Scoliosis: A Sensible Approach
Mark S. Rosenthal, M.D.
There are several types of scoliosis. Fortunately, most are rare. The common type is "idiopathic scoliosis," so called because the cause is unknown. It affects about 4% of the population, but is more common among females. Idiopathic scoliosis usually starts between the ages of 10 and 12. As the child grows, there is a chance the curve can progress (worsen). Most curves will not worsen during adolescence and worsening after growth is complete is unusual.
Other types of scoliosis include congenital (caused by an abnormally shaped bone that is present at birth); neuromuscular (due to a neuromuscular disease such as cerebral palsy, muscular dystrophy, etc.); acquired (following a fracture, radiation therapy for cancer, etc.); and juvenile. Juvenile scoliosis is similar to adolescent scoliosis, but it is much more likely to progress.
Before considering treatments for scoliosis, it is important to know the natural history of the disease (what happens if left untreated). Curves that measure 10 degrees or less are considered "normal" and do not interfere with strength, joint mobility, endurance, or any other body function. They are not true scoliosis, almost never progress, and do not increase the likelihood of developing back pain, arthritis, disc herniation, or any other musculoskeletal problem. Treatment of scoliotic curves of 10 degrees or less is therefore unnecessary. Sometimes these minimally curved spines even get straighter on their own.
Curvatures that measures between 10 and 20 degrees bear watching. These behave much the same as those under 10 degrees (and thus would cause no problem later in life), except that they may progress during growth. Therefore, if a patient has finished growing and has a curve less than 20 degrees, no further treatment or follow-up is needed. A child with a curve between 10 and 20 degrees should be examined periodically and treatment begun if the curve exceeds 20 degrees (or, depending on other factors, such as location, 25 degrees). Curves that are discovered when they exceed 20 degrees should get treated immediately, if there is still a potential for growth.
Treatment options include bracing and surgery. Bracing works well for curves of up to 45 degrees. The smaller the curve, the more effective the brace. Beyond 45 degrees, a brace will be ineffective, and surgery is the treatment of choice. Early detection and treatment with a brace may therefore prevent worsening that would require surgery.
Because braces work so well if treatment is started early, early detection of curves should be a major objective. Medical doctors, especially orthopedic surgeons, have instituted aggressive educational campaigns to increase the likelihood that children with significant curvature will be found early. The Scoliosis Research Society and the American Academy of Orthopaedic Surgeons have promoted these campaigns. Pediatricians now routinely screen children on a regular basis. School screening programs are almost universal across the United States. As these programs became more prevalent, the rates for surgery dropped dramatically. Surgery is reserved for those children whose curves were discovered when they were too large for a brace, or the approximately 10% of children who fail brace treatment.
The medical profession would like to be able to offer a treatment that is easier and more pleasant than a brace. Much effort and research have been put into developing more comfortable and more effective braces, so that treatment is better tolerated and surgery can be avoided. Over the years many alternative treatments have been proposed. These include spinal manipulation, massage therapy, exercising, and electric stimulation. Unfortunately, when subjected to rigorous scientific testing, these approaches have been found to be either worthless or much less effective than bracing. Surgery is the only treatment method that can significantly lower the magnitude of a scoliotic curve. The goal of brace management is to stop the curve from worsening. Remember that a patient with a curve maintained at a small degree is indistinguishable from a patient with no curve. For the majority of patients there is no advantage in lessening the magnitude of the curve.
Curves of 60 degrees or more, which are rare, present a special problems. Even after the child finishes growing, there is a strong likelihood the curve will continue to progress. This leads to significant deformity of the chest and interference with the function of the heart and lungs. The muscles are displaced and can cause pain. With time, the unequal forces on the spine lead to arthritis. No treatment other than surgery has ever been shown to work for these patients.
The Bottom Line
The mainstay of scoliosis management is early detection. If the curve progresses to the point that treatment is needed, a brace is prescribed. In 90% of such cases, a brace will work very well. Scoliosis screening programs have drastically reduced the number of children who need surgery.
Dr. Rosenthal, a Quackwatch advisor, is assistant professor of orthopaedic surgery at the University of Maryland School of Medicine in Baltimore, Maryland.
This article was revised on February 7, 1998.