The Anatomy of the Spine

The spine is made up of many individual small bones called vertebrae. These bones are joined together by muscles and ligaments. Soft, flat "intervertebral discs" separate and cushion the vertebrae from each other. As the bones are all separate, the spine is flexible and bends. The vertebrae, discs, muscles and ligaments together make up the spine.

The normal healthy spine has front to back curves and individual spines can vary in size and shape. The neck area is called the "cervical" spine and normally curves slightly inward. The chest area is called the "thoracic" spine and curves outward. The lower area of the back is called the lumbar and sacral spine and also curves slightly inward. When the curve in any of these areas becomes too big, or curves side-to-side forming a C-shape or S-shape is when it becomes a problem.

What Causes Abnormal Curves of the Spine?

There are many causes of abnormal spinal curves:

"Congenital" causes are defects of the spinal vertebrae from birth that cause the spine to grow unevenly. These defects may include absence of one or more vertebrae, partially formed vertebra, or lack of or abnormal separation of the vertebrae.
"Neuromuscular" causes come from problems with the nerves and muscles either present from birth or acquired. These include such diagnosis as cerebral palsy, spina bifida, muscular dystrophy, spinal cord tumors, and neurofibromatosis.
"Syndrome related" spine abnormalities are typically related to those children with a syndrome such as Down's syndrome, Klippel-Feil syndrome, or Marfan's syndrome.
"Idiopathic scoliosis" is the most common type of spine deformity, which means there is no known cause. There is nothing that was done to cause it and nothing that could have been done to prevent it. It often affects adolescents as they go through their last major growth spurt, which is generally ages 11-13 years for girls and 13-15 years for boys. It also may affect younger children. Idiopathic scoliosis frequently, but not always, runs in families and may be related to genetics or hereditary influences. There is ongoing scientific research to help scientists and physicians understand who is affected by scoliosis, why some scoliosis progresses while some cases do not, and why some scoliosis responds to bracing and some do not.

What is Scoliosis?

When the trunk is viewed from behind, the normal spine appears straight. Also, the shoulders and hips appear level. The spine affected by scoliosis demonstrates a lateral or sideways curve. The spine not only curves sideways but also twists, which may give the appearance that the person is leaning sideways and/or that they have a hump on one side of their back. Also, the head may not be centered over the pelvis (hips). Your clothes may hang unevenly. Many people with scoliosis also have "hypo-kyphosis". Hypo-kyphosis is a flattening of the mid part of the back, which is normally somewhat rounded. These physical signs are more obvious in some people than others but usually become more obvious as the curve progresses. Because of all the different and different combination of spinal curvatures, scoliosis may present very differently in each individual.

In early childhood, idiopathic scoliosis occurs in both boys and girls equally. As children enter adolescence, girls are twice as likely to develop scoliosis and 8-10 times more likely to have more severe cases of scoliosis requiring treatment. Scoliosis may be first noticed in a school screening, a routine physical exam, sports physical, or by a family member. This is an important finding and requires follow-up.

There are some neurological symptoms that are NOT associated with idiopathic scoliosis. These include leg pain, weakness, numbness and/or tingling, changes in bowel or bladder habits and severe back pain or back pain at night that awakens the child from sleep. Also some symptoms of scoliosis may resemble other spinal conditions such as injury, infection or tumors. Presence of any of these conditions should be further evaluated by a physician.

What Should Be Done?

In 90% of cases, scoliotic curves are mild and do not require active treatment. However, it is especially important in the rapid growth period before and during adolescence to monitor the curve for progression. This is done by periodic physical exams and x-rays. Increases in the spinal deformity should be evaluated by an orthopaedic surgeon. Although scoliosis rarely seems to be a problem to the child with the curve, the curve can become a problem in adulthood. These curves are much more successfully treated early before they become more severe in adulthood.

Brace treatment may be offered versus "watchful waiting". In a small number of patients surgical correction may be recommended based on your physical exam and any neurological findings or physical complaints. Your orthopaedic surgeon may also order an MRI (magnetic resonance imaging) to evaluate your spinal cord, before any treatment is initiated.

Brace Treatment for Spinal Deformity?

Brace treatment (orthosis) may be offered or recommended for increasing scoliosis or kyphosis. Recommendation for bracing is based on the degree of the curvature, skeletal maturity, and readiness of the patient and family for the bracing regimen. There are different types of braces that are all designed to prevent the spine curve from progressing as the adolescent grows. Your orthopaedic surgeon will recommend a specific type of brace depending on your child's age and type of curve. A scoliosis brace works by pushing on the curve of the spine to hold it in a straighter position while the child is growing. A scoliosis brace is made specifically for each individual person. A bracing program can be very difficult. For example theBoston brace should be worn approximately 20 hours a day until the end of growth which can be from one year to several years. It is important to be physically active and continue with sports, dance, etc during hours out of the brace. Physical fitness is very important! A brace will not make the spine straight and cannot always keep a curve from progressing. Increasing the chances of successful brace treatment requires:

Early detection of curve, ideally before or early on in the adolescent growth spurt.
Mild to moderate scoliosis curves (25-40 degrees).
Well fitted brace with regular exam and x-rays with orthopaedic surgeon and orthotist.
Cooperative patient and supportive family.
Maintenance of normal activities and sports with elective time out of the brace for these activities and other physical exercise.

Operation Considerations

There are specific risks with spine surgery and anesthesia, as there are with other surgeries. These should be discussed with your surgeon in a pre-operative conference.

The most important "personal" operative consideration for the patient and family is readiness for the surgery and a positive mental attitude. The patient and/or family may not be ready to commit to surgery the first time the topic of surgical treatment is presented. Spine surgery for idiopathic scoliosis is not an emergent procedure and time should be taken to prepare both mentally and physically for the procedure. A general state of good health and nutritional status are important to successful surgery and recovery.

"Straight Facts" Related to Scoliosis and Treatment

A lack of calcium will not cause scoliosis but does affect overall bone health and could potentially have implications in surgical treatment.
Poor posture and carrying heavy book bags or musical instruments does not cause scoliosis but may contribute to back pain.
Scoliosis and/or Kyphosis may or may not be associated with back pain in adolescence.
Bracing does not make the spine straight.
SMOKING DOES INTERFERE with bone healing. This includes passive smoke exposure.
Surgery does not interfere with normal child bearing.
The metal implants may activate the metal detectors at airports, you are not required to carry any special documentation however, tell the attendant you have surgical implants. You will be required to undergo additional examination with "wand" and "pat down" is you set off the alarm.
Your diagnosis and any treatment of scoliosis is an important part of your medial history. Include your diagnosis and treatment when giving your medical history to any healthcare provider.
There is currently no known prevention for scoliosis however; there is ongoing research in this area. At some point during your diagnosis and treatment of scoliosis, you may be asked to participate in a scoliosis research study. While participating in a study may not directly benefit you, it may possibly benefit children that you may have in the future.

Useful Books

Kitchen Table Wisdom: Stories that Heal - Rachel Naomi Remen, MD

Vertebral Body Stapling to Treat Scoliosis- PREFACE

Useful Articles

Vertebral Body Stapling - ARTICLE

Topics for Health Care Providers

Back Pain in Children & Referral to Orthopaedics or OtherSpecialties

Back in Pediatric Athlete