What Is Scoliosis (Curvature of the Spine)? Symptoms and Treatment

The spine is a load-bearing structure that holds the body upright, distributes weight during movement and protects the spinal cord running through it. Seen from behind, a healthy spine is expected to follow a straight line from the neck to the tailbone; seen from the side, the natural curves inward at the neck and lower back and outward at the upper back become visible. Scoliosis is a three-dimensional deformity that arises when this line, which should be straight, deviates sideways while the vertebrae rotate at the same time around their own axis. For a medical diagnosis to be made, the angle of the curve measured on X-ray must exceed 10 degrees. Deviations below this threshold are not called a disease but "spinal asymmetry", and in most cases they do not create a health problem. Scoliosis is most often noticed during the rapid growth spurt of adolescence, but it can appear at any period from infancy to old age. Because it can progress without giving any sign in the early stage, regular observation is of great importance, particularly in children who are still growing.

What Is Scoliosis?

The word scoliosis carries the meaning of "curving, bending" in its origin and describes an abnormal curvature of the spine to the right or left. When the curve forms in a single region the spine takes on an appearance resembling the letter "C", while two curves that balance one another produce an "S" shape. The level at which the apex of the curve lies determines the name given to it: a curve in the neck region is called cervical, one in the upper back thoracic, one in the lower back lumbar, and a curve involving both regions together is defined as thoracolumbar scoliosis. Curves in the upper back region are the ones most frequently encountered in clinical practice. In scoliosis there is not only a sideways deviation; an asymmetry also develops in the ribs and the trunk because of the rotation of the vertebrae, and this is why one side of the back stands higher than the other when the person bends forward. This three-dimensional structure is the fundamental feature that separates scoliosis from a simple postural problem. When the degree of the curve, the region in which it lies and the person's growth potential are assessed together, both the risk of progression and the appropriate course of treatment become clear.

Why Does Scoliosis Occur?

Scoliosis does not have a single cause; in the great majority of cases no clear reason can be established. This group, in which the cause cannot be determined, is called idiopathic scoliosis and makes up roughly three quarters to four fifths of all cases. In the remaining cases, developmental defects of the spine in the womb, diseases affecting the nervous and muscular systems, certain genetic syndromes, spinal trauma, infections or tumours may be the underlying reason for the curve. At older ages, degenerative processes such as wear of the discs and joints between the vertebrae and loss of bone density may set the picture in motion. A family history of scoliosis is accepted as a factor that increases the risk, yet a significant proportion of children with scoliosis have no family history at all. Factors such as hormonal changes, connective tissue characteristics and the rate of growth are also thought to contribute to the picture. In short, scoliosis is a multifactorial condition in which not one single agent but several factors play a part together.

Idiopathic Scoliosis

This is the most common type of scoliosis and, as its name suggests, its cause is not known with certainty. According to the age at which it appears, it is divided into subgroups as infantile (0-3 years), juvenile (4-9 years) and adolescent (10-18 years) idiopathic scoliosis. Among these, the most frequently encountered type is adolescent idiopathic scoliosis, which becomes apparent during the rapid growth spurt of adolescence. In girls it is both more common and carries a markedly higher risk of the curve progressing. Since the curve may increase for as long as growth continues, regular check-ups at set intervals in this age group form the basis of the treatment decision. Although a genetic predisposition is thought to play a role, it cannot be explained by a single gene or a single environmental factor. When recognised early, the great majority of cases can be brought under control without the need for surgery.

Congenital Scoliosis

This arises when the structures forming the vertebrae during the baby's development in the womb are incompletely shaped, divided incorrectly or fused to one another. Because the structural defect in the spine is present from birth, the curve may be noticed even in infancy. Scoliosis of this kind generally follows a progressive course and becomes more marked as the child grows. In some cases findings such as a change of colour on the back, excessive hair growth or a dimple in the skin may accompany the picture and may be a sign of underlying spinal cord anomalies. For this reason advanced imaging methods are used earlier in children in whom congenital scoliosis is suspected. Early diagnosis is decisive for bringing the progression under control.

Neuromuscular Scoliosis

This is the type of scoliosis that develops as a result of weakening or unbalanced working of the muscles that support the spine. Diseases affecting the nerve-muscle system, such as cerebral palsy, muscular dystrophies, spina bifida and spinal muscular atrophy, may lead to this picture. Because the muscles are not sufficient to hold the spine upright, the curve is generally wide-angled, long and progressive. Loss of sitting balance, an increase in pressure sores and a reduction in respiratory capacity are the problems that come to the fore in this group. The treatment plan is drawn up with regard not only to the spine but also to the person's overall functional state. Follow-up intervals are kept closer than in other types of scoliosis.

Degenerative (Adult) Scoliosis

This appears when the balance of the spine is disturbed as a result of the discs between the vertebrae losing water and becoming thinner with ageing, together with the development of arthritis in the facet joints. It is mostly seen in individuals over the age of 50 and, more frequently, in the lower back region. In this group the leading complaint is pain rather than the appearance of the curve; low back pain may be accompanied by numbness, tingling or weakness radiating into the legs. In parallel with this, the aim of treatment is not so much to correct the curve as to bring the pain under control and preserve daily life functions. The progression in adulthood of a curve remaining from childhood is the second important cause of adult scoliosis.

Functional (Non-structural) Scoliosis

These are temporary curves that develop in order to adapt to another problem, without any real deformity in the bones of the spine. A difference in leg length, muscle spasm, constantly leaning to one side because of pain, or established postural habits may lead to this picture. The absence of rotation in the vertebrae and the largely disappearance of the curve when lying down allow it to be distinguished from structural scoliosis. When the underlying cause is removed, the curve also tends to correct itself. Treatment is therefore directed not at the spine but at the source of the problem. Even so, a physician's assessment and, where necessary, an X-ray are required in order to establish the distinction with certainty.

What Are the Symptoms of Scoliosis?

The most striking feature of scoliosis is that in the early stage it most often causes no pain or any obvious complaint. For this reason mild curves may progress unnoticed for years and are frequently detected by chance on an X-ray taken for another reason. Symptoms generally show themselves in the form of disturbances in body symmetry, and the first person to notice them is most often a family member, a teacher or a sports instructor. As the degree of the curve increases the asymmetry becomes more marked, and in advanced cases back and low back pain may be added to the picture. In very advanced curves a reduction in respiratory capacity may be seen because the shape of the rib cage changes. The severity of the symptoms varies from person to person according to the site and degree of the curve.

The findings most frequently encountered in scoliosis are as follows:

• One shoulder standing higher than the other
• One shoulder blade appearing more prominent and sticking out
• The hollows of the waist not being equal on the two sides
• A difference in the height of the hips, one hip appearing more prominent
• The head not sitting in the exact middle of the trunk but shifted to one side
• One side of the back remaining higher than the other when bending forward
• The ribs being more prominent on one side, at the front or at the back
• Clothes not sitting symmetrically on the body, the belt or hemline hanging crookedly
• Back and low back pain that increases after standing or sitting for long periods
• A change of skin colour or marked hair growth in the back region
• Shortness of breath and becoming tired quickly in advanced curves

In Whom and at What Ages Is Scoliosis More Common?

The frequency of scoliosis in the general population is reported to be roughly between 2 and 3 per cent. The period in which it is most frequently encountered is the stage of rapid growth before and throughout adolescence; for this reason the great majority of diagnoses are made between the ages of 10 and 16. Although the rate at which mild curves are seen in girls and boys is close to one another, progression of the curve to a level requiring treatment is markedly more frequent in girls. In girls the period before and after the onset of menstruation in particular is accepted as the interval of greatest risk for progression. After skeletal development is complete the rate of progression slows markedly, but in curves exceeding certain degrees a slow increase may continue throughout life. In adults the picture is mostly related to age-dependent degenerative changes. It is recommended that children with a family history of scoliosis be followed more closely throughout their growing years.

How Is Scoliosis Recognised? A Simple Observation That Can Be Made at Home

A simple observation that families can carry out at home may help scoliosis to be suspected at an early stage. For this, the child is asked to stand with the back uncovered, feet together and knees straight, and then to bend forward from the hips with the arms hanging freely. While this is done, attention is paid from behind and at the level of the back to whether there is a difference in height between the two sides; one side standing markedly higher than the other is a warning sign for scoliosis. In the same way, while the child stands upright the symmetry of the shoulders, shoulder blades, waist hollows and hip levels can be compared. Clothes not hanging properly on the body is also frequently one of the first clues noticed. This observation is not a diagnostic method; it is only a guide for the decision to consult a physician. When any asymmetry is noticed, an orthopaedics or physical medicine and rehabilitation specialist should be consulted.

How Is Scoliosis Diagnosed?

Diagnosis of scoliosis begins with taking the patient's history and a detailed physical examination. The physician first assesses whether there is scoliosis in the family, when the curve was noticed and what stage of growth the child is at. The best-known step of the examination is the Adams test, carried out by having the patient bend forward; during this test the difference in rib and back height caused by the rotation of the vertebrae becomes apparent. Neurological examination checks muscle strength, reflexes and whether there is any loss of sensation. When suspicion arises, standing front-to-back and side X-ray films covering the whole spine are taken. On these films the angle formed by lines drawn from the vertebrae at which the curve begins and ends is measured; this measurement, accepted as the gold standard, is called the Cobb angle. Where necessary a wrist X-ray may be requested to determine bone age; this information is used to predict the remaining growth potential and hence the risk of progression.

In some cases an X-ray alone is not sufficient. If there are neurological findings such as pain, loss of strength or numbness in the legs, if the curve is in an unusual direction or if it has appeared at a very young age, the spinal cord and nerve structures are examined in detail with magnetic resonance imaging (MRI). Computed tomography (CT) may be of use in advanced curves where the bone structure needs to be assessed more clearly, or at the surgical planning stage. Once the diagnosis has been made, the process does not end with a single assessment; for as long as growth continues, examination and imaging are repeated at set intervals. The frequency of follow-up is determined according to the degree and type of the curve and the child's stage of development, and generally varies between six and twelve months. This regular monitoring is the most important element in ensuring that the treatment decision is made at the right time.

Degrees of Scoliosis: Classification According to the Cobb Angle

The degree of scoliosis is the fundamental criterion determining both the seriousness of the condition and the course of treatment to be followed. The ranges used in classification may show small differences between sources and centres; the table below summarises the approach widely used in clinical practice. The values given here provide a general framework, and the treatment decision for each patient is made not on the basis of the angle alone but by assessing age, remaining growth potential, the site of the curve and the rate of progression together. For example, of two children with the same angle, the one who is still growing may require far closer follow-up. The table should therefore be regarded not as a definite treatment prescription but as a map that helps in understanding how the process works.

Treatment of Scoliosis

There is no single standard method in the treatment of scoliosis; the plan is drawn up separately for each patient. In making the decision, the degree of the curve and the region in which it lies, the person's age, skeletal maturity, how much the curve has increased at recent check-ups and the level of pain, if any, are assessed together. In children of growing age the primary aim is to stop the curve progressing and to prevent health problems that might develop later. In individuals who have completed their growth the aim is more to control pain, preserve function and prevent possible effects on the respiratory and circulatory systems. Treatment options are gathered under four headings: observation, scoliosis-specific exercise programmes, use of a brace, and surgery. These steps are not alternatives to one another but approaches that most often complement each other.

Observation and Regular Follow-up

In mild curves active intervention is most often not needed; what really has to be done is to monitor regularly whether the curve is progressing. During this process physical examination is carried out at set intervals and the X-ray is repeated where necessary. The follow-up interval is generally planned as six months, but more frequent check-ups may be needed in children in a period of rapid growth. The detection of a marked increase between two successive measurements requires the treatment plan to be reviewed. Observation does not mean doing nothing; on the contrary, it is the most critical stage in being able to intervene at the right time. Giving the family detailed information about the course of the curve and about what to watch for is also part of the treatment during this period.

Scoliosis-specific Exercise and Physical Therapy

It is necessary to distinguish scoliosis-specific exercises from general sporting activities. Although there is no scientific evidence that activities such as swimming, pilates or yoga correct an existing curve, these sports are recommended because they support general muscle strength and postural control. Scoliosis-specific exercises, on the other hand, are programmes planned individually according to the direction, type and degree of the curve, and include special positioning and breathing techniques. The basic aim of these programmes is to give the person awareness of their body, to enable them to perform the three-dimensional correction themselves and to teach them to maintain the corrected posture in daily life. The main approaches used worldwide include the Schroth, BSPTS, SEAS, FITS, Lyon, Dobomed and Side Shift methods. These exercises should be planned with the guidance of physiotherapists who have received special training in this field and applied with the correct technique. The effectiveness of the programme depends on regular continuity and on the home exercises being maintained without interruption.

Brace Treatment

The brace is the non-surgical method most frequently used in moderate curves and in individuals whose skeletal development is not yet complete. It generally comes into play in curves above 25 degrees that carry a risk of progression, and it is produced specially according to the person's measurements. The purpose of the brace is not to correct the existing curve completely but to prevent it from increasing further while growth continues; in this respect setting expectations correctly is decisive for compliance with treatment. For it to be effective, it is recommended that it be worn for long periods during the day, mostly between 18 and 23 hours, and its use is continued until skeletal maturity is complete. Because modern braces are produced in a slim form and can be worn under clothes, they do not greatly affect daily life and school life. When used regularly and correctly, brace treatment can remove the need for surgery in many patients. Compliance by the patient and the family is the most important factor determining the success of this treatment.

Surgical Treatment

Surgery comes onto the agenda in curves that continue to progress despite conservative methods and that exceed certain thresholds. The general approach is that surgical treatment should be considered in individuals who have completed their growth for curves above 50 degrees in the upper back region and above 40 degrees in the lower back region; in children of growing age these thresholds may be kept somewhat lower. The aim of the operation is to correct the curve as far as possible, to fix the spine in a balanced position and to stop the progression permanently. The most commonly performed method is spinal fusion surgery, in which the vertebrae are fixed with screws and metal rods and fused to one another. In young children who are still growing, extendable rod systems may be preferred so as not to hinder growth in height and lung development. Fusionless methods based on tightening a band passed between screws, which aim to preserve the mobility of the spine, can also be applied in selected patients. The decision as to which technique is appropriate is made by assessing the angle, position and flexibility of the curve together with the patient's level of bone maturity.

The Recovery Process After Scoliosis Surgery

Scoliosis surgery requires a high degree of precision because it is performed around the spinal cord and nerve roots; for this reason neuromonitoring systems that follow nerve function during the operation and imaging technologies are today used routinely. In the first days after the operation, pain control and wound care come to the fore; patients are generally helped to their feet within a short time with a physiotherapist. Although the length of hospital stay varies from person to person, it mostly comes to about a week. In the first months after discharge it is necessary to avoid lifting heavy objects and sudden bending and twisting movements. While a return to daily life activities is possible within a few weeks for most patients, three to six months are generally awaited before sporting activities are begun. The metal implants that are placed remain permanently in the body and do not need to be removed unless a particular problem develops. During the recovery process, regular medical check-ups and compliance with the physiotherapy programme directly affect the quality of the result.

As with every surgical procedure, scoliosis surgery also carries certain risks. Infection, bleeding, problems related to the position of the implants, pain that may appear at a later stage and rarely seen nerve damage are foremost among them. The likelihood of these risks occurring is markedly lower in operations carried out by experienced teams in well-equipped centres. Holding a detailed discussion with the patient and the family before the decision to operate is made, and sharing expectations and possible complications openly, is an inseparable part of the process. It should not be forgotten that treatment of scoliosis does not end with the operation and requires long-term follow-up.

What Happens If Scoliosis Is Not Treated?

A significant proportion of mild curves follow a course that does not lead to any serious problem throughout life and require only regular check-ups. However, in curves that carry a risk of progression and are left untreated, the picture may worsen over time. As the curve increases, the muscles around the spine begin to work in an unbalanced way; this in turn prepares the ground for chronic back and low back pain. In curves of the upper back that go above certain degrees, the shape of the rib cage is disturbed, the volume of the chest cavity narrows and expansion of the lungs may be restricted. In advanced curves appearing during the growing years in particular, this may adversely affect lung development and lead to a permanent reduction in respiratory capacity. In very advanced cases cardiac function may also be affected. In addition to these, the asymmetry of the trunk becoming more marked may cause problems of self-confidence and psychological strain, particularly in adolescents. For this reason the aim in the treatment of scoliosis is not merely the correction of an angle but the preservation of long-term health and quality of life.

Daily Life Recommendations for People with Scoliosis

Daily habits do not by themselves cause scoliosis or cure it; but in individuals with an existing curve, reducing unnecessary load on the spine contributes to pain management and to the success of treatment. Taking care to keep the spine in a balanced alignment while sitting, standing, walking and working at a desk forms the basis of this approach. Avoiding staying in the same position for long periods and taking breaks at regular intervals for short walks both reduces muscle tension and creates the effect of exercise. Carrying a backpack on both shoulders and checking its weight regularly is important for preventing low back and upper back pain, particularly in school-age children. For sleeping, it is recommended that a medium-firm mattress be chosen, that back or side positions be preferred and that the pillow be adjusted so as to support the alignment of the neck. Maintaining a healthy weight is another important factor that reduces the load on the spine.

On the subject of exercise, the basic rule is to act in line with the recommendations of the physician and physiotherapist. A sport that is enjoyed and practised a few times a week supports general health and postural control. By contrast, care is advised regarding heavy weight training that places a serious axial load on the spine and high-contact sports carrying a risk of trauma; approval from a physician should be obtained on this subject, particularly in individuals who have undergone scoliosis surgery. Taking concerns about appearance seriously in adolescents, and a supportive attitude from the family and the school environment, make the treatment process easier. Where necessary, one should not hesitate to seek psychological counselling support. Finally, the most decisive element in keeping the process under control is that individuals who are undergoing treatment or who carry a risk do not neglect their regular check-ups.

Frequently Asked Questions About Scoliosis

Does scoliosis correct itself?

Mild curves may decrease somewhat with appropriate exercise programmes, particularly during the growing years. In structural scoliosis, however, the basic aim is not to remove the curve completely but to stop its progression and keep it under control. In advanced cases meaningful correction is generally achieved with surgery.

Does sitting crookedly or carrying a heavy bag cause scoliosis?

There is no scientific data showing that a healthy child develops structural scoliosis because of not sitting properly. Heavy bags are likewise not the cause of structural scoliosis; but they can lead to low back, upper back and neck pain. In people with an existing curve, one-sided and excessive loading is not recommended, as it may increase complaints.

Does scoliosis cause pain?

In children and adolescents scoliosis mostly follows a painless course. Muscle imbalances and spasms related to the curve may lead to pain over time. In adults, and particularly in degenerative scoliosis, pain is the most frequently seen complaint. In severe pain accompanied by numbness or loss of strength in the legs, a physician must be consulted.

Which sport is recommended in scoliosis?

Activities such as swimming, pilates and yoga support muscle balance and general posture. Even so, there is no evidence that these sports correct the curve. Sport does not take the place of a scoliosis-specific exercise programme; it complements it.

Up to what age does scoliosis progress?

Progression is seen most during the period in which bone development continues and slows down largely when growth in height is complete. In curves exceeding certain degrees, slow progression may also continue into adulthood. Whether growth is complete can be assessed with a wrist X-ray.

Is scoliosis hereditary?

The presence of scoliosis in the family is a factor that increases the risk, but a significant proportion of children with scoliosis have no family history. It is recommended that children whose parents or siblings have scoliosis be followed more closely throughout their growing years.

Does the curve correct itself when a brace is worn?

The basic function of the brace is not to correct the curve but to prevent it progressing while growth continues. When used regularly and for a sufficient length of time, it makes an important contribution to keeping the curve at its present level and can remove the need for surgery in many patients.

Does scoliosis lead to loss of height?

A limited loss of height may be seen because of the sideways curving of the spine. This difference generally does not exceed a few centimetres and does not occur in every patient.

Does scoliosis affect pregnancy and childbirth?

Scoliosis does not prevent fertility, and in most women pregnancy follows a normal course. It is important that women who have previously undergone spinal fusion surgery or who have an advanced curve inform their physicians in advance about the birth plan and the use of epidural anaesthesia.

Which department should be consulted for scoliosis?

For a first consultation the orthopaedics and traumatology and physical medicine and rehabilitation departments are appropriate. Where necessary, the paediatric orthopaedics and neurosurgery departments may also become involved in the process.