If you or your pediatric doctor notice that your child’s shoulders are uneven, your child might have scoliosis. It’s a common diagnosis, affecting up to one in ten teenagers and young adults. Scoliosis is a twisting or bending of the spine which sometimes occurs during periods of rapid growth in adolescents.
Treatment for scoliosis rarely requires surgery, or even a brace, as long as the spinal changes are noticed and monitored in a timely manner. However, in cases where a spinal curve is especially exaggerated, bracing is considered the first line of correction. If you find that your child has missed the opportunity for observation or bracing during a rapid growth spurt, and the spinal curve is greater than 40 degrees, your pediatrician will likely recommend surgery.
Large spinal curves worsen over time, even if discovered after the spine is fully grown. Fortunately, modern surgery stops curves from worsening through the use of pedicle screws, which de-rotate the spine and reduce the prominence of curves. Additional benefits to modern spinal surgery are increased height and improved posture.
You can learn more about scoliosis by visiting the website for the Scoliosis Research Society, an organization of specialists committed to the research, understanding, and treatment of scoliosis.
Spinal diseases and surgery is our another field of study. Spinal curvatures and fractures are the main parts of the treatment. Spinal curvature disorders may be congenital or developmental. Though spinal fractures usually develop after high-energy injuries, sometimes osteoporosis or tumour dissemination may have a role in development of spinal fractures. The nerves, that pass through the vertebrae and move from the brain to the locomotor system, increase the risks of this region. Diagnosis and treatment of spinal diseases are performed successfully in our hospital.
Scoliosis in Children and Teenagers
Avoiding scoliosis and maintaining good posture are global concerns among patients and parents today. Many patients and their families may be surprised to know that small curves are a normal part of spine anatomy. Like many aspects of growth in young children, healthy development of the spine can vary slightly from child to child with small curves constituting a normal part of spine anatomy. But if curves are observed by a parent,or physician, the child should receive an evaluation by a specialist for early onset scoliosis.
Children and adolescents who are noted to have any curvature in their spines require medical attention. These children may be diagnosed with scoliosis – a sideways curvature of the spine that may affect in any one or a combination of its three major sections:
- Cervical Spine (neck)
- Thoracic Spine (chest and upper back region)
- Lumbar Spine (lower back)
Forms of scoliosis in children and teenagers
Pediatric scoliosis is diagnosed as one of several types:
- Idiopathic scoliosis is a curvature of unknown origin.
- Congenital scoliosis is present at birth. A congenital scoliosis curve is where bones are asymmetrical at birth and the spinal vertebrae may be partially formed (hemivertebra) or wedge-shaped.
- Neuromuscular scoliosis is caused by an underlying systemic condition such as cerebral palsy, muscular dystrophy, spina bifida, spinal cord tumors, or paralysis.
- Syndromic scoliosis is a term for a unique group of spine conditions. Diseases such as Marfan’s Syndrome, Ehlers-Danlos Syndrome, osteogenesis imperfecta, neurofibromatosis, Prader-Willi Syndrome, arthrogryposis, and Riley-Day Syndrome are some of the common syndromic causes of this type of scoliosis.
Idiopathic scoliosis – the most common form of the condition – may first be recognized during a routine pediatrician’s visit. “School screenings are an important safeguard for many children, especially for children who may not have a regular healthcare provider,” notes John Blanco, MD, Associate Attending Orthopedic Surgeon at HSS. While children with idiopathic scoliosis usually do not experience pain, parents and caregivers may see cosmetic signs of the condition, such as a shoulder or hip that appears higher than the other or asymmetry of the rib cage. Cases can develop during infancy, childhood or adolescence, and patients who have idiopathic scoliosis are subcategorized by the age of the child when the condition appears:
- infantile idiopathic scoliosis − from birth to three years
- juvenile idiopathic scoliosis − from three to nine years
- adolescent idiopathic scoliosis − from 10 to 18 years
Adolescent idiopathic scoliosis is seen more frequently in girls than in boys. Although it is thought to be genetic, its true cause is unknown and thought to be a combination of many factors. It is characterized by a curvature of the spine measuring greater than 10 degrees (10°), has no other symptoms, and rarely causes pain.
Diagnosis of Scoliosis
The primary goal for a patient with any form of scoliosis is to get an early diagnosis. Treatment is guided by the specific scoliosis type, the amount of growth the child has left, the degree of the spinal curve, and anticipated progression of the condition. Children with infantile and juvenile scoliosis have the greatest risk of curve progression, as well as the greatest risk of developing secondary pulmonary complications from scoliosis.
Pediatric orthopedists use physical examination and X-rays to diagnose early onset scoliosis. An initial X-ray is taken to determine the magnitude, location, and direction of the curve. Based on that X-ray, a determination is made regarding the type of scoliosis present, as well as its possible cause, and a treatment strategy is instituted.
In children younger than 10 years of age, an MRI of the entire spine is often recommended to ensure that there are no other pathologies affecting the spinal cord. Children with congenital scoliosis should be assessed for the presence of any cardiac or kidney problems associated with their condition.
In some cases, even though the vertebral bones may be healthy, the spinal cord may not be according to the specialists. MRI images can help the orthopedist detect the presence of other problems such as syrinx (a cyst in the spinal cord) or tethered cord (when the spinal cord is abnormally attached to the bony portions of the spine).
Children with congenital scoliosis should also be assessed for the presence of any cardiac or kidney problems associated with their condition.
This condition is rarely diagnosed at birth, since it is an acquired form of scoliosis, in which the development and progression of the scoliosis often is dependent upon the severity of the underlying medical condition, such as cerebral palsy.
Children with syndromic scoliosis often have curves in the spine early in life. As children with this condition grow, the curvature can progress and worsen. It’s important for a pediatric orthopedic surgeon to monitor the condition closely, because in some cases the curvature may eventually need to be treated.
Patients with this condition should also be evaluated by a geneticist and neurologist to determine which underlying condition could be the cause of the spine curvature. Sometimes these patients may have respiratory and cardiac conditions, related to the syndrome or secondary to severe spinal curvatures. Due to this risk, it is also important for these patients to be evaluated by a pediatric pulmonologist and cardiologist.
Treating scoliosis in the growing child
Treatment decisions must consider the age of the patient, the type of scoliosis, the size of the deformity, and the anticipated progression of the curve. The period from birth to five years is crucial, because it is during this time that the lungs grow dramatically. If the chest cavity is constricted owing to scoliosis or other spinal deformities, lung growth can be significantly restricted and serious pulmonary complications may develop.
Based on all the information available, the pediatric orthopedist may recommend one or more nonsurgical or surgical treatments.
Nonsurgical treatments of scoliosis
For patients with smaller curves, those greater than 10° and up to 20°, the pediatric orthopedist may recommend careful monitoring of the condition with physical examinations and follow-up X-rays taken at three- to four-month intervals. If the curve progresses, additional treatment measures are introduced.
For curves in the range of 20° to 40°, bracing can be an effective means of controlling some forms of early onset scoliosis, such as idiopathic scoliosis and some syndromic forms of the condition. (However, bracing is not appropriate for neuromuscular or congenital scoliosis.) Moreover, it must be emphasized that bracing does not correct the curve. Bracing is intended to prevent progression.
Casting: The Risser cast
A renewed interest in casting for early onset scoliosis has occurred. Casting can produce good results in children with infantile idiopathic scoliosis and those with syndromic scoliosis. Body casts to correct the curve called the Risser cast. Extending from just under the arm pit − some also have “straps” that go over the shoulders − to the curve of the waist area, Risser casts remain on the patient for two to three months at a time, based on the age of the child. The cast is then changed to increase the amount of correction.
Surgical correction of scoliosis
Children with more advanced scoliosis (those with a curve of 45° or more) and that are progressing despite non-operative treatment are in danger of developing cardiac and/or respiratory problems may be candidates for surgical intervention. Although 2% to 3% of the adolescent population is diagnosed with adolescent idiopathic scoliosis, less than 10% of these patients require any surgical intervention.
The types of scoliosis surgery performed is usually one of two types:
- Growing Rods Placement
- Spinal Fusion surgery
- Nonfusion Scoliosis Surgery (Vertebral Body Tethering)
In younger patients with significant growth remaining, magnetic growing rods may be preferable. In this procedure, two adjustable rods are anchored to the spine to hold it in proper alignment. As the child grows, the rods can be adjusted in length. Growing rods are also effective in that the child’s lungs and chest cavity can continue to grow along with the spine. Additionally, spinal fusion can be delayed until the child is significantly older.
Growing rod technique
Growing rods (MAGec rods) are expandable devices that are attached to the top and base of the spine using screws or hooks. Every six months the orthopedic surgeon lengthens the rod by about one centimeter, which is the amount of growth expected in the spines of young children.
While the initial surgery to attach the growing rods lasts two or more hours, subsequent adjustments are brief procedures involving only a small incision. When the device has reached its full extension, the child may require another surgery to introduce a new longer set of growing rods.
Spinal fusion surgery
Fusion, the traditional scoliosis surgery, usually is reserved for older children. In this surgery, two or more vertebrae are fused together with bone grafts and internal devices, such as metal rods, to stabilize the spine or correct a deformity. Sophisticated fusion techniques and new instrumentation to surgically correct progressive curves, enhances the recovery of patients. Such techniques include new endoscopic procedures that allow specialists to access the spine through the chest cavity, and perform the fusion with three or four small incisions.
Computer navigation is utilized to optimize safe placement of the rods, screws and bone graft to facilitate alignment and fusion of the spine. To decrease the risk of neurologic injury, pediatric orthopedists use nerve monitoring throughout the surgery. This monitoring provides the doctors with instant feedback, allowing the surgical team to adjust the deformity correction as needed or, if need be, change the implants.
Mature patients with curves less than 45° are not candidates for spinal fusion surgery since many of these curves will progress slowly or not at all during adult life. Curves measuring greater than 50° are generally managed surgically, since these curves may progress up to one degree per year after maturity is reached. This can present problems for the patient later in adult life.
Vertebral body tethering (VBT) is a surgical treatment for idiopathic scoliosis in growing children whose scoliosis continues to progress despite bracing. The treatment was approved by the FDA in August 2019.
This “growth modulation” treatment uses anchors and an attached flexible cord to guide the spine into an upright alignment as a child grows. Vertebral body tethering can be used instead of spinal fusion surgery for some children with idiopathic scoliosis.
Vertebral body tethering takes advantage of the spine’s natural growth to correct sideways curvatures while allowing the spine to continue growing.
Surgeons attach metal anchors to the vertebrae on the side of the spine that curves outward. A flexible cord, called a tether, is connected to these anchors and placed under tension. Over time, as the child continues to grow and their spine lengthens, the tether slows the growth on the curved side of the spine. This allows the other side of the spine to catch up. Over time, as a child grows, the spine grows straighter.
The anchors and tether will remain attached to child’s spine permanently unless problems develop.
Compared to spinal fusion surgery, vertebral body tethering allows for greater spine mobility and flexibility. As the name implies, after spinal fusion surgery, the affected vertebrae fuse into solid bone. This section of spine will not bend or grow beyond its height at the time of surgery.
Vertebral body tethering is a surgical option for some children with idiopathic scoliosis whose spinal curves have not improved with bracing or who can not tolerate bracing.
After a thorough examination and medical history, our surgeons will talk with you about the pros and cons of a variety of treatment options. The following facts about VBT will help determine if it is an option for your child:
- Because VBT corrects scoliosis by guiding the growth of the spine, it is only effective in children who have not yet reached their mature height.
- Children must have strong enough bones to support the anchors that will be attached to their spines.
- Although every child is different, the majority of kids who undergo this procedure are between ages 8 and 16.
- Children with curves less than 45 degrees are at risk of overcorrection (spine curves in the opposite direction) with this procedure.
- The procedure is not as effective on curves greater than 65 degrees.
- Vertebral body tethering is indicated mainly for children with idiopathic scoliosis that is not related to neurological conditions or another deformity or injury.
Recovery from scoliosis surgery
Scoliosis surgery generally involves ten days hospital stay, and most children are back to school within three to four weeks after surgery.