Scoliosis

Introduction

Scoliosis is the abnormal curvature of the spine to the sides.

It does not usually cause noticeable symptoms in children other than affecting the appearance of the back.

Physical signs of scoliosis may include:

  • a visibly curved spine
  • one shoulder or hip being more prominent than the other
  • clothes not hanging properly
  • a tendency to lean to one side

Ususally only adults with scoliosis experience back pain.

Read more about symptoms of scoliosis.

Seeking medical advice

If you or your child shows physical signs of scoliosis, you should make an appointment to see your GP.

Your GP can carry out a physical examination of your back, but you may be referred for an X-ray to confirm the diagnosis.

Read more about diagnosing scoliosis.

Why does scoliosis happen?

The cause of scoliosis is often not identified. This is known as idiopathic scoliosis and accounts for about eight out of every 10 cases.

Some cases of scoliosis are caused by other medical conditions, including:

  • cerebral palsy – a condition caused by brain damage that occurs during birth or shortly afterwards
  • muscular dystrophy – a genetic condition that causes muscle weakness 
  • Marfan syndrome – a disorder of the connective tissues

In rare cases, scoliosis can be present from birth, due to a problem with the development of the spine in the womb.

In adults, the condition can be the result of damage to the spine or due to previously undiagnosed scoliosis that worsens over time.

Read more about the causes of scoliosis.

Who is affected?

It used to be thought that scoliosis was a childhood condition. However, it is now recognised as a condition that increasingly affects older adults. This is most likely due to the increasing age of the population.

In the UK, scoliosis affects three to four children out of every 1,000. It can develop at any age, but is more common at the start of adolescence.

It is thought that as many as 7 out of 10 older adults aged 65 or over have some degree of scoliosis.

Scoliosis is more common in females than males.

How is scoliosis treated?

The majority of children with scoliosis do not require treatment because the condition is mild and corrects itself as the child grows.

If treatment is necessary, a back brace worn until the child stops growing is usually successful in preventing the spine from curving further. Very few children will require surgery to correct the position of their spine.

In adults, it is usually too late to correct the position of the spine so treatment aims to relieve the symptoms of pain. Non-surgical options, such as painkillers, are the first line of treatment with surgery seen as a last resort.

Read more about treating scoliosis in children and treating scoliosis in adults.

Further problems

Scoliosis can sometimes cause further emotional and physical problems.

Having a visibly curved spine or wearing a back brace can cause problems related to body image, self-esteem and overall quality of life. This is particularly the case for children and teenagers with scoliosis.

In rare cases, scoliosis can cause the upper spine to twist (kyphosis) and the curvature of the spine can put increased pressure on the heart and lungs.

Read more about the possible complications of scoliosis.



Symptoms of scoliosis

Most people with scoliosis notice a change in the appearance of their shoulders, chest or hips.

Physical appearance

Signs of scoliosis include:

  • one shoulder being higher than the other
  • one shoulder blade being more prominent than the other
  • one hip being more prominent than the other
  • clothes not hanging properly
  • the child may lean to one side

If you or your child is usually in a wheelchair, there may be a tendency to lean to one side.

Make an appointment to see your GP if you notice any of the symptoms listed above in yourself or your child.

Back pain

Most cases of scoliosis do not cause back pain. However, the condition can become painful if the curvature of the spine worsens. This is more common in adults who had mild scoliosis that became gradually more severe.

The pain is usually located at the site of the curve, with nearby muscles also feeling sore and tender.

Some people find the pain is worse when they are sitting or standing and that it improves when they lie down flat on their back or on their side. In other cases, the back pain is constant, regardless of the position you are in.

You may feel pain that travels from your spine into your hip, legs or, less commonly, your arms. This can happen when you’re standing or walking.

Other symptoms

Although uncommon, scoliosis can also affect the nervous system. Problems occur when the bones in the spine compress on one or more nerve endings. This may lead to symptoms including:



Causes of scoliosis

In most cases, the cause of scoliosis is unknown and it cannot usually be prevented.

The condition is not thought to be linked with things like bad posture, exercise or diet.

Unknown cause

If the cause of scoliosis is unknown, it is called idiopathic scoliosis. About 8 out of every 10 cases of scoliosis are idiopathic.

However, researchers have found that in about a third of idiopathic scoliosis cases, there is some family history of the condition, which suggests a genetic link.

Idiopathic scoliosis can affect adults and children. Many cases of scoliosis in adults are thought to be milder cases of idiopathic scoliosis that have only become more severe in later life.

Other health conditions

Many cases of scoliosis are caused by conditions that affect the nerves and muscles (neuromuscular conditions), such as:

  • cerebral palsy – a condition caused by brain damage that occurs during or shortly after birth
  • muscular dystrophy – a genetic condition that causes muscle weakness

Although rare, scoliosis can also develop as part of a pattern of symptoms called a syndrome. This is known as syndromic scoliosis. Conditions that can cause syndromic scoliosis include:

  • Marfan syndrome – a disorder of the connective tissues inherited by a child from their parents
  • Rett syndrome – a genetic disorder, usually affecting females, which causes severe physical and mental disability

These conditions are usually diagnosed at a young age and children with them are often monitored for problems such as scoliosis.

Birth defect

In rare cases, scoliosis is present at birth. This is known as congenital scoliosis. Congenital scoliosis is caused by the bones in the spine developing abnormally in the womb.

Long-term damage

In adults, scoliosis can sometimes be caused by gradual damage to the parts of the spine. This is known as degenerative scoliosis.

Some parts of the spine are known to narrow and weaken with age, which can explain some cases of degenerative scoliosis.

Other possible causes include:



Diagnosing scoliosis

Scoliosis can usually be diagnosed after a physical examination of the spine, ribs, hips and shoulders.

You may be asked to bend forward to see if any areas are particularly prominent. For example, one of your shoulders may be higher than the other or there may be a bulge in your back.

Initial examinations are usually carried out by a GP, although a school nurse may carry them out if they suspect scoliosis in a child.

After an examination, you or your child may be referred to an orthopaedic specialist (a specialist in conditions that affect the skeleton) for further tests.

Scans

The orthopaedic specialist will take an X-ray to confirm the diagnosis of scoliosis.

The X-ray images will also help determine the shape, direction, location and angle of the curve. The medical name for the angle the spine curves is known as the Cobb angle.

In some cases, further tests such as a magnetic resonance imaging (MRI) scan or a computerised tomography (CT) scan may be recommended. 

If you have symptoms suggesting damage or irritation to your nerves, you may be referred for a more advanced type of X-ray where a special dye is injected to highlight the area around the spine.



Treating scoliosis in children

If your child has scoliosis, the treatment they receive will depend on their age and the severity of their condition.

There are three main treatment options:

  • observation
  • bracing
  • surgery

Theses are described below.

Observation

Treatment for scoliosis is often unnecessary because most cases are not severe and the condition often corrects itself as the child grows.

However, X-rays are needed every six months so that the progress of the curvature can be carefully monitored.

Bracing

If the curve of your child's spine is more severe (with an angle of more than 20 degrees) or it gets gradually worse, a brace will usually be required. A brace cannot cure scoliosis or correct the curve, but it can stop the curve from getting worse.

The brace will need to be carefully fitted to your child's spine. To do this, a cast of your child's back will need to be taken. This can be done on an outpatient basis, which means that your child will not have to stay overnight in hospital. Instead, they will have one or more appointments at a hospital or clinic.

It is usually recommended that the brace is worn for 23 hours a day, and that it is only removed for baths and showers. The brace should not interfere with normal everyday activity and can be worn during most non-contact sports. However, it is recommended that the brace is removed during contact sports.

It is important for children who wear a brace to take regular exercise. This will help improve muscle tone and body strength, and will help make wearing the brace more comfortable.

The brace will have to be worn for as long as your child's body is still growing. Boys typically stop growing at around the age of 17 and girls typically stop growing at around the age of 15.

Most braces are made of rigid plastic, although a type of flexible brace has been developed more recently. Availability of flexible braces is limited however, and they are only available privately in some areas.

In general, modern back braces are designed so that they are virtually impossible to see under loose-fitting clothing

Surgery

If your child's scoliosis is severe (if their spine has a curve of more than 50 degrees), or other treatments are unsuccessful, spinal fusion surgery may be required.

Spinal fusion surgery is a complicated technique where the spine is straightened using metal rods and screws, before being fused into place using bone grafts.

The surgery will take several hours. After surgery, your child will be transferred to an intensive care unit (ICU), where they will be given intravenous fluid (administered through a vein) and pain relief. Most children are well enough to leave intensive care after 24 hours, although they will often need to spend another 5-10 days in hospital.

After the operation, most children can return to school after four to six weeks and can play sports a few months after having surgery. Some children may need a back brace to protect the metal rods after surgery.

Your child will need to return to hospital about every six months to have the rods lengthened to keep up with their growth. This is usually done as an outpatient procedure, using small incisions (cuts) in the back.

A newer type of rod that can be extended using magnets is being developed, but these are not yet in common use. Incisions are not required to lengthen these rods.

Sometimes the rods are removed during surgery when your child is older and their spine has grown, although they may be left in if they don't cause any problems.

Risks of spinal fusion surgery

There are several risks associated with spinal fusion surgery. It will not be recommended for your child unless the surgeon feels the benefits outweigh the risks. It is important that parents and children understand the risks of spinal fusion surgery so that they can make an informed decision about treatment.

The known risks of spinal fusion surgery are described below:

  • Rod displacement. In around 5% of people who have surgery, one of the rods used to straighten the spine will move from its correct position. This should not cause any discomfort, but additional surgery may be required to return the rod to its correct position.
  • Pseudarthrosis occurs when one or more of the bones used to fuse the spine into place fails to graft properly. Pseudarthrosis happens in around 1-5% of cases. It can cause mild discomfort and, in some people, can also cause some loss of the correction of the curvature of the spine. Further surgery will be needed to re-graft the relevant bones.
  • Infection. Around 1-2% of people develop an infection after surgery. However, this can usually be easily treated with antibiotics.
  • Nerve damage. In very rare cases (in about one or two cases in every 1,000), spinal fusion surgery will cause damage to the nerves in the spine. The results of this nerve damage can be relatively mild (a feeling of numbness in one or both legs), or it can be more severe and cause a loss of all lower bodily functions (paraplegia).

Additional therapies

There is no reliable evidence to suggest that additional therapies such as osteopathy (manipulation of the muscles, nerves and joints), reflexology (massage of certain areas of the body to improve general health) and acupuncture (sticking needles into certain points of the body to improve health) can be used to correct the curvature of the spine or stop it progressing.

However, physiotherapy may be beneficial when used in combination with a back brace.



Treating scoliosis in adults

In adults, treatment usually focuses on relieving any pain.

Medication

Painkilling medication is usually recommended to help relieve the painful symptoms associated with scoliosis.

Paracetamol is usually the first line of treatment. If paracetamol does not work, non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can be used.

If you are experiencing nerve pain as a result of your spine compressing or irritating the nerve endings, a nerve block may be recommended. This involves having local anaesthetic injected directly into the affected nerves. A nerve block should provide short-term relief because the local anaesthetic stops the pain signals that are being transmitted from the nerves reaching your brain.

If it is thought that osteoporosis of your spine is contributing to your symptoms, you may be given medication and supplements to help strengthen your bones. Find out more about treating osteoporosis

Braces

Braces are not often used to treat scoliosis in adults, although they can provide pain relief.

If you find that walking irritates your spine because one leg is longer than the other due to the curve of your spine, you may benefit from using special shoe inserts called orthotics that can help correct your posture.

Exercise

General strengthening and stretching exercises are commonly advised for people with scoliosis. These may be carried out alone or combined with other treatments.

However, there is some debate as to the effectiveness of exercise in helping people with scoliosis. Recent research into this issue has shown no evidence for or against exercise as a treatment for scoliosis.

Nevertheless, exercise remains a good way to improve your general health and wellbeing.

Read more about health and fitness.

Surgery

Due to the relatively high risks associated with spinal surgery, surgery for scoliosis is usually only recommended in severe cases.

Surgical options for scoliosis include:

  • decompression – if a disc is pressing down on a nerve, the disc can be removed to reduce the pressure on the nerve
  • spinal fusion surgery – where the position of the spine is corrected using metal rods, plates or screws before being fused into place using bone grafts

Common complications of spinal surgery include:

  • the surgery fails to achieve a significant reduction in symptoms of pain; this occurs in around 30% of adults with scoliosis
  • in cases of spinal fusion surgery, sections of the spine may fail to fuse together properly; this occurs in an estimated 5-10% of cases

Less common complications of spinal surgery include:

  • infection – which occurs in an estimated 1 in 50 cases
  • blood clots – which occur in an estimated 1 in 100 cases
  • retrograde ejaculation in men – where sperm travels backwards into the bladder when you ejaculate rather than out of your penis; this happens as a result of nerve damage and occurs in an estimated 1 in 100 cases

More serious nerve damage can result in the loss of bladder or bowel function and cause urinary and bowel incontinence. However, this is rare.



Possible complications of scoliosis

Physical complications of scoliosis are rare. However, if left untreated, serious complications can develop.

Some problems scoliosis can cause are outlined below.

Emotional issues

Having a visibly curved spine or wearing a back brace can be difficult as it may cause problems related to body image, self-esteem and overall quality of life. This is particularly the case for children and teenagers with scoliosis.

Modern back braces are designed to be difficult to see under loose-fitting clothing. However, your child may still worry that they look different or unusual.

Encouraging your child to talk with other teenagers who have scoliosis can help improve their confidence and lessen any feelings they are alone with their condition.

There are several support groups, such as Scoliosis Association UK, that provide information and support for people with scoliosis. Some also host message boards so teenagers from across the world can compare experiences, share tips and exchange messages of encouragement.

Kyphosis

If a severe case of scoliosis is left untreated, it can cause the upper spine to twist, resulting in a rounded or hunched back. This is known as kyphosis and will also cause back pain.

Lung and heart problems

In severe cases of scoliosis (where the curve is 70 degrees or more) the ribcage can be pushed against the heart and lungs, causing breathing problems and making it difficult for the heart to pump blood around the body.

In very severe cases of scoliosis (where the curve is 100 degrees or more) the ribcage will be pushed harder against the heart and lungs, causing physical damage. Strain or damage to the heart and lungs increases the chances of lung infections developing, such as pneumonia and heart failure.

Other back problems

Adults who had scoliosis when they were children are more likely to develop chronic (long-term) back pain. Those with scoliosis that is untreated are also more at risk of developing arthritis in their spine.