What is scoliosis?

Scoliosis, which has several causes, is defined as a lateral curvature of the spine in the frontal plane of the body, which means that the spine curves from side-to-side. Normally, the spine is straight, as seen from the front or behind. With scoliosis, the spine curves to the side in the shape of the letter “S” or “C”. 

The most common form of Scoliosis is termed ‘IDIOPATHIC’-which literally means ‘of unknown cause or origin’, and may occur in early childhood or adolescence. Scoliosis may occur anywhere in the spine but is usually found in the Lumbar (lower back), and Thoracic (mid-back) regions.

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.

Classification of scoliosis curves is a critical requirement in selecting the best approach to managing the deformity. We use evidence based classification methods specific to conservative treatment. This is different to the surgeon’s approach to classification which is used by surgeon’s when planning corrective surgery and not conservative management. (King and Lenke are the common surgical classifications, whereas the Rigo method is specific to brace and conservative management)

What does it look like?

Signs and symptoms of scoliosis can include:

  • The body (trunk) leaning more to one side than the other.
  • A rib “hump” and/or a protruding shoulder blade.
  • The opposite sides of the body may not appear level.
  • A tilted head that does not line up over the hips.
  • One hip or shoulder that is higher than the other, causing an uneven waist.
  • In developing girls, breasts appearing to be of unequal size or at different heights.
  • Unequal distance between arms and body.
  • Clothes that do not “hang right,” i.e., uneven hemlines.
  • Standing with one knee slightly bent a lot of the time.
  • There is often a family history of Scoliosis or Scheurmanns disease, although this may not always be the case.

 

A common fallacy is that “everyone has one limb shorter than the other”. This is not correct, unless there is either a congenital shortening, or, there has been a fracture of a long bone in the leg. Often, one leg may APPEAR to be shorter than the other. This may be as caused by a tilted pelvis, which may have Scoliosis as an underlying cause. A tilted pelvis may also be the underlying cause of Scoliosis. It is important to determine which originated first – the tilted/rotated pelvis, or the actual Scoliosis causing the pelvis to tilt!

How will a diagnosis be confirmed?

If you are concerned that your child may have Scoliosis, Scheurmanns diseases, or other postural deformity of the spine, consult your healthcare practitioner. They will request X-rays of the spine to confirm a diagnosis. They may wish to refer( or you may ask them to) you to an orthopaedic surgeon (specialising in disorders of the adolescent spine), physiotherapist or Orthotist for further treatment.

What are treatment options?

Protocol depends on several factors such as, skeletal maturity, size of the curve & other underlying conditions.

The condition may be monitored with X-rays, Physiotherapy may be advised, bracing either full-time or night-time, or surgery may be recommended. This applies to both Scoliosis and hyper – kyphosis (Scheuermann’s).

There is a perception that neither specific physiotherapy nor bracing is effective. This is not correct. There is lots of clinical data on trials and international research which have been conducted, proving the effectiveness of both physiotherapy and bracing.

Research has also shown that general fitness exercises and some other exercises can make the patient worse. However, specific methods such as the Schroth method (Germany) and SEAS Method (Italy) and others have shown favourable results and improve the condition. These methods are conducted by therapists trained in these methods.

RSC (Rigo System Cheneau) Brace

Idiopathic Scoliosis exists as a 3-dimensional deformity. (Frontal plane, Sagittal plane and Transverse Plane). It therefore needs to be treated as a 3D deformity with all 3 planes of the deformity being treated simultaneously.

There are only a few brace methods which are capable of managing all 3 dimensions simultaneously. Peer reviewed research has shown that without doubt, 3D correction is more effective at retarding progression, correcting deformity and preventing surgery for Idiopathic Scoliosis.

The Rigo-Cheneau brace is usually selected because of its clinically proven ability to change the natural history of AIS.

Using advanced technology and computer-assisted design and manufacture (CAD-CAM), a new age of bracing is now available. The RSC Brace. These braces are lightweight and of low profile, and pressure pads and corrective force vectors are accurately placed to provide maximum efficiency. The braces are easily adjusted and adapted to the existing curve profile and are further adjusted to increase in height and size of the growing child. An optimal fit of the brace can only be achieved if it is made to measure. That is why each RSC Brace is manufactured individually. A better fit means more comfort. Thus the patients are more willing to embrace the treatment.

Boston Night Shift Bracing

New clinical studies have proven that night time bracing is effective at controlling idiopathic scoliosis if patients are compliant and are braced timeously. Although the patient will probably be in the brace for a longer duration, the cosmetic element is less significant because the brace is only worn at night. (8 hours). The major advantage of night-time bracing is that is has low impact on social and activity levels of the child.

The differences between soft bracing (E.g. SpineCor) and rigid bracing (Rigo-Cheneau “RSC”):

Rigid 3D bracing (RSC or Rigo-Cheneau)

  • Uses distraction against the gravitational collapse of the thoracic/thoraco-lumbar spine.
  • Brace is built to de-rotate the upper trunk (for the Tx/Tx-Lx curve) and counter-rotate the lumbar region.
  • Lateral force vectors use 3 point leverage to reduce curve magnitude (approx.50% correction is observed on in-brace x-ray)
  • Lower section of the brace shifts the pelvis underneath the transitional point or apex of lumbar curve.
  • Brace high pressure and low pressure area’s use breathing mechanics to dynamically correct the curve during normal breathing (unique to RSC only).

Soft Spinal brace (SpineCor)

  • Works on compression/decompression.
  • Cannot counter the effect of gravity.
  • Hygiene is difficult as brace needs to be washed and dried daily – reducing wear time. (often patients need to have 2 braces made to facilitate hygiene – greater expense) Brace needs to be removed and reapplied for toileting.
  • Not much good clinical evidence regarding initial and long-term outcomes. (much of the literature has been rejected by peer review because the author/s were the designers of the brace method)
  • Can be used on small curves in young patients.

 

Extract from clinical research: CONCLUSIONS:

The SC brace did not prevent curve progression as effectively as the rigid 3D brace. Although it has the potential benefit of increasing mobility during brace wear, the SpineCor brace was associated with increased curve progression in comparison with the Bb. There is also a trend for increased risk of requiring surgery when the SpineCor brace is worn.(Gutman et.al. Spine J. 2016 )

Scheurmann’s & Postural Hyper-kyphosis (Roundback)

Kyphosis is a spinal disorder in which an excessive outward curve of the spine results in an abnormal rounding of the upper back. The condition is sometimes known as “roundback” or—in the case of a severe curve—as “hunchback.” Kyphosis can occur at any age, but is common during adolescence.

Postural Kyphosis

Postural kyphosis, the most common type of kyphosis, usually becomes noticeable during adolescence. It is noticed clinically as poor posture or slouching, but is not associated with severe structural abnormalities of the spine. The curve caused by postural kyphosis is typically round and smooth and can often be corrected by the patient when he or she is asked to "stand up straight."

Postural kyphosis is more common in girls than boys. It is rarely painful and, because the curve does not progress, it does not usually lead to problems in adult life. Scheuermann's Kyphosis Like postural kyphosis, Scheuermann's kyphosis often becomes apparent during the teen years. However, Scheuermann's kyphosis can result in a significantly more severe deformity than postural kyphosis—particularly in thin patients.

Scheuermann's kyphosis is caused by a structural abnormality in the spine. In a patient with Scheuermann's kyphosis, an x-ray from the side will show that, rather than the normal rectangular shape, several consecutive vertebrae have a more triangular shape. This irregular shape causes the vertebrae to wedge together toward the front of the spine, decreasing the normal disk space and creating an exaggerated forward curvature in the upper back. Scheuermann's kyphosis usually affects the thoracic (upper) spine, but occasionally develops in the lumbar (lower) spine.

The condition is more common in boys than girls and stops progressing once growing is complete. Scheuermann's kyphosis can sometimes be painful. If pain is present, it is commonly felt at the highest part or "apex" of the curve. Pain may also be felt in the lower back. This results when the spine tries to compensate for the rounded upper back by increasing the natural inward curve of the lower back. Activity can make the pain worse, as can long periods of standing or sitting.

Modern state-of-the-art Kyphosis brace designs

Reclination brace

When professionally fit and worn for the prescribed time, Reclination braces can be effective at straightening a kyphosis-affected spine and preventing further curvature and related problems.

The low profile design and lightweight material can dramatically improve and maintain the desired anatomical position. The brace is easily taken off and put on by the patient, and is unobtrusive under conventional clothing and school uniforms. The brace is equally as effective for men and women and they can maintain a normal level of activity, such as sport or exercise, as well as social interaction.

Untreated or failed treatment scoliosis in adult patients.

Lightweight and comfortable braces designed on CAD-CAM systems are available for adults who suffer from scoliosis – either from previously undetected scoliosis which went untreated, or where conservative has treatment failed. Mostly these patients are not surgical candidates and suffer from significant pain and deformity.

Highly effective braces for both scoliosis and kyphosis are made of patient measurements and are low profile and lightweight. They can be worn under clothing and are easily donned and doffed by the patient.

FAQ

Most frequent questions and answers

There are several types of scoliosis. The most common type is the ‘idiopathic type’. Idiopathic literally means ‘of unknown cause or origin’. There are several suggestions which have been put forward as to what may cause idiopathic scoliosis, but to date, now known cause has been identified. In idiopathic structural scoliosis the curves cannot be straightened voluntarily and it usually progressive – meaning that the spine will continue to bend to the side unless it is managed and controlled.

Idiopathic scoliosis is truly a 3-dimensional deformity. When one looks at a scoliosis X-ray one tends to only see the “S” or “C” shape curve on the film. (and often the Radiologist will only report on this view, or this is the only view requested when a patient is sent for scoliosis X-Ray’s), however, because we don’t exist as 1 or 2 dimensional beings, one needs to consider the same spine from the other 2 views. These are the views of the same spine from the front or back, as well as the amount of rotation that the scoliosis causes. (True idiopathic scoliosis always has a rotation component to it – which is what causes most of the visible deformity).

To simply treat the 1st dimension (the curve as viewed from the front or back) and ignore the other 2 dimensions, may resolve 1 dimension but will leave deformities in the other 2 planes.

While many Orthotists consider it adequate to only treat the main deformity, international guidelines have consistently recommended treating scoliosis by addressing all 3 planes of the deformity simultaneously. There are only certain bracing methods which are truly 3 dimensional, and which successfully alter the natural history of idiopathic scoliosis.

2 main factors broadly determine successful outcomes:

  1. Brace design and construction.
  2. Patient compliance with the treatment.

A thermal data recording device (about the size of a watch battery) is implanted into the brace. This data reader (data logger) is calibrated to read temperature over time. While the brace is being worn, the logger records a temperature reading at regular intervals. when the patient comes in for a check-up, the data is downloaded from the logger in the form of a graph, and gives us an indication as to how long the brace has been worn over a time frame. This has a remarkable effect on patient compliance, and helps the Orthotist (and parents) to determine the compliance level of the patient.

3 options. 

  1. Observation: this implies that once an abnormal spine deformity has been detected, record is made of the specific vertebrae and angles involved. Sometimes exercise is used to try and retard progression or reverse the deformity, and in other cases, nothing is done. Repeat X-ray are done +- 6 months later to see if the deformity has progressed. If there is no sign of progression, then the same ‘treatment’ is continued and re-checked 6 months later.
  2. Bracing: if the curve sizes are beyond certain measurements, then observation alone is not sufficient. Bracing is then recommended, either full time use, or in certain cases, night-time bracing. The bracing is designed to retard/slow down/stop the progression, and to reduce the deformity. A very important part of this method is a specific physiotherapy program (also known as Schroth method). Once brace treatment is initiated, on-going monitoring of the progress in the brace is done roughly every 6 weeks. X-Rays are also done at roughly 6 monthly intervals both in and out of brace to monitor effectiveness of the treatment.
  3. Surgery: Spinal surgery is not easily considered, as it is extensive surgery. Furthermore, this type of surgery stops the growth of the spine in the area’s of the fusion. The problem with this, is that the arms and legs continue growing, while the spine stops growing. This will result in severe and disproportionate trunk deformity. Sometimes unfortunately, despite the best attempts at bracing, the curves progress to an extent that only surgical intervention can stop the progression. In most of these cases the surgery is only considered at the end of the growth phase.