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Could that problem back be scoliosis?

Case history

Mrs Jones brings in her seven-year-old daughter Natasha to see you. Over the last six months mum has noticed Natasha seems to have become a little 'lopsided'. She thinks it's because Natasha does not stand up straight. What really got her worried was the teacher at school mentioned that Natasha might have 'scoliosis'. She would like you to have a look as the problem appears to be worsening.

Dr Tanvir Jamil discusses.

What do I need to know about scoliosis?

Scoliosis is a curvature of the spine in the coronal plane. It is a descriptive term and not a diagnosis. Non-structural or mobile scoliosis has no rotational element. The curvature is secondary or compensatory to some condition outside the spine and disappears when that is corrected ­ for example leg inequality produces a scoliosis that disappears on sitting.

In structural or true scoliosis, the deformity is non-correctible. The curve is associated with rotation and, sometimes, wedging of the vertebrae.

Scoliosis affects 2 per cent of women and 0.5 per cent of men in the general population. As well as this female preponderance scoliosis is also more likely to progress and require treatment in girls than boys ­ possibly related to the more rapid female pubertal growth spurt.

There are many causes of scoliosis, including congenital spine deformities

(eg hemivertebrae), neuromuscular problems (eg muscular dystrophies), metabolic (eg Paget's disease, rickets), infection (eg TB) and limb length inequality.

Other causes include cerebral palsy, spina bifida, spinal muscular atrophy and tumours. Hereditary tendencies also occur ­ approximately 20 per cent of children with scoliosis have family members with the same condition.

Although the daughters of affected mothers are more likely than other children to experience scoliosis, the magnitude of curvature in an affected individual is not related to the magnitude of curvature in relatives.

More than 80 per cent of scoliosis cases, however, are idiopathic. Idiopathic scoliosis has four categories based on age:

·infantile: children aged three and under ­ mainly boys affected

·juvenile: three to nine years old

·adolescent: 10-18

·adult: after skeletal maturity.

What kind of history do I need from Natasha's mum?

When considering scoliosis there are several areas you need to ask about:

·At what age was the spinal deformity first noted? This information is important in determining the prognosis and severity of the scoliosis.

·Who first noted the problem?

·What is the Natasha's prenatal history? Was there anything unusual about the pregnancy?

·Did she meet her normal developmental milestones?

·Is there a family history of scoliosis or other spinal problems?

·Does Natasha experience any back pain? Generally speaking, scoliosis in children and adolescents is not painful. If pain exists, further tests should be conducted for tumours, herniated discs or other abnormalities.

What signs should I be looking for?

·Shoulders are different heights ­ one shoulder blade is more prominent than the other

·Head is not centred directly above the pelvis

·Appearance of a raised, prominent

hip

·Rib cages are at different heights

·Uneven waist

·Changes in look or texture of skin overlying the spine (dimples, hairy patches, colour changes)

·Leaning of entire body to one side

What about the examination?

The Adam's Forward Bend Test is an easy method of examination that can be used as a simple screening test.

The patient is asked to lean forward with her feet together and bend 90 degrees at the waist. The examiner positions himself behind the patient and from this position can easily view any asymmetry of the trunk or any abnormal spinal curvatures.

This test can detect potential problems, but cannot determine accurately the exact severity of the deformity. The presence of a hump or asymmetry is the hallmark of a scoliotic deformity. The corresponding area opposite the lump is typically depressed due to spinal rotation.

What kind of investigations will Natasha need?

X-rays (PA and lateral standing) of the entire spine must be obtained for assessment of the scoliosis. The degree of curvature is measured between the most tilted vertebrae at each end of the curve. Other radiographic procedures that may occasionally be used include CT scanning and MRI.

MRI is the procedure of choice for evaluating coexisting spinal cord defects in children with congenital scoliosis.

What can I tell Natasha's mum about treatment options?

There are several things to take into consideration when discussing treatment options:

·Spinal maturity ­ is the patient's spine still growing and changing?

·Degree and extent of curvature ­ how severe is the curve and how does it affect the patient's lifestyle?

·Location of curve ­ thoracic curves are more likely to progress than thoracolumbar or lumbar curves.

·Potential for progression ­ patients who have large curves prior to their adolescent growth spurts are more likely to experience curve progression.

Tanvir Jamil is on sabbatical in Canada

Treatment of scoliosis

There are three basic types of treatments

for scoliosis: observation, orthopaedic bracing, or surgery.

Observation is appropriate for small curves and curves that are at low risk of progression, for example if a child is diagnosed with a curve of 25 to 40 degrees and has completed growth (ie boys older than 17, girls older than 15). Statistically, these curves are at low risk of progression and are not likely to cause problems in adulthood. Follow-up X-ray once a year for several years would confirm non-progression. As an adult, an X-ray every five years, or if there are symptoms, is sufficient.

Orthopaedic braces are used to prevent further spinal deformity in children with a curve within the range of 25 to 40 degrees. If there is a substantial amount of skeletal growth left, then bracing is a viable option. Bracing is used to prevent further deformity, not to correct the existing curvature or to make the curve disappear. Braces are 60-75 pr cent effective in controlling curve progression.

Surgery is an option used primarily for severe scoliosis (curves greater than 45 degrees) or for curves that do not respond to bracing. There are two primary goals for surgery: to stop a curve from progressing during adult life and to diminish spinal deformity. Most surgical techniques involve a posterior spinal infusion and bone grafting. Metal rods attached to the spine ensure the backbone remains straight while the spinal fusion takes place. Endoscopic procedures are also available for certain types of curve correction.

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