Scoliosis: Therapy and Symptoms

Brief overview

• Treatment: physiotherapy, corset, plaster, brace technique, surgery, special exercises
• Symptoms: shoulders standing up at different heights, crooked pelvis, crooked head, lateral “rib hump”, back pain, tension
• Causes and risk factors: predominantly unknown cause; secondary scoliosis, for example, due to congenital or acquired diseases or injuries
• Diagnosis: Physical examination, Adams test, mobility/strength tests, X-ray, determination of skeletal maturity
• Prognosis: With treatment, usually good prognosis; the earlier the therapy, the better the prognosis; untreated, progression of the disease, stiffening of the respective vertebral segment, early wear and tear
• Prevention: Concrete prevention is usually not possible; early detection and therapy prevent later consequences

What is scoliosis?

Scoliosis is a permanent lateral curvature of the spine in which the vertebrae themselves are also twisted and displaced. To understand exactly what constitutes scoliosis, it is helpful to know how a healthy spine is structured.

Short excursion into anatomy: The structure of the spine

Viewed from the side, the spine has the shape of a double “S”. The cervical and lumbar spine each curve forward (lordosis), while the thoracic and sacral spine (sacrum) curve backward (kyphosis). If you look at the spine from behind, it forms an approximately straight line from the head to the anal fold with its spinal processes. The vertebral bodies lie evenly on top of each other and an intervertebral disc lies between every two of them as a shock absorber.

The spine is an important part of the supporting skeleton and also protects the spinal cord, a bundle of nerve pathways that transmits signals between the body and brain.

Scoliosis

Scoliosis is a condition in which the spinal structure is disturbed. The name of the disease is derived from the Greek word “scolios”, which means “crooked”: in this case, the spine curves not only forward and backward, but also to the side.

In addition, the individual vertebral bones are twisted in themselves and the entire spinal column in its longitudinal axis (rotation and torsion). As a result, the bony vertebral body processes (spinous process, processus spinosus) do not point straight backward. Thus, the side of the processes facing the abdomen or chest rotates in the direction of the spinal curvature. The rotation is greatest at the apex of the scoliosis and decreases again at the extensions of the curved spinal segment.

As scoliosis progresses, it is possible for the corresponding vertebral segment to stiffen.

The varying degrees of torsion create tension and pressure forces between the individual vertebrae. As a result, the vertebral bone also has a twisted bone structure (torqued): On the outwardly curved side, the vertebral body is higher than on the inwardly facing side. The same applies to the intervertebral discs between the vertebral bones. This results in a permanent crookedness. Experts also refer to the twisted and crooked spine as torsion scoliosis.

What forms of scoliosis are there?

Scoliosis can be divided into different forms, depending on the point of view. For example, a general distinction is made between idiopathic scoliosis and secondary scoliosis.

• Idiopathic means that no specific trigger for the condition can be found.
• Secondary scoliosis, on the other hand, is always the result of a known cause.

These “true” (structural) scolioses must be distinguished from a scoliotic malposition (also functional scoliosis).

Scoliotic malalignment passes and returns to normal with passive or active movements. It occurs, for example, to compensate for a pelvic obliquity.

Since in many cases the cause of a scoliosis is not known, it cannot be effectively prevented.

True scoliosis can be further differentiated by age and curvature pattern.

Scoliosis of different age groups

However, adolescent scoliosis is most common from the age of eleven. The spine is usually curved to the right in the thoracic vertebrae (right convex scoliosis). Girls are affected more frequently than boys.

Curvature pattern

Scoliosis can also be classified according to the center (or vertex) of its main curvature in the spine. In thoracic scoliosis, the curvature is in the thoracic spine (thoracic spine). Thoracolumbar scoliosis has its most pronounced lateral curvature where the thoracic spine transitions into the lumbar spine (LS). A spinal curvature in the lumbar region is called lumbar scoliosis.

• In some cases, affected individuals suffer from both thoracic and lumbar scoliosis. A curvature pattern forms which – when looking at the patient’s back from behind – is reminiscent of the letter “S” (double arched).
• If the spine is completely curved to one side, doctors call it a C-shaped scoliosis.
• If the spine curves alternately to the right and left in all sections (thoracic spine, lumbar spine and their transition), the result is a double-S spine, also called triple scoliosis.

Degree of curvature

• Mild scoliosis: angle up to 40 degrees (1st degree scoliosis).
• Moderate scoliosis: angle between 40 and 60 degrees (2nd degree scoliosis)
• Severe scoliosis: angle from 61 to 80 degrees (3rd degree scoliosis)
• Very severe scoliosis: angle over 80 degrees (4th degree scoliosis)

Frequency: This is how often the disease occurs

About two to five percent of the population suffers from idiopathic scoliosis. According to a study by the Maimonides Medical Center (USA), the incidence rises to as much as 68 percent in old age (60 to 90 years).

The greater the spinal curvature and the older the age, the more frequently women and girls are affected. Mild scolioses are most common in boys. More pronounced scolioses, with a Cobb angle of more than twenty degrees, are found about seven times more frequently in women than in men.

Severe disability

The local pension offices are usually responsible for recognizing a GdB; your doctor is the contact person.

How is scoliosis treated?

Doctors treat scoliosis conservatively with physiotherapy or a brace and, in severe cases, surgically. It is advisable to start scoliosis therapy as soon as possible after diagnosis. The choice of treatment depends on the extent, cause and location of the spinal curvature, as well as the age and physical condition of the patient. Physiotherapy is often sufficient for mild scoliosis, while doctors treat more severe forms with a scoliosis corset. If the curvature is very severe, surgery is often helpful.

Goals of scoliosis therapy

With the treatment of a spinal curvature, doctors together with other specialists such as physiotherapists try to achieve that the scoliosis recedes or at least does not worsen.

Scoliosis corset

A scoliosis corset is used for more severe spinal curvatures of the child (Cobb angle 20-50 degrees). It often achieves very good results in cases of scoliosis that are not due to serious underlying diseases (malformations, muscle or nerve diseases or others).

The brace (orthosis) is made of plastic and has both built-in pressure pads (pads) and free spaces (expansion zones).

It is made to measure, fastened to the body by means of straps and Velcro fasteners and has the task of returning the spine to its natural shape. The patient usually wears the orthosis for 22 to 23 hours a day. Different scoliosis corsets are available depending on the level of the main curvatures.

In girls, the daily wearing time can be gradually reduced about two to three years after the first menstrual period, depending on the patient’s progress. In boys, a certain skeletal maturity should first be reached (Risser stage four or five), so that major growth of the spine is no longer to be expected.

Regular gymnastic exercises additionally support successful scoliosis therapy with orthoses.

Plaster treatment

In some cases of early spinal curvature (under five years of age, early-onset scoliosis), scoliosis therapy using a plaster corset may be considered. In this case, the spine continues to grow normally. Plaster treatment is usually followed by therapy with a scoliosis corset.

Surgical scoliosis therapy

In some cases, conservative scoliosis therapy (physiotherapy, corset) is not sufficient. If a scoliosis worsens visibly and the curvature is severe, doctors usually recommend surgical scoliosis therapy. In doing so, they take several factors into account:

• the severity of the curvature (from a Cobb angle of about 40 lumbar and 50 degrees thoracic),
• rapid progression and impending wear and tear,
• age (if possible, not before the age of ten to twelve), and
• the general physical condition (psychological stress, continuous pain).

During the actual surgical procedure, the surgeon exposes the affected section of the spine. The operation is performed either from the front, via the thoracic or abdominal cavity, or from behind. All surgical scoliosis therapies have as a common goal that the crooked spine is stretched and its rotation is eliminated. In addition, the doctor stabilizes the spine, for example, by means of screws and rods.

Therapy through stiffening

With the so-called spondylodesis (spinal fusion), one intentionally causes the vertebrae to grow together in the affected area. The aim is to stiffen the spine in its previously corrected shape.

Newer surgical scoliosis therapies for children and adolescents

Stiffening of the spine prevents its natural growth. Therefore, it is not an option for children and adolescents. Instead, doctors use special titanium rods in these cases, for example.

The so-called VEPTRs (vertical expandable prosthetic titanium rib) are inserted in such a way that they do not prevent the spine from growing – for example, from the rib to the vertebra.

Modern variants of such rods, the “growing rods”, contain a small remote-controlled motor. This allows them to be adjusted to the respective spinal growth from the outside and without further intervention.

A complex system of screws, rods and a special plate called the Shilla method also promises scoliosis therapy without impeding growth. The rods used “grow with” the patient as they slide in their mounting screws. Once bone growth is complete, the system can be removed.

Correction system

Another method is the “ApiFix” correction system. It is attached vertically in the arc of curvature of the scoliosis. In the months following implantation, physiotherapeutic treatments follow.

The correction system reacts to this by means of a ratchet mechanism: if the spine stretches as a result of an exercise, the system is pulled along and locks into a new position. As a result, the spine no longer falls back into its initial curved position. This scoliosis therapy is gradual so that the surrounding tissue adapts better.

Brace technique

Rehabilitation

Depending on the surgical scoliosis therapy performed, further treatments follow, for example:

• Scoliosis corset, which can be taken off as soon as the operated parts of the spine have ossified
• @ Controlled physiotherapeutic applications and physiotherapeutic exercises

Rehabilitation is done either on an outpatient or inpatient basis. Affected patients are encouraged to learn new movements as early as possible in any case. With such rehabilitation measures, surgical scoliosis therapy can be usefully supported and later damage prevented.

Treatment of underlying diseases

If scoliosis is the result of another condition, this should always be treated at the same time. This applies in particular to diseases or malformations that would promote the progression of the spinal curvature. For example, if a patient has legs of different lengths, an attempt is made to compensate for this difference with special shoes.

Pain therapy

Sometimes transcutaneous electrical nerve stimulation (TENS) helps to relieve pain caused by scoliosis. Electrodes are applied to the skin over the painful area. These electrodes release electrical impulses that act on deeper nerves. They thus inhibit the pain transmission of these nerves to the brain. The German Scoliosis Network also lists acupuncture as part of a comprehensive scoliosis therapy – it, too, is said to relieve pain in some patients.

Scoliosis exercises

For mild spinal curvatures, physiotherapy exercises are suitable as scoliosis therapy. They are intended to correct posture. In addition to physiotherapeutic applications, there are also exercises for scoliosis that can be performed by the patient at home. Exercises as part of scoliosis therapy should:

• Improve posture
• Strengthen the muscles
• Eliminate forward and backward curvatures
• Increase lung and heart function

Meanwhile, there are very many methods to treat scoliosis using exercises.

Read more about how scoliosis can be treated with exercises in the article Scoliosis Exercises.

Aids

For example, there are special pillows and mattresses that help sufferers sleep better or without pain.

In severe cases, walking aids are possible, and special ergonomic office chairs also help sufferers in everyday life or at work.

Symptoms

In many cases, scoliosis is a rather cosmetic problem. However, the longer it remains untreated, the more likely it is that pain will occur in the course of the disease. This is because how pronounced the symptoms are always depends on how advanced the curvature is.

External scoliosis symptoms that can be seen with the naked eye include.

• Shoulders that stand up at different heights
• Crooked pelvis or pelvis protruding on one side
• Crooked head

In pronounced scoliosis, the so-called rib hump often appears, and in many cases muscle bulges form in the lumbar and cervical regions.

Read more about scoliosis symptoms here.

Causes and risk factors

About 90 percent of all scolioses are idiopathic, i.e. it is not known why they develop. For the remaining ten percent – secondary scolioses – there are various possible causes that lead to spinal curvature.

Malformation scoliosis

This form of scoliosis is due to congenital malformations of individual parts of the spine, for example

• Wedge-shaped vertebral bodies (different marginal heights)
• Split or half-formed vertebral bones
• Congenital malformations of the ribs (synostoses)
• Defects in the spinal canal (such as diastematomyelia)

Experts therefore refer to them as congenital (congenital) scoliosis.

Myopathic scolioses

Arthrogryposis also often leads to pronounced scoliosis in severe cases. This is a congenital joint stiffness caused by changes in the tendons, muscles and connective tissue.

Neuropathic scoliosis

In this form, damage to the nervous system results in a crooked spine. Muscles that stabilize the spine (abdominal and back muscles) then no longer function as usual. This creates an imbalance and the spine curves in the direction of the slack muscles.

Among other things, these disorders of the nervous system lead to scoliosis.

• Myasthenia gravis (muscle paralysis).
• Viral spinal cord inflammation (myelitis)
• Early childhood brain damage (such as infantile cerebral palsy)
• Neurodegenerative diseases with damage and loss of nerve cells (for example, spinal muscular atrophy with decline of the second nerve pathway to the musculature)
• Cavity formations in the spinal cord due to cerebrospinal fluid congestion (syringomyelia)
• Malignant or benign growths (such as spinal tumors)

Other causes of scoliosis

Disease group	Causes of scoliosis (examples)
Connective tissue disorders
Rheumatic diseases
Malformations of the bone-cartilage structures (osteo-chondro-dysplasias)
Bone infections (acute, chronic)
Metabolic disorders (metabolic disorders)
Lumbosacral changes in the lumbar vertebrae-cruciate bone region

In addition, in some cases accidents lead to scoliosis. These post-traumatic scolioses occur, for example, after the book of a vertebral bone, burns or spinal cord injuries. Furthermore, some medical interventions cause spinal curvature, such as radiation or laminectomy. In the latter, a part of the vertebral bone (vertebral arch possibly with spinous process) is removed.

As with many diseases, experts suspect that scoliosis is also hereditary. In 97 percent of cases, scoliosis is found to run in families. Among identical twins, both suffer from scoliosis in up to 70 percent of cases. Since scoliosis increases with age, researchers assume that wear and tear (degenerative changes) ultimately also have a decisive influence.

Diagnosis and examination

• When did you first notice the crooked spine?
• Do you suffer from complaints such as back pain?
• Have you already had your first menstrual period (menarche) or voice change?
• How fast have you grown in the past years?
• Are there any other known conditions, such as deformities of the feet, a crooked pelvis, muscle or nerve diseases?
• Are there any known cases of scoliosis in your family?

The US Scoliosis Research Society regularly publishes questionnaires for patients suffering from scoliosis (current version SRS-30). In German translation, doctors here also use this questionnaire.

It makes sense for those affected to fill out the questionnaire at regular intervals. This makes it possible to indicate how they feel about the course of the disease and to assess the success of therapies that have been carried out.

Physical examination

In addition, he checks the lateral equality of the shoulder blades (symmetrical shoulder position) and the waist, as well as the outline of the torso. In the case of scoliosis, the shoulders are at different heights. The two so-called waist triangles are also different in size, i.e. the distances from the left or right drooping arm to the torso.

In the course of the physical examination, the doctor also looks at the still image from the side. In this way, he recognizes an excessive hump (hyperkyphosis) or a spine that is strongly curved toward the abdomen (hyperlordosis, such as hollow back).

In rare, pronounced cases, a distinct thoracic spine hump forms. The thoracic spine is then not only curved to the side, but also strongly curved backwards (kypho-scoliosis).

Such kypho-scoliosis usually occurs with other diseases, for example, rickets, bone marrow inflammation or tuberculosis of the vertebral bodies.

In addition, a crooked pelvis or legs of different lengths (leg length difference) are also noticeable in the context of scoliosis.

Light brown and uniform patches on the skin, so-called café-au-lait patches, on the other hand, are typical of the hereditary disease neurofibromatosis type 1 (Recklinghausen’s disease), which mainly affects the skin and the nervous system. Affected individuals also suffer from scoliosis in some cases, especially kypho-scoliosis.

Physical examination in infants

Scoliosis in infants can be made visible by various posture tests. For example, if the child lies with its abdomen on the examiner’s hand, the examiner can easily detect a crooked spine, as the curvature is usually clearly visible on the back.

In the Vojta side-tilt reaction, differences in arm and leg development can be detected. To do this, the doctor holds the child sideways and pays attention to the infant’s body tension. When held on the side away from the curvature, the body usually falls much more limply than on the side toward which the curvature is directed.

Scoliosis is also clearly visible in the vertical hanging reaction according to Peiper and Isbert. Held by the feet and hanging upside down, the infant’s entire body shows a C-shaped curvature to one side.

Adams test

As a rule, the doctor measures the extent of the rib hump or muscle bulge using a so-called scoliometer or inclinometer. In doing so, he compares the heights of the left and right sides. According to the guidelines, deviations of more than five degrees are considered pathological. In these cases, further examinations follow, in particular X-ray images of the spine.

Examination of mobility, strength, extensibility and reflexes

As part of the physical examination, the doctor will also ask you to lean forward and backward and to the side. By doing this, he will check the mobility of the spine. He will also measure the finger-to-floor distance in a maximally forward-bent posture with your legs extended. Ideally, you should be touching the floor (0 cm), but this is rarely possible with pronounced scoliosis.

In addition, the doctor will check whether the spinal curvature can be actively compensated for by your own movements or by manual assistance from the doctor (passive, manual redressability). “Real”, structural scolioses can hardly be changed, if at all.

X-ray

In many cases, the doctor will already diagnose scoliosis on the basis of the physical examination alone. However, if a spinal curvature is suspected, he or she will always order an X-ray examination. This involves imaging the entire spine while standing, once viewed from the front (or back) and once from the side.

With the help of the X-ray images, the doctor measures the Cobb angle (in infant scoliosis rather the rib departure angle RVAD), determines major and minor curvatures, identifies the vertebrae at the apex and the terminal vertebrae and determines the curvature pattern. This procedure is important for subsequent scoliosis therapy. In addition, malformations or deformations of the bones can be detected in this way.

Determination of skeletal maturity

To assess the progression of scoliosis in adolescents, it is important to determine the stage of spinal growth. To do this, X-rays are used to assess skeletal maturity based on the ossification of the iliac crest processes (apophyses).

Although age is usually related to skeletal maturity, it may differ in some circumstances. For prognosis of scoliosis, bone age is more reliable than life age.

X-ray alternatives

In addition to a conventional X-ray diagnosis, there are a number of imaging methods available for the examination of scoliosis that do not involve radiation exposure. Alternatives include the Optimetric method, Moiré photogrammetry, the video raster steriometry Formetric system or the 3D spinal analysis “ZEBRIS”. However, these methods can only be used to assess scoliosis to a limited extent, especially in comparison with X-ray images.

Further examinations

In exceptional cases, the physician will obtain cross-sectional images using a magnetic resonance tomograph (MRI), especially if malformations of the spinal cord or changes in the spinal canal (such as tumors) are suspected.

In severe scoliosis, heart and lung function are disturbed by the curvatures and twists of the entire thoracic region. In these cases, the physician will arrange for further tests. These include, for example, ultrasound examinations of the heart and a lung function test (spirometry).

Course of the disease and prognosis

The course of scoliosis varies greatly. In principle, the earlier a spinal curvature occurs, the more likely it is to progress (untreated).

Infantile scoliosis is an exception. Within the first two years of life, a crooked spine regresses on its own in up to 96 percent of cases. It can also be positively influenced by suitable positioning measures and physiotherapy.

If a residual scoliosis of more than 20 degrees remains, the parents of the affected baby must expect the scoliosis to progress.

Risk of worsening of the scoliosis

If scoliosis only occurs in the following years of life, the prognosis depends on various criteria. For example, underlying diseases of the muscular or nervous system often worsen the course of the disease. In idiopathic scolioses, other factors are important in addition to age (possible residual growth):

• Initial Cobb angle
• Risser stage (skeletal maturity)
• Time of first menstrual period (menarche, proven association with episodic bone growth in subsequent years)

Cobb angle in degrees	10-12 years	13-15 years	16 years
smaller 20	25 percent	10 percent	0 percent
20-29	60 percent	40 percent	10 percent
30-59	90 percent	70 percent	30 percent
greater 60	100 percent	90 percent	70 percent

Course of the disease in old age

Scoliosis worsens in many cases even in adulthood. This is especially true if the Cobb angle at growth completion is above 50 degrees. Calculations of thoracic and lumbar scolioses have shown that the curvature increases by about 0.5 to one degree per year.

In the case of severe scolioses, especially in the lower back, the risk of painful complaints increases. Particularly pronounced curvatures often also irritate spinal nerves, causing discomfort or pain.

If the scoliosis reaches a value of about 80 degrees, it reduces life expectancy in many cases.

There is a risk of serious complications such as inflammation of the lungs, chronic bronchitis or inflammation of the lung pleura (pleurisy). In addition, the heart is also put under increasing strain (cor pulmonale).

Complications after scoliosis surgery

Like any surgical procedure, spinal surgery carries certain risks, such as bleeding, infection (especially in acne patients) or wound healing disorders. Sensory disturbances or paralysis do not usually occur in idiopathic scoliosis. However, surgical scoliosis therapy can lead to nerve or spinal cord injuries.

However, the probability of such a complication is very low. According to studies, it is 0.3 to 2.5 percent. The risk increases when major surgery is performed and other conditions (especially of the spinal cord) are present. In some cases – spinal cord disorders, for example – doctors have the patient wake up during surgery and check their movements and sensations on the skin.

Effusions and “pneu

Correction loss

After some stiffening operations, the counter-curvature of a scoliosis also increases. In addition, the correction achieved is sometimes partially lost in the first few years after the operation. As a rule, however, a scoliosis stabilizes after surgery.

In young patients who are stiffened at the earliest bone age (Risser 0), loss of correction may be problematic. As the vertebral bodies continue to grow, in many cases the spinal torsion increases. Physicians refer to this as the crankshaft phenomenon. To prevent this, stiffening scoliosis therapy is usually performed from both the front and the back.

Other special complications include metal fractures of the rods and screws used during surgery. In these cases, there is almost always a loss of correction. In some fusion surgeries, the vertebral bodies do not fuse as planned. “False” joints, so-called pseudarthroses, are formed. They may cause persistent pain (especially in lumbar scoliosis).

Scoliosis and pregnancy

Contrary to many fears, scoliosis does not have a negative effect on pregnancy. It does not matter whether patients were treated conservatively (physiotherapy, corset) or surgically. As with all pregnant women, scoliosis patients sometimes experience lower back pain, but an increase in the Cobb angle has not yet been demonstrated.

Control examinations

Depending on the extent of the scoliosis, the doctor checks the curvature regularly. Childhood spinal curvatures of less than 20 degrees are checked approximately every three to six months by physical examinations. If the doctor suspects an increase in curvature, he will order an X-ray. Scolioses over 20 degrees are checked at least once a year by X-ray examination. Clinical examinations are also performed at least every six months as part of scoliosis therapy.

If the affected person has had surgery, no further routine examinations are necessary two years after the operation if the stiffening is stable and the Cobb angle is less than 40 degrees.

Living with scoliosis

In most cases, patients live well with their scoliosis. The important thing is to actively work against the spinal deformity. Integrate scoliosis exercises into your daily routine.

Play (school) sports. Various sports are suitable for this, such as different forms of yoga, swimming – especially backstroke. Archery, cycling, Nordic walking or therapeutic horseback riding are also considered suitable sports. If you have concerns about some activities, be sure to consult your doctor.

If your scoliosis is bothering you in your daily life, for example at work or in your free time, don’t hesitate to ask for help. Contact your employer, your physiotherapist or friends. Some sufferers also get involved in self-help groups.

Prevention

Since the causes of most scolioses are unknown, scoliosis cannot generally be prevented. However, in the case of known risk disorders, regular preventive examinations help to detect the onset of scoliosis in good time and prevent it from worsening.

The same applies to the standard check-ups for children and adolescents, which allow a diagnosis to be made early in the growth phase. With appropriate therapy, the progression of scoliosis and subsequent damage can be prevented.