Scoliosis

You probably remember being evaluated for #scoliosis as a kid, whether at your primary care provider's office or by the school nurse. Maybe you even remember a kid in school who had to wear a back brace. My best friend in my early high school years was one of those unfortunate youths. We were in band together, marching band even, and she was our drum major. Imagine mastering all the fancy footwork in time, while commanding a bunch of teenagers, under the blistering sun while sweating under the hard and unforgiving plastic brace strapped around your torso. She did this and ended up having to have surgery to correct the curve in her spine anyway.

Approximately 2% to 4% of adolescents are diagnosed with scoliosis which is a lateral curve to the spine greater than 10 degrees with vertebral rotation (Horne et al., 2014 & Janicki & Alman, 2007). My son visited the chiropractor when he was a young teenager and then missed treatment for a while. About a year later he returned to start again and the chiropractor showed him an X-ray he used in his office as an example of scoliosis and it ended up being his, funny enough. He did continue with chiropractic care and it resolved. His scoliosis was significant, impressive even, but related to nearly two feet of growth in just about a year.

Scoliosis can present at birth, which is congenital, or it may be related to neuromuscular issues, such as cerebral palsy, or even idiopathic, meaning one side simply grows faster than the other (Horne et al., 2014). Most all are the latter, which can occur at anytime in childhood. This typically doesn't cause a lot of problems, but sometimes can lead to visible deformity, emotional distress, and respiratory impairment from rib deformity. Prior to antibiotics, scoliosis was a much more significant risk for children because they would suffer complications of pneumonia with the inferior lung a bit more vulnerable to the collection of fluid. Adolescent girls sometimes notice a difference in their breast sizes (Janicki & Alman, 2007). Others notice shoulder asymmetry and overall posture imbalance.

Functional scoliosis occurs with patterns of movement, such as those who might work in an occupation that requires the same, repetitive movement or if they carry something heavy on one shoulder. This creates changes in the soft tissue, like muscles, rather than from uneven growth in the bone (Horne et al., 2014). We can see the difference between idiopathic, from the bones or uneven ribs, and functional, from the muscles, by evaluating the spine in a forward fold.

Scoliosis occurs equally between boys and girls, although girls are far more likely to progress towards more severe disease (Horne et al., 2014). Our goal as the primary care provider is to identify the issue, then decide if imaging is appropriate and ultimately treatment. My clients would also be encouraged to join yoga, and hang from his hands or knees from playground equipment or from his pelvis in a pelvis sling.

Is Scoliosis Painful?

While not necessary for diagnosis, and often not a presenting symptom, pain can be a normal with scoliosis (Janicki & Alman, 2007). About a quarter of adolescents with idiopathic scoliosis do experience back pain, and many in their posterior chest wall on the side of their rib prominence. Lower back pain is also common and when significant and unremitting, radiographs should be utilized. Acute back pain associated with fever should inspire clinicians to evaluate for a spinal infection. When isolated to one side, and when worse at night and relieved somewhat with NSAIDs, then this may be indicative of a spinal tumor, potentially osteoid osteoma. Neurological evaluations are really important in these scenarios, whether weakness, sensory changes, problems with balance, gait and coordination, as well as bowel and bladder difficulties such as incontinence are all ruled out or identified. Significant disturbances may suggest intraspinal pathology, such as tethered cord.

Controversy Regarding Routine Screening

Although screening was super popular in the 80s and 90s with the school nurse, into the early 2000s screening was no longer recommended as the U.S. Preventive Services Task Force (USPSTF) found screening was actually more harmful than helpful (Horne et al., 2014). Interesting since this is a seemingly benign evaluation, right? However, the screenings themselves aren't super consistent so radiologic screenings, which have significant risk, are performed more often and even when scoliosis is identified, almost never do these result in need for treatment and surgery. Those that do are apparent, symptomatic and can be addressed. Admittedly, in all my years in practice, I've never seen a scoliometer in practice, which is the tool that measures the degree of curvature to determine when radiologic screening is appropriate.

There are professional groups though that argue this, stating that screenings are low cost and radiologic screening isn't as significant as it once was. They also argue that brace treatment and earlier recognition could maybe prevent severe deformities requiring surgery (Horne et al., 2016). The challenge then for the primary care provider is discerning which cases are more significant and which ones can be observed without intervention. The USPSTF suggests those that are significant, really will be identified without routine screening as visible curvature of the spine is not likely to go unnoticed by provider or adolescent.

What You Need to Know

Here are a few interesting points though, you might keep in mind. Almost all scoliosis curves lead to the right, so the spinal curve is convex to the right (Horne et al., 2016). Those that lean more left are more often associated with additional pathology such as a tumor or a neuromuscular disorder, or an Arnold-Chiari malformation or occult syrinx. Rarely does scoliosis cause pain, so pain in itself should prompt timely evaluation as discussed. And midline hairy patches or cafe au lait spots are indication for further investigation, as are any neurologic deficits or findings. Joint and skin hyperlaxity along with curvature, may suggest Ehlers-Danlos syndrome. Those with high-arched or cavus feet may be associated with a neurological disorder such as Charcot-Marie-Tooth disease.

There are a number of yoga poses great for addressing the asymmetry of the lumbar when scoliosis is present. We're essentially working to create space for counterbalancing this bend. We want to stretch the con-cavity, and derotate the rotated segments. Simply standing tall and placing one foot slightly forward of the other to help derotate the the spine can be helpful. When the spine rotates forward, bring the left foot forward to increase weight-bearing on that aspect of the spine, and ultimately reducing the side bending in that area.

Those with scoliosis often sit more straight when one side of their pelvis sits a little more forward. There are additional poses as well, that I often guide clients, or my littles into to assist with scoliosis, in addition to using blocks as wedges to prop under their body while lying on their back. Certainly yoga poses less risk than surgery, so early and often is helpful, although not a cure all.

Treatment though in general, and even prognosis, is based on remaining spinal growth (Janicki & Alman, 2007). The most reliable method of monitoring growth is simple height measurements, which is a normal aspect of the primary care provider's evaluation. It's also important to evaluate other markers of growth and maturity, including signs of puberty, onset of menarche and breast development. Most often addressing scoliosis is about aesthetics or cosmetics, but certainly addressing scoliosis can help minimize progression of deformity. The most important aspect of scoliosis is whether one is happy with their appearance or not.

References

Horne, J. P., Flannery, R., & Usman, S. (2014). Adolescent idiopathic scoliosis: Diagnosis and management. American Family Physician, 89(3), 193-198.

Janicki, J. A. & Alman, B. (2007). Scoliosis: review of diagnosis and treatment. Paediatric Child Health,, 12(9), 771-776.