• Medical history

This will include the patient’s medical history, the medical history of the patient’s parents, and questions about symptoms. Female patients will be asked about their age at their first period. Skeletal maturity is an important consideration in the diagnosis. In some cases, skeletal maturity may cause scoliosis to stop (particularly if the curve is less than about 45 degrees). This is less likely in patients whose scoliosis curve is more than 45 degrees.

• Physical and neurological examinations

This is when the doctor learns about the patient’s health and general fitness.  Both exams provide the doctor with a baseline from which future curve progression can be estimated.  A typical examination may include the following:

Table 1

Diagnostic tests

May include the following:

Table 2

Non-operative Treatment

Some cases of AIS do not require spine surgery and are treated by observing the curve for progression and bracing.

Small curves (less than 15- to 20-degrees) are observed for possible progression over a period of time.  At this stage, no specific treatment is needed.  Larger curves (between 20- to 40-degrees) require bracing to prevent curve progression.

Some adolescents find wearing a brace 16- to 23-hours every day difficult.  Braces can be uncomfortable, unattractive, hot, and make a youngster self-conscious, even though the brace is well-disguised beneath clothing.  However, when bracing works and surgery is avoided, the required commitment is worthwhile. A carefully designed exercise program may be recommended.

Unfortunately, some curves do not respond to bracing.  Cervicothoracic curves (from the middle of the back up into the neck) and curves greater than 40-degrees tend not to respond well to bracing.  

Older patients who are closer to skeletal maturity may not respond to bracing.

Surgical Treatment

Surgery may be recommended to treat curves greater than 40-degrees.  

Scoliosis surgery usually involves spinal instrumentation (i.e., rods, screws) and fusion (bone graft). The goal of surgery is to realign and stabilize the spine. Instrumentation and fusion secure the spine to stop curve progression. Surgery does not cure scoliosis, but helps to correct and manage curve progression to avoid further deformity.

The surgeon may perform surgery through the front (anterior) or back (posterior) of the spine. There are different types of instrumentation, bone graft and graft products, procedures, and minimally invasive techniques.  

Conclusion

Left untreated, adolescent idiopathic scoliosis can lead to significant physical deformity, debilitating pain, and psychological distress.  However, proper AIS treatment can help prevent curve progression and stabilize the spine while the child grows.  The spine surgeon can discuss the risks and benefits of different treatment options.

Reference:

1.  Weinstein SL, Dolan LA, Cheng JC, Danielsson A, Morcuende JA.  Adolescent idiopathic scoliosis.  Lancet. 2008 May 3;371(9623):1527-37.