Adolescent Idiopathic Scoliosis

Adolescent Idiopathic Scoliosis (AIS) is a 3-dimensional deformity of the spine which statistically effects girls more than boys.

Scoliosis is a relatively uncommon deformity of the spine. It generally affects adolescents and sometimes younger children, but also can develop in mature adults. We also treat a condition called Hyperkyphosis, often known as Scheuermanns Disease.

X ray Jan2015

The deformity comprises changes in 3 planes: front-to-back (known as sagittal), side to side (known as coronal) and also rotation (known as tranverse).

The severity, presentation, rate of change and associated symptoms vary enormously, and no two individual scoliosis patients are the same. The diagnosis of scoliosis can be a highly emotional experience for both the patient and their family. There is a vast amount of information available on the internet, much of it conflicting or contradictory, and there will be many practitioners who will offer a ‘miracle’ cure.

In reality, there is no ‘cure’ for scoliosis, but there are various methods which increase the chance of maintaining the curve, or at the very least, slow down its’ rate of progress, improving spine health and hopefully reducing the chance of surgical intervention should it come to that. There is also some anecdotal evidence that by using these techniques, the outcome of surgery can be enhanced, although this is not yet proven.

Research on treatment of scoliosis is notoriously difficult as comparative studies are impossible unless you happen to have a number of adolescent twins each of whom have exactly matching curves, and then treat only one of each pair. The progress (or otherwise) of a curve cannot be predicted , so conservative intervention may or may not be of benefit, but according to most recent research, it is likely that, following the correct exercise regime in conjunction with the best bracing, the curve is given the best possible chance of being maintained.

The effects of Scoliosis

It is one of the peculiar characteristics of scolisis that the side effects are not necessarily related to the severity of the curve. Of course, it is likely that the greater the Cobb angle, the more complications you are likely to encounter, but sometimes even small curves can produce a disproportionate level of pain, or those with a major, 3-curve scoliosis have no pain at all.

The most common complications encountered with scoliosis are:

  • Pain, either intermittent or constant
  • Reduced flexibility
  • Loss of height
  • Asymetry, causing problems with clothing
  • Neurological deficit
  • Problems with child-bearing (in very severe cases)

Surgical intervention should be considered as a last resort, apart from the obvious risks of the procedure itself, it is irreversible. Fusion of large segments of the spine can often lead to short-term gains in pain relief and significant improvements in the cosmetic appearance of the back, but the natural mechanics of the spine are seriously compromised and very often, the pain will return in later life even if the symptoms are reduced when surgery is performed on adolescents.

Some of the complications associated with the insertion of spinal rods (often referred to as ‘Harrington Rods’ or instrumentation) are:

  • Fixing the spine, thus preventing normal movement
  • Metalwork becoming loose or screws protruding against the skin
  • Recurrent procedures to allow for normal growth
  • ‘Hinging’ – where the spine flexes around one end of the rods beyond its’ natural range of movement

The more research we do, the more we are finding out about the problems associated with insertion of complex instrumentation during adolescence – yes, there are often significant gains to be made in terms of cosmetic improvements, which cannot be underestimated, but this has to be balanced against the loss of function, which is a major, life-long issue

This is not to say that a spinal operation should never be considered, as in some cases, the intervention is both appropriate and timely, but where there is a non-surgical treatment as an alternative to invasive techniques, this should always be your first port of call.

Detecting scoliosis

Very often, scoliosis can go unnoticed for quite some time, and often first observed when on holiday by the seaside or at the swimming pool, where a parent will notice an uneven (assymetric) shoulder height, or when one shoulder blade (scapular) is more prominent than the other.

A simple test is the Adams Forward Bending Test, where the child bends forwards at the hips, keeping their knees straight. Looking at the spine from behind will show a ‘rib hump’ on one side or the other (most

diagram-1

 

If you have any concerns, then you should first of all go to your GP who can arrange an X ray (sometimes known as a Scoliogram) and a referral to an Orthopaedic Surgeon, who will be a specialist in this field.

 

Unfortunately, in the UK, there is not really a culture for using braces as a first line of treatment, and your surgeon may not offer or even suggest it. It is ALWAYS worth bringing it up in discussion. It is possible that the curve is not yet of a great enough degree to warrant intervention or it may have reached an angle where bracing will be ineffective, but success with bracing is more likely if the curve is caught at an early stage. Sadly, the experience that surgeons may have had with traditional bracing has been somewhat negative, which may be a reason that they tend not to recommend it. RSC bracing changes the approach to how we manage scoliosis in the UK

diagram-3It is unlikely that the Cobb angle will change in an even manner, growth spurts –  particularly during the onset of puberty – are likely to accelerate change, and it is at these times the spine can be the most challenging to manage with non-surgical interventions. One of the terms that Health Professional use to determine the stage of growth is the Risser Scale. This is a feature seen on X rays which include the pelvis, and is a subtle line running along the top of the crests of the pelvic bones. The length of this line is known as the Risser Sign and starts at 0 for no skeletal maturity, to 5 which is considered to be full maturity (although not all adolescents will have completely finished growing by the time 5 is reached).

Whilst scoliosis is largely seen in adolescents, it can have an earlier onset, and can be seen in Infants (IIS) and juveniles (JIS). Conservative treatment can be more difficult, mainly due to compliance, as younger children are often by nature less cooperative!

This table gives a broad indicator of the treatment regimes considered to be the most effective.

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