Scoliosis is a medical condition in which a person’s spine has a sideways curve. The curve is usually “S”or “C”-shaped. In some the degree of curve is stable while in others, it increases over time. Mild scoliosis does not typically cause problems, while severe cases can interfere with breathing. Typically, no pain is present. The cause of most cases is unknown, but is believed to involve a combination of genetic and environmental factors. Risk factors include other affected family members. It can also occur due to another condition such as muscles spasms, cerebral palsy, Marfan syndrome, and tumors such as neurofibromatosis.
According to the American Association of Neurological Surgeons (AANS), scoliosis affects between 2% and 3% of the American population, or about six to nine million people. It is characterized by an abnormal lateral curvature of the spine and there are many different forms. The various types of scoliosis are classified by cause and age of onset; the speed and mechanism of progression also plays a role in determining the specific type of scoliosis.
Though all forms of scoliosis involve some degree of spinal curvature, some are more severe than others.
Types of Scoliosis
|Neuromuscular: Following two types are
Scoliosis is classified according to the patient’s age at the time of diagnosis, as follows:
infantile (under age 3),
juvenile (age 3 to 9), and
adolescent scoliosis (age 10 to 18).
There are a number of ways to differentiate between the various forms of scoliosis, but the most common method for classification is based on etiology, or the underlying cause for the condition. There are three categories into which the different forms of scoliosis fit: idiopathic, congenital, and neuromuscular.
Most types of scoliosis are idiopathic, which means that the cause is unknown or that there is no single factor that contributes to the development of the disease.
Congenital – forms of scoliosis typically result from a spinal defect present at birth, and are therefore usually detected at an earlier age than idiopathic forms of scoliosis.
Neuromuscular – scoliosis is spinal curvature that develops secondary to some kind of neurological or muscular disease, such as muscular dystrophy or cerebral palsy. This form of scoliosis tends to progress much more quickly than others.
Knowing how spinal curvature disorders are classified provides a foundation of knowledge on which to build understanding of the specific types of scoliosis.
Congenital scoliosis is fairly rare, affecting only 1 in 10,000 newborns, and it results from spinal abnormalities that develop in the womb. During fetal development, malformation of the vertebrae is one of the most common causes for congenital scoliosis. It may also result from partial formation of certain bones or the absence of one or more bones in the spine. Not only can congenital scoliosis lead to a sideways curvature of the spine, it can cause the child to develop additional curves in the opposite direction – the body’s attempt to compensate for the abnormality.Because congenital scoliosis is related to spinal defects present at birth, it is typically diagnosed much earlier than other forms of the disease.
Symptoms of congenital scoliosis include tilted shoulders, an uneven waistline, a prominence of the ribs on one side, head tilt, and an overall appearance of the body leaning to one side. When symptoms develop, diagnostic tests such as EOS imaging, x-rays, MRIs, and CT scans can be used to confirm the diagnosis.
Early Onset Scoliosis
The most common age range at which scoliosis is diagnosed is during adolescence – which is why it is called adolescent scoliosis. When scoliosis is present prior to the age of 10, however, it is referred to as early onset scoliosis.
It is important to differentiate between adolescent and early onset scoliosis because children over the age of 10 have already completed most of their spinal growth while children under 10 are still growing. Because children under 10 are still growing, early onset scoliosis can affect more than just the spine – it can also lead to malformed ribs, which can affect lung development.
In many cases, children with early onset scoliosis do not show any outward signs of spinal problems, especially if the curve is mild. In order to detect early onset scoliosis, it is important to pay attention to the symmetry of the affected child’s body. Uneven shoulders, asymmetric contour of the waist, uneven hips, tilted head, and leaning can all be signs of scoliosis in children under the age of 10. Upon diagnosis, treatment for this form of scoliosis is more important than for other forms of scoliosis because the child is still developing. Lack of treatment can contribute to lung and heart problems and may even increase the risk of death due to lung and heart disease.
Adolescent Idiopathic Scoliosis
By far the most common form of scoliosis, adolescent idiopathic scoliosis affects as many as 4 out of 100 children between the ages of 10 and 18. The name for this condition comes from the age of onset (adolescence) and the fact that no single cause has been identified.
Idiopathic scoliosis is classified according to the age of the patient at the time of diagnosis. On the basis of the notion that three growth spurts correspond to the phases of highest risk for worsening of scoliosis, the condition is subdivided into three types:
infantile scoliosis (under age 3),
juvenile scoliosis (ages 3 to 9), and
adolescent scoliosis (ages 10 to 18).
By the age of 10, spinal growth has started to slow; if the child has already developed a significant degree of spinal curvature by this point, the curve may continue to progress into adulthood.
There are a number of theories regarding the cause of adolescent idiopathic scoliosis, which range from hormonal imbalances to asymmetric growth. About 30% of all adolescent idiopathic scoliosis patients have a family history of scoliosis, which suggests a genetic link. In most cases, adolescent idiopathic scoliosis patients do not experience any pain or neurologic abnormalities – they may even look normal when viewed from the side. When symptoms do develop, they typically take the form of uneven shoulders, a rib hump, or a leaning torso. This form of scoliosis is also sometimes correlated with lower back pain.
While curve progression may naturally slow as the child reaches skeletal maturity , ScoliSMART Clinics highly recommends muscle retraining through Early Stage Scoliosis Intervention (ESSI) as soon as a curve is detected.
Degenerative Scoliosis (De Novo Scoliosis)
Also known as adult onset scoliosis, late onset scoliosis, or de novo scoliosis, degenerative scoliosis is characterized by a sideways curvature of the spine that develops slowly over time. One of the natural consequences of aging is degeneration of the joints and discs in the spine. (In younger individuals, facet joints function like hinges, helping the spine to bend in a smooth motion with intervertebral discs to cushion the individual bones.) Uneven degradation of these discs and joints can cause spinal curvature to become more pronounced on one side – a hallmark of scoliosis.
Degenerative scoliosis most commonly develops in the lumbar spine, or the lower back, and it forms a slight C-shape. When the degree of sideways curvature exceeds 10 degrees (as measured by the Cobb angle), it is diagnosed as scoliosis. Although many forms of scoliosis are not painful, degenerative scoliosis certainly can be. Common symptoms include a dull ache or stiffness in the lower back, a radiating pain that spreads to the legs, a tingling sensation that runs down the leg, or a sharp pain in the leg that occurs while walking but subsides during periods of rest.
A recent study suggests that more than 60% of the adult population over the age of 60 has some degree of degenerative scoliosis.
De novo scoliosis is directly caused by age-related degeneration of the spine and occurs in adult patients who have no prior history of scoliosis. It is most commonly diagnosed in people over the age of 50 and it can be diagnosed through physical examination and x-rays. Patients with de novo scoliosis frequently complain of muscle fatigue and lower back pain, as well as stiffness and leg symptoms such as numbness or weakness. Over time, patients often develop poor posture and loss of balance, but treatment is tricky because there are increased risks associated with surgery in older individuals.
Technically a type of idiopathic scoliosis, neuromuscular scoliosis develops secondary to various disorders of the spinal cord, brain, and muscular system. Spinal curvature occurs when the nerves and muscles are unable to maintain the proper alignment and balance of the spine and trunk. This curvature is likely to progress into adulthood and may become increasingly severe in patients who are unable to walk. Patients who are confined to wheelchairs may have trouble sitting upright and may have a tendency to slump to one side.
Some of the underlying conditions known to contribute to neuromuscular scoliosis include myelodysplasia, cerebral palsy, Duchenne muscular dystrophy, Freidrich ataxia, and spinal muscular atrophy. Symptoms associated with neuromuscular scoliosis are typically not painful unless the spinal curvature becomes very pronounced. In many cases, the first sign of scoliosis is a change in posture – either leaning forward or leaning to one side while standing or sitting. Diagnosis can be confirmed through clinical exam and full spinal x-rays, which typically show a long, C-shaped curvature that affects the entirety of the spine.
Spine Anatomy for Scoliosis
To understand scoliosis, you first need to know what a healthy spine looks like. There are four regions in your spine
- Cervical spine – This is your neck, which begins at the base of your skull. It contains seven small spinal bones (called vertebrae), which doctors label C1 to C7 (the “C” means cervical). The numbers one to seven indicate the level of the vertebrae. C1 is closest to your skull, while C7 is closest to your chest.
- Thoracic spine – Your mid-back has 12 vertebrae that are labeled T1 to T12 (the “T” means thoracic). Vertebrae in your thoracic spine connect to your ribs, making this part of your spine relatively stiff and stable. Your thoracic spine doesn’t move as much as the other regions of your spine.
- Lumbar spine – In your low back, you have five vertebrae that are labeled L1 to L5 (the “L” means lumbar). These vertebrae are your largest and strongest vertebrae, responsible for carrying a lot of your body’s weight. The lumbar vertebrae are also your last “true” vertebrae; down from this region, your vertebrae are fused. In fact, L5 may even be fused with part of your sacrum.
- Sacrum and coccyx – The sacrum has five vertebrae that usually fuse by adulthood to form one bone. The coccyx—commonly known as your tail bone—has four (but sometimes five) fused vertebrae.
Normal Spinal Curves of Scoliosis
Lordosis and Kyphosis – When viewed from the side, you can see the spine has both inward and outward curves. These curves help your back carry your weight and are also important for flexibility.
There are two types of normal curves in your spine, and they are called kyphosis and lordosis. Kyphosis means the spine curves inward, and lordosis means the spine curves outward. There are two kyphotic and two lordotic spinal curves in a normal spine. Your cervical and lumbar spines each have a lordotic curve. Your thoracic spine and sacrum have kyphotic curves. While kyphosis and lordosis refer to a healthy curvature in your spine, they also describe abnormal spinal curves that are different than scoliosis. Abnormal lordosis is an extreme inward spinal curve.
Whereas scoliosis is defined as an abnormal curvature of the spine when viewed from the front, kyphosis is a forward rounding of the spine. Scoliosis most frequently affects the lower spine, or lumbar spine, while kyphosis usually affects the cervical spine and thoracic spine. Scheuermann’s kyphosis is one of three types of kyphosis and it is typically diagnosed during adolescence. It develops secondary to some structural deformity in the vertebrae and early symptoms include poor posture, back pain, muscle fatigue, and stiffness in the back. In most cases, these symptoms remain fairly consistent and they generally do not worsen over time except in severe cases.
As the name suggests, syndromic scoliosis is a form of scoliosis that develops secondary to some kind of syndrome. Some of the syndromes that are most commonly linked to syndromic scoliosis include Rett’s syndrome, Beale’s syndrome, muscular dystrophy, osteochondral dystrophy, and various connective tissue disorders. Because this condition can be linked to many different disorders, its symptoms are highly variable. Though symptoms are not typically painful, they can cause discomfort or pain with sitting when they are severe. Because the connection between various disorders and syndromic scoliosis is well-known, children who develop these disorders can be screened for scoliosis at an early age.
Causes of Scoliosis
Below are some of the possible causes of scoliosis
- Cerebral palsy
- Muscular dystrophy
- Birth defects
- Genetic conditions like Marfan syndrome and Down syndrome
- Neuromuscular conditions – these affect the nerves and muscles and include cerebral palsy, poliomyelitis, and muscular dystrophy.
- Congenital scoliosis (present at birth) – this is rare and occurs because the bones in the spine developed abnormally when the fetus was growing inside the mother.
- Specific genes – at least one gene is thought to be involved in scoliosis.
- Leg length – if one leg is longer than the other, the individual may develop scoliosis.
- Syndromic scoliosis – scoliosis can develop as part of another disease, including neurofibromatosis and Marfan’s syndrome.
- Osteoporosis – can cause secondary scoliosis due to bone degeneration.
- Other causes – bad posture, carrying backpacks or satchels, connective tissue disorders, and some injuries.
|Neuologic Disorders||Sign and Symptoms|
Tethered cord syndrome
|Weakness, sensory changes, problems of balance, gait and coordination, as well as bowel and bladder difficulties such as incontinence|
|Neurofibromatosis||café-au-lait spots or axillary freckles|
|Friedreich’s ataxia||Gait disturbance to speech problems. Heart disease and diabetes|
|Familial dysautonomia (Riley-Day syndrome)||Insensitivity to pain, instability to produce tears, poor growth and labile blood pressure|
|Werdnig-Hoffmann disease||Inefficiency of respiratory system – and pneumonia-induced respiratory failure|
|Duchenne muscular dystrophy||Progressive proximal muscle weakness of the legs and pelvis associated with a loss of muscle mass|
|Cerebral palsy||Spasticities, spasms, unsteady gait, problems with balance and decreased muscle mass|
|Poliomyelitis||Flaccid paralysis in one or more limbs with decreased or absent tendon reflexes, without sensory or cognitive loss.|
|Charcot-Marie-Tooth disease||High- arched or cavus feet|
|Connective Tissue Disorders|
|Ehlers-Danlos Syndrome||Marked ligamentous hyperlaxity and or skin elasticity|
|Marfan syndrome||Tall, long fingers, increased arm span to height ratio and cardiac abnormalities|
|Homocystinuria||Family history, seizures, Marfanoid habitus, seizures and mental retardation|
|Leg length discrepancy||Previous injury/fractures|
|Developmental dysplasia of the hip||Family history, positive Ortolani and Barlow tests|
|Osteogenesis imperfecta||Family history, multiple fractures, loose joints and respiratiory problems|
|Klippel-Feil syndrome||Spina bifida, cleft palate, short stature and cardiorespiratory problems|
Resulting from other conditions
Secondary scoliosis due to neuropathic and myopathic conditions can lead to a loss of muscular support for the spinal column so that the spinal column is pulled in abnormal directions. Some conditions which may cause secondary scoliosis include muscular dystrophy, spinal muscular atrophy, poliomyelitis, cerebral palsy, spinal cord trauma, and myotonia. Scoliosis often presents itself, or worsens, during an adolescent’s growth spurt and is more often diagnosed in females than males.
Scoliosis associated with known syndromes is often subclassified as “syndromic scoliosis”. Scoliosis can be associated with amniotic band syndrome,
- Arnold–Chiari malformation,
- Charcot–Marie–Tooth disease,
- Cerebral palsy,
- Congenital diaphragmatic hernia,
- Connective tissue disorders,
- Muscular dystrophy,
- Familial dysautonomia,
- CHARGE syndrome,
- Ehlers–Danlos syndrome (hyper-flexibility, “floppy baby” syndrome, and other variants of the condition),
- Fragile X syndrome,
- Friedreich’s ataxia,
- Loeys-Dietz syndrome,
- Marfan’s syndrome,
- Nail-patella syndrome,
- Osteogenesis imperfecta,
- Prader–Willi syndrome,
- Proteus syndrome,
- Spina bifida,
- Spinal muscular atrophy and
Symptoms of Scoliosis
Symptoms associated with scoliosis can include:
- Pain in the back, shoulders, and neck and buttock pain nearest the bottom of the back
- Respiratory and/or cardiac problems in severe cases
- Constipation due to curvature causing “tightening” of stomach, intestines, etc.
- Limited mobility secondary to pain or functional limitation in adults
- Painful menstruation
- Uneven musculature on one side of the spine
- Rib prominence or a prominent shoulder blade, caused by rotation of the rib cage in thoracic scoliosis
- Uneven hips, arms, or leg lengths
- Slow nerve action
- Heart and lung problems in severe cases
- Calcium deposits in the cartilage endplate and sometimes in the disc itself
Recent longitudinal studies reveal that the most common form of the condition, late-onset idiopathic scoliosis, causes little physical impairment other than back pain and cosmetic concerns, even when untreated, with mortality rates similar to the general population. Older beliefs that untreated idiopathic scoliosis necessarily progresses into severe (cardiopulmonary) disability by old age have been refuted by later studies.
Diagnosis of Scoliosis
The standard screening test for scoliosis is the “Adam’s forward bend test.” During the test, your child will bend forward with feet together, knees straight and arms hanging free. Your doctor will observe your child from the back, looking for a difference in the shape of the ribs on each side. A spinal deformity is most noticeable in this position.
The person’s gait is assessed, with an exam for signs of other abnormalities (e.g., spina bifida as evidenced by a dimple, hairy patch, lipoma, or hemangioma). A thorough neurological examination is also performed, the skin for café au lait spots, indicative of neurofibromatosis, the feet for cavovarus deformity, abdominal reflexes and muscle tone for spasticity.
When a person can cooperate, he or she is asked to bend forward as far as possible. This is known as the Adams forward bend test and is often performed on school students. If a prominence is noted, then scoliosis is a possibility and an X-ray may be done to confirm the diagnosis.
- A medical history – in which you answer questions about your health, symptoms, and activity.
- A physical exam to assess your strength – reflexes, sensation, stability, alignment, and motion. You may also need blood tests.
- Laboratory testing – may include white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).
- Elevated ESR – could indicate infection, malignancy, chronic disease, inflammation, trauma, or tissue ischemia.
- Elevated CRP – levels are associated with infection.
- Magnetic resonance imaging (MRI) scan – which uses magnetic fields and computers to produce three-dimensional images of your spine.
- A myelogram – an X-ray of the spinal canal after injection of contrast material which can pinpoint pressure on the spinal cord or nerves.
- X-rays – will provide clear images of the bones in your child’s spine. They allow your doctor to see the exact location of the curve and to measure how severe it is. In general, curves greater than 25° are considered serious enough to require treatment.
- A computed tomography (CT) scan.
- Urodynamic studies – may be required to monitor recovery of bladder function following decompression surgery.
- Imaging scans – If there are further symptoms, such as back pain, or if symptoms are severe, an MRI or CT scan may be ordered.
- As an alternative, a scoliometer may be used to diagnose the condition – When scoliosis is suspected, weight-bearing, full-spine AP/coronal (front-back view) and lateral/sagittal (side view) X-rays are usually taken to assess the scoliosis curves and the kyphosis and lordosis, as these can also be affected in individuals with scoliosis. Full-length standing spine X-rays are the standard method for evaluating the severity and progression of scoliosis, and whether it is congenital or idiopathic in nature. In growing individuals, serial radiographs are obtained at 3- to 12-month intervals to follow curve progression, and, in some instances, MRI investigation is warranted to look at the spinal cord.
- The standard method for assessing the curvature quantitatively is measuring the Cobb angle, which is the angle between two lines, drawn perpendicular to the upper endplate of the uppermost vertebra involved and the lower endplate of the lowest vertebra involved. For people with two curves, Cobb angles are followed for both curves. In some people, lateral-bending X-rays are obtained to assess the flexibility of the curves or the primary and compensatory curves.
Treatment of Scoliosis
Treatment options for idiopathic scoliosis could include
- Observation – Typically, a doctor will advise observation for a scoliosis curve that has not yet reached 25 degrees. Every 4 to 6 months, the doctor will take another X-ray of the spine to see if the scoliosis is progressing or not.
- Bracing – If scoliosis has progressed past 20 or 25 degrees, a back brace could be prescribed to be worn until the adolescent has reached full skeletal maturity. The goal of bracing is to prevent the curve from getting worse and to avoid surgery.
- Thoracolumbosacral orthosis (TLSO) – the TLSO is made of plastic and designed to fit neatly around the body’s curves. It is not usually visible under clothing.
- Milwaukee brace – this is a full-torso brace and has a neck ring with rests for the chin and the back of the head. This type of brace is only used when the TLSO is not possible or not effective
If the curve continues to progress despite bracing, surgery could be considered. The most common surgical option for scoliosis today is a posterior spinal fusion, which can offer better corrections with fewer fusion levels (preserving more back mobility) than what was done in years past.
Braces used for scoliosis
- Bracing – For curves between 25 and 45 degrees below the level of T8 in general, and there is a risk of curve progression. Bracing should be considered so that the curve does not progress with time. In past braces were uncomfortable and embarrassing. Now thoracolumbar braces come in a variety of shapes, size, and padding (Milwaukee brace, Boston brace and the Charleston brace). A meta-analysis by Row et al. [rx] has shown a 93% success rate for bracing 23 hours per day. Although bracing has been shown to be effective, compliance is poor and it is associated with psychological stress [rx]. It is important to counsel adolescents and their parents that bracing does not correct scoliosis but may prevent significant progression of the spinal curvature. Use of a brace is continued until the patient reaches Risser grade 4 or 5. Although bracing is moderately successful, its efficacy is not fully proven due to lack of strong evidence [rx].
Actually, 25 papers were found on this topic. It should be emphasized that the aim of this article was only to introduce the orthoses not to compare their performances. As can be seen from [rx], the spinal orthoses can be divided into rigid and soft orthoses based on the structure of the orthosis.
- One of the commonly used high profile orthoses is Milwaukee orthosis. This is the first modern orthosis designed to treat spinal deformities. It was developed by Blount and Schmidt for postoperative treatment of postpolio scoliosis.[rx]
- This orthosis consists of pelvic section (which is mainly made from plastic), anterior and posterior uprights, and neck ring with throat mold anteriorly and occipital pads posteriorly. It is used mostly for the patients with apex of curve above T8.[rx] Another types of braces used for scoliosis are TLSOs which were first applied by Watts team for the patients with progressive AIS and curve apex below T8.[rx]
- Actually, it is the most common used braces in North America, which was developed by John Hall and William Miller at Boston children Hospital in 1972.
- Now, this brace is produced commercially in six different sizes to reduce manufacturing time and cost. This is a posterior opening TLSO which passively correct the scoliotic curve.[rx]
- This brace was introduced by Dr. Jacques Chenean in the sixth decade. However, officially was presented in 1979 in Bratislava. It has been shown that this orthosis has two mechanisms of actions including active and passive.
- Although the aim of orthotic treatment of scoliosis is curve progression control, Cheneau brace seems to correct the curvatures in some cases.[rx]
Rigo Cheneau brace
- This brace was developed by Rigo Manuel in the early 90s. This brace is mostly recommended for the patients with mild to moderate juvenile scoliosis. It is based on concept of equilibrium at L4/L5 level.[rx]
- The Cobb angle correction of the main curvature is considered to be set at 53.7%. However, in the patients with a single long dorsal curvature, the curve correction is set at 76.7% and 55% in axial rotation cases.[rx]
Cheneau light brace
- This brace is actually a TLSO with front opening. It applies specific pressure on torso to modify scoliotic curve and to prevent curve progression. It is recommended to use this orthosis particularly at night for low curvature (Cobb angle <30).[rx]
- In contrast to other previous orthoses, this brace provides a dynamic correction force to correct scoliosis. Due to the location of the hinge section of the orthosis, this orthosis can be only used for curve below T11.[rx]
- The name of Triac comes from three C’s including comfort, control, and cosmesis. The main point of the design of this orthosis was that the brace follows the motion of the patients. The interesting point regarding this orthosis is that the immediate correction of 22% can be achieved for primary curve and 35% for the secondary curve.[rx]
- Actually, this brace acts on single curve deformity and the design of the brace allows trunk movement, and hence, patients have more comfort while wearing the brace.[rx]
Scoliosis Lycra orthosis
- This orthosis is used for the patients with neurological scoliosis. In this orthosis, a simple panel was added on the convex side of the brace to decrease the progression of the curve. Use of this orthosis is mostly recommended for the patients with cerebral palsy.[rx]
- Actually, this is a dynamic orthosis which was developed in 1992–1993. The design of this orthosis is based on active biofeedback mechanism. The effectiveness of the SpineCor brace has been recommended for mild and moderate curves.[rx]
- This is a custom-molded spinal orthosis which holds the patients in overcorrected position. This brace seems to alter the natural history in retrospective studies with 5–10 h wearing time.[rx]
Long lever scoliosis brace
- This orthosis was designed to treat large translational displacement associated with idiopathic scoliosis. The amount of the force required to stabilize the scoliosis curve decreases follow the use of long lever arm system.[rx]
- This is also an orthosis which can be used during night. This brace puts the spine in an overcorrected position by application of the opposing forces. It is designed especially for curvature abnormalities.[rx]
- This brace was named in honor of the Medieval Sferza family in 2004 to avoid casting procedure, especially for the worst patients based on SPoRT (symmetric patient-oriented, rigid three-dimensional, active) concept of bracing.
- It is constructed from polycarbonate in two pieces which connected in anterior and posterior sides by a closure and a vertical aluminum bar, respectively.[rx]
- This has the same structure as Sforzesco brace which is made from polycarbonate. The only difference was that Lapadula brace does not have the upper plastic part over the breast. It is also recommended to be used for the patients with hyperkyphosis and scoliosis.[rx]
- This orthosis has the same structure as Lapadula brace and also made from polycarbonate sheet.[rx]
Dynamic derotational brace
- This orthosis was designed and used by surgeon and spine unit of KAT orthopedic Hospital in Athens, with collaboration of Mr Nikolas Vastatzidis of Athen.[rx] Actually, this is a modification of Boston limited pressure, with addition of a system of light and slightly flexible blades made of aluminum. The results of the study of this brace showed that the brace not only restrict the progression of the curve but also correct it. It can be produced based on traditional cast method or use of CAD/CAM technology.[rx]
Progressive Action Short Brace
- It is a custom-made TLSO introduced by Dr. Lorenzo Aulisa at Institute of orthopedic Catholic University. The brace is based on principle that constrained spines can achieve the correction through the use of inverting the abnormal loads distribution during growth.[rx]
Spinealite soft brace
- This orthosis is also called CMCR brace (Correct Monocoque Carbone respectant la Respiration). This monoshell brace was developed by Lecanto society at the center des Massues in Lyon, in 1997. The pads of the brace in contrast to the pads of Lyon are mobile and more comfortable. This is a light brace reinforced by carbon blades and implemented without prior casting.[rx]
- Actually, after the development of CAD/CAM modeling, most of the braces have been developed by use of this system. In 2013, the new generation software (OrthenShape) allowed the overlay of different CAD/CAM modulus.
- The brace which was produced by the use of this technology, based on Lyon approach, is called ART brace. ART is the acronym for asymmetrical, rigid, torsion brace. The name was created by Stefano Negrini, the inventor of Sforzesco brace.[rx]
- Actually, Lyon brace created in 1947 by Pierre Stagnara to be adjustable, active, decompressive, symmetrical, stable, and transparent. It is possible to adjust the orthosis up to 7 cm of growth. It was made of polymethyl methacrylate which is transparent to monitor the skin conditions.[rx]
- The design of this brace is based on stretching of the ligaments of the spine to a certain point for a prolonged period by the use of plaster cast for 4 weeks. After that, the brace can be used especially during night to maintain viscoelastic level of the structure.
- The indication of use of this orthosis is the same as other orthoses. However, it is recommended to not be used for juvenile and infantile scoliosis to avoid a tubular thorax and also for those with sever thoracic lordosis for whom the treatment is mostly surgical.[rx] It is also recommended to not be used for those with major psychological reactions and those with nonacceptation of the plaster cast.
- This brace was designed by G Dean Mac Even to improve patients’ compliance by making the brace less bulky and light weight compared to other braces. Actually, it is a custom-made TLSO orthosis from orthoplast.
- The design of this orthosis is the same as body jacket with an anterior opening. There are some adjustable straps to secure the orthosis. It is recommended to wear the orthosis as full time (23 h per day).[rx]
- It should also be emphasized that the scoliotic brace can be categorized into soft and rigid orthoses. Figure [rx] shows the classification of the braces based on structure. It is also possible to classify the scoliosis brace based on the time of wear.
- Another type of conservative treatment which is recommended for scoliotic patients is exercise. Beside of the routinely used exercise for scoliosis, some especial approaches have prescript for the patients with scoliosis which can be mentioned as following.
Functional individual therapy of scoliosis
- It is based on inclusion of many elements selected from variety of therapeutic approaches that have been adapted from a different treatment concepts.[rx] This method was created in Poland, which was aimed to improve postural problems and scoliosis.
- Actually, this is a method of diagnosis and therapy for idiopathic scoliosis. It can be used to correct scoliosis, a supportive therapy to bracing, preparation of children for surgery, and may be used after surgery to correct shoulder and pelvic girdles.[rx]
- It is a postural reeducation method which consists of combinations of corrective movement and global muscles rebalance exercise.[rx]
The Lyon approach
- Lyon approach is a method of physical therapy which is used in combination with Lyon brace. Three main parameters are considered with this approach including patient age, postural imbalance, and Cobb angle.[rx]
Dobomed physical therapy approach
- It should be emphasized that this method was also developed in Poland that addresses both trunk deformity as well as respiratory function impairment. This method requires a high degree of patient cooperation. Therefore, it is not recommended for children.[rx]
Barcelona scoliosis physical therapy
- This method of treatment is based on this assumption that scoliosis posture and soft tissue imbalance promote curve progression. Actually this is physical therapy method which can be defined as a therapy plane of cognitive, sensory motor, and kinesthetic training.[rx]
Scientific exercise approach to scoliosis
- As can be understood from the title, this approach is based on scientific principles. This is an extension of Lyon approach which is based on four principles including improving the patient’s awareness of their deformity, autonomous correction by the patients, use of exercise to stimulate a balanced reaction, and use of in brace scoliosis specific exercise.[rx]
- Actually, this method was developed in Germany in 1927 by Katrina Schroth. This is a method to correct the scoliosis in three dimensions. It was aimed to reduce the incidence of scoliosis progression, reduce postural rotation, improve mobility, improve postural stability, reduce pain, and improve cardiopulmonatory function in scoliosis.[Rx]
- There are some evidences in the literature regarding the effects of these exercises on scoliosis correction. Footwear, wedge, and insoles are the other conservative approaches used for the patients with scoliosis. This is based on this theory that incongruity of pelvis, especially sacroiliac joint, can induce deformation of lower extremity which finally lead to scoliosis.[rx] However, there is no evidence regarding the effectiveness of this method.
Functional electrical stimulation
- Although the development of this method returned to around 1980, it seems to be ineffective in treatment of scoliosis. At present, the results of some studies showed that if FES combine with other exercise or brace, it may be more effective.[rx]
- Actually, sharp and sensitive needles are used to stimulate a certain part of body. It used most often in Chinese medicine also for scoliosis and to reduce the pain associated with low back pain. Based on the available literature, it is too difficult to reach a strong conclusion regarding the effects of acupuncture on scoliosis.[rx]
Scoliosis surgery (spinal fusion)
In severe cases, scoliosis can progress over time. In these cases, the physician may recommend spinal fusion. This surgery reduces the curve of the spine and stops it from getting worse.
Scoliosis surgery involves the following
- Bone grafts – two or more vertebrae (spine bones) are connected with new bone grafts. Sometimes, metal rods, hooks, screws, or wires are used to hold a part of the spine straight while the bone heals.
- Intensive care – the operation lasts 4-8 hours. After surgery, the child is transferred to an ICU (intensive care unit) where they will be given intravenous fluid and pain relief. In most cases, the child will leave the ICU within 24 hours but may have to remain in the hospital for a week to 10 days.
- Recovery – Children can usually go back to school after 4-6 weeks, and can take part in sports roughly 1 year after surgery. In some cases, a back brace is needed to support the spine for about 6 months.
The patient will need to return to the hospital every 6 months to have the rods lengthened – this is usually an outpatient procedure, so the patient does not spend the night. The rods will be surgically removed when the spine has grown.
A doctor will only recommend spinal fusion if the benefits are thought to outweigh the risks. The risks include:
- Rod displacement – a rod may move from its correct position. Although not uncomfortable, the patient may need further surgery.
- Pseudarthrosis – one of the bones used to fuse the spine into place does not stick properly. Some patients may experience mild discomfort, and the spine will not be corrected as successfully. Further surgery may be needed.
- Infection – this is usually treated with antibiotics medication.
- Nerve damage – damage occurs to the nerves of the spine. Results can range from mild, with numbness in one or both legs, to paraplegia (loss of all lower bodily functions). A neurosurgeon may be present for scoliosis surgery.