Copied From http://www.srs.org/
In Depth Review of Scoliosis: Preface
This work provides information about the causes, diagnosis and
scientifically documented, effective available treatment options for
common types of spinal deformity.
Last Reviewed: September 2000
In Depth Review of Scoliosis: Introduction
Figure 1a&b SRS Patient Handbook
Figure 2a&b SRS Patient Handbook
When one views a normal spine form behind, the back appears
straight and the trunk symmetrical. When the normal spine is
viewed from the side, curves are seen in the neck, upper trunk
and lower trunk. The upper trunk has a gentle rounded contour
called kyphosis and the lower trunk has a reverse direction of
the rounded contour called lordosis. Certain amounts of cervical
(neck) lordosis, thoracic (upper back) kyphosis and lumbar
(lower back) lordosis are normally present and are needed to
maintain appropriate trunk balance over the pelvis (Fig. 1a&b).
Deviations from this normal alignment may reflect abnormal
kyphosis or lordosis or, more commonly, scoliosis.
Scoliosis is defined as a side-to-side deviation from the normal
frontal axis of the body (Fig. 2a&b).Although traditional, this
definition is limited since the deformity occurs in varying
degrees in all three planes: back-front; side-to-side;
top-to-bottom. Scoliosis is a descriptive term and not a
diagnosis. As such, a search is made for the cause. In more than
80% of the cases, a specific cause is not found and such cases
are termed idiopathic, i.e., of undetermined cause. This is
particularly so among the type of scoliosis seen in adolescent
girls. Conditions known to cause spinal deformity are congenital
spinal column abnormalities, neurological disorders, genetic
conditions and a multitude of other causes. Scoliosis does not
come from carrying heavy things, athletic involvement,
sleeping/standing postures, or minor lower limb length
Figure 3a Adam's Bend Test - clinical (Frontal view)
Figure 4 Scoliosis - clinical (Posterior view)
Clinical evaluation focuses on history and physical examination
findings. Consideration is given to circumstances surrounding
the patient's birth, delivery and development histories. Was the
pregnancy full term? What was the child's birth weight? When did
the child begin to walk?--are some of the important guide posts
which are sought. Abnormalities in these areas may lead one to
consider neuromuscular or congenital etiologies. With congenital
anomalies, if one congenital anomaly is found, others are
sought, e.g., kidney abnormalities are often associated with
congenital scoliosis. Intermittent backache may occur with
idiopathic scoliosis, but complaints of pain radiating into the
legs, night pain, or systemic complaints (for example changes in
bowel or bladder habits) are highly abnormal and are not common
complaints in patients with idiopathic scoliosis and usually
require further study. A family history of spinal deformity is
looked for since certain types of spinal deformity are more
prevalent within families.
Physical examination centers on assessment of trunk symmetry.
The Adam's forward bend test is done with the patient bending
forward with arms extended and knees straight. Asymmetry of the
trunk when viewed from the front or the back as well as abnormal
increases or decreases in lordosis or kyphosis when viewed from
the side are assessed (Fig.3). This test is used during school
screening for scoliosis. The test is sensitive to detect trunk
asymmetry but it is not specific for spinal deformity. A common
finding that is often misinterpreted as spinal deformity is
truncal asymmetry from unequal trunk muscle development on the
patient's dominant hand side.
Further physical findings depend on the patient's deformity
location and magnitude. Shoulder heights may be uneven and there
may be an increased space between the elbow and trunk because of
trunk deviation (Fig.4). Prominence of a "hip", pelvis or breast
may be seen. Examination of the skin overlying the spine
assesses the presence of dimples, sinuses, hairy patches and
skin pigmentation changes. The effect of any limb length
inequality is tested with the patient standing on blocks to
level the pelvis or seated on a flat surface. Neurological
examination includes evaluation of the function of the muscles
and nerves of the upper and lower limbs.
In Depth Review of Scoliosis: Radiographic Imaging
Figure 5 Screening PA erect
Figure 6 Risser's sign and triradiate cartilage status
Initial imaging evaluation of a patient suspected of having
scoliosis is by a standing posterior-anterior thoracolumbar
spine radiograph done on a single long film. Modern radiographic
techniques minimize radiation exposure (Fig.5).
A standing side view radiograph of the thoracolumbar spine is
suggested if significant deformity is present in the
front-to-back (sagittal) plane. Radiographs are assessed for
spinal column contour and to rule out congenital, developmental,
degenerative or neoplastic abnormalities. The amount of each
deformity is calculated using a standard, reproducible
measurement technique. An estimate of skeletal maturity is made
by assessment of the growth areas at the upper pelvis and hips
Specialized imaging studies such as (CT scans or magnetic
resonance imaging (MRI)) may occasionally be needed. Magnetic
resonance imaging is done to evaluate the spinal cord and spinal
As with all studies, MRI is done for a specific indication and
correlated with clinical examination. Myelography, a
radiographic study which uses an injected dye to provide
contrast to study the spinal canal and its contents, has been
largely replaced by magnetic resonance imaging techniques. CT
scans are used to provide improved definition of abnormalities
of vertebral size, shape or number (Fig.8).
Figure 7 Lateral T-L spine
Figure 8 Congenital lumbar scoliosis - 3D
In Depth Review of Scoliosis: Congenital and Neuromuscular
Figure 9a Congenital Scoliosis (AP radiograph)
Figure 9b Congenital Scoliosis (lateral radiograph)
Figure 9c Congenital Scoliosis (CT scan of hemivertebra)
Figure 10ab Spinal deformity in Muscular dystrophy (Pre-op)
Figure 10cd Spinal deformity in Muscular dystrophy (Post-op)
Congenital scoliosis is caused by abnormal vertebral formation.
Vertebral absence, partial formation or lack of separation can
cause asymmetrical growth and resultant deformity (Fig.9).
Patients with congenital scoliosis require a renal ultrasound to
rule out renal anomalies such as a single kidney which is the
most common associated finding. Magnetic resonance imaging may
be necessary to rule out suspected associated abnormalities of
the spinal cord or spinal nerves if clinical neurologic
examination findings are present. The treatment of congenital
scoliosis is individualized and dependent upon the type of
vertebral malformation. Early surgical intervention may be
required to prevent deformity progression.
Spinal deformity is common and often severe in patients with
neuromuscular disease especially in those patients who do not
walk because of their underlying neurological disease. Seating
modification and bracing in the vast majority of cases have no
long-term effect on the natural, i.e., untreated course, of
spinal deformity in neuromuscular disease. Such techniques may
improve sitting ability but do not alter curve progression.
Surgical correction and stabilization are done to prevent curve
progression. With modern spinal instrumentation and surgical
techniques, most patients do not require post-operative
immobilization with braces or casts. In patients with muscular
dystrophy, the curve often increases when walking ability
diminishes. Surgical intervention is indicated for progressive
spine deformity in patients with muscular dystrophy while
pulmonary function is still adequate, i.e., preferably when the
curves are less than 30° (Fig.10). Myelodysplasia (spina bifida)
often produces major progressive deformities from both paralytic
and congenital factors, particularly in patients with high
levels of paralysis. Progressive spinal deformity in patients
with cerebral palsy often leads to difficulty with seating and
care, especially in patients who do not walk (Fig. 11).
Figure 11a Spinal deformity in cerebral palsy (Pre-op)
Figure 11b Spinal deformity in cerebral palsy (Pre-op)
Figure 11c Spinal deformity in cerebral palsy (Post-op)
In Depth Review of Scoliosis: Idiopathic Scoliosis
Figure 12 Adolescent idiopathic scoliosis with significant
progression over two years
Figure 13a Infantile Idiopathic Scoliosis of 20 month-old boy
Figure 13b Infantile Idiopathic Scoliosis of 20 month-old boy
Figure 14 7yr old boy with juvenile idiopathic scoliosis
Idiopathic Scoliosis - Infantile; Juvenile; Adolescent
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 (Fig.12).
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 (Fig.13).
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 (Fig.14).
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
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
In Depth Review of Scoliosis: Treatment of Adolescent Idiopathic
Figure 15 Brace types
Figure 16 Radiograph of a patient with AIS undergoing brace
Figure 17a Radiograph of patient with AIS (Pre-op)
Figure 17bc Radiograph of patient with AIS (Post-op)
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 (Fig.15). The type of braces and amount of
time the braces are worn daily vary according to the
orthopaedist's choice (Fig.16).
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 (Fig.17).
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
There is no scientifically documented role for exercises,
manipulation or electrical stimulation in the management of
Clinical photos of
patient with AIS (Pre-op)
Clinical photos of
patient with AIS (Post-op)
In Depth Review of Scoliosis: Kyphosis - Abnormal
Figure 19 Clinical photo of kyphotic deformity in a 13yr-old boy
with Scheuermann's disease
Figure 21 14yr-old girl with Scheuermann's disease (radiograph
Figure 22 Congenital kyphosis & scoliosis radiographs
Figure 23 MRI: Congenital kyphosis due to formation defect with
normal cord, roots.
Figure 24ab AP and lateral adolescent AIS radiographs
Similar imaging guidelines exist as described for scoliosis.
With the patient erect, radiographs are taken to show
side-to-side alignment. Spinal radiographs are sometimes taken
with the patient erect and supine are helpful to document
flexibility of a rigid deformity. Specialized imaging studies
(CT scan, MRI, bone scan) are used as required.
Pertinent historical points include those previously mentioned
for scoliosis assessment. Examination includes the forward bend
test and the patient is viewed from the side to see if the
normal spine contours are present (Fig.19). Prominence of the
patient's thoracic kyphosis or failure to reverse their lumbar
lordosis with bend requires further investigation.
Postural "Round Back"
Postural "round back" is defined as an increase in thoracic
kyphosis while standing. Curve flexibility is seen when the
patient "stands tall" or, when prone or supine, the "deformity"
resolves (Fig.20). This non-progressive condition is commonly
seen in middle school children, especially girls, and almost
always resolves by itself and requires no specific treatment.
Parental "nagging" should be avoided.
Scheuermann's disease is a condition of unknown cause which
produces an increased thoracic kyphosis (>40° ) with true
structural changes within the thoracic vertebra with 5° of
wedging in each of three adjacent vertebrae measured on
side-view radiographs (Fig.21). This localized deformity is
usually painless. Treatment is dependent upon the magnitude of
the deformity, pain complaints and patient maturity. Observation
is done for deformity of less than 60° and brace treatment for
curves between 60° and 80° if the patient is skeletally
immature. Surgery is rarely required. A subtype of Scheuermann's
disease occurs in the lumbar spine, usually in male patients
during late adolescence who are involved in heavy lifting tasks.
The changes of the vertebra and disc are considered to reflect
the physical stress effects. Treatment is by elimination of the
Sagittal plane deformities may be due to congenital defects of
vertebral formation or failure of vertebral segmentation
(Fig.22). Deformities due to congenital vertebral formation
failure are predictably progressive and require early surgical
treatment. Because of potential associated renal anomalies,
renal ultrasonographic assessment is recommended. MRI of the
spinal canal may also be needed to rule out associated spinal
cord abnormalities (Fig.23).
Spinal deformity is due to a myriad of causes. Scoliosis,
kyphosis and lordosis are descriptive and not diagnostic terms
and efforts must be made to establish the deformity's cause. The
etiology of the most common type of spinal deformity, adolescent
idiopathic scoliosis, is unknown, but it is strongly familial.
Initial radiographic examination for scoliosis requires a
standing back-to-front (PA) thoracolumbar spine radiograph on a
single film. Sagittal plane concerns are evaluated by side view
Treatment varies according to the deformity's cause, location,
magnitude, patient maturity and evidence of progression.
Treatment decisions are based on a complex equation taking such
factors into account. Modern bracing techniques provide cosmetic
braces which allow patients to continue their routine activities
including sport participation. Modern methods of surgical
management allow for patients' rapid mobilization and return to
routine daily activity.