Scoliosis

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Scoliosis is a condition characterised by an abnormal lateral curvature of the spine. The spine may curve to the left or right and can take on a "C" or "S" shape. While mild scoliosis is often asymptomatic, severe cases can lead to significant deformity and impact respiratory and cardiovascular function.

Aetiology

Scoliosis can be classified based on its aetiology:

• Idiopathic scoliosis: The most common type, especially in adolescents, with no known cause. It is further classified by age: infantile (0-3 years), juvenile (4-10 years), and adolescent (11-18 years).
• Congenital scoliosis: Caused by vertebral anomalies present at birth due to abnormal development of the spine.
• Neuromuscular scoliosis: Associated with neuromuscular disorders such as cerebral palsy, muscular dystrophy, or spinal muscular atrophy, where muscle imbalance contributes to spinal curvature.
• Degenerative scoliosis: Occurs in older adults due to degeneration of the spine's intervertebral discs and joints.
• Syndromic scoliosis: Associated with syndromes like Marfan syndrome, Ehlers-Danlos syndrome, or neurofibromatosis.

Pathophysiology

The pathophysiology of scoliosis involves:

• An imbalance in the growth of the vertebrae or a muscle imbalance, leading to an abnormal lateral curvature of the spine.
• In idiopathic scoliosis, the exact mechanism is unknown, but it may involve genetic factors, abnormal vertebral development, or hormonal influences during growth spurts.
• In neuromuscular scoliosis, the curvature results from muscle weakness or paralysis, leading to uneven forces on the spine.
• In degenerative scoliosis, the curvature arises from the wear and tear of spinal structures, such as discs and joints, leading to asymmetrical degeneration.
• The degree of curvature may worsen during periods of rapid growth in children and adolescents, particularly in idiopathic scoliosis.

Risk Factors

• Family history of scoliosis, particularly in idiopathic cases.
• Adolescence, particularly during growth spurts.
• Female gender, as scoliosis is more common and tends to progress more in girls.
• Presence of neuromuscular disorders, which increases the risk of developing scoliosis.
• Congenital spinal anomalies, which predispose to congenital scoliosis.
• Osteoporosis and degenerative spinal conditions, which can contribute to scoliosis in older adults.

Signs and Symptoms

The signs and symptoms of scoliosis can vary depending on the severity of the curvature and may include:

• Visible curvature of the spine, with a noticeable hump or uneven shoulders, hips, or waist.
• Back pain, which may be more pronounced in degenerative scoliosis.
• Uneven leg length, leading to an abnormal gait.
• In severe cases, respiratory issues due to reduced lung capacity from thoracic deformity.
• Fatigue, particularly after prolonged sitting or standing.
• Neurological symptoms, such as numbness or weakness, if the spinal cord or nerves are compressed (more common in congenital or degenerative scoliosis).

Investigations

Specific investigations to diagnose scoliosis include:

• Physical examination: Assessment of spinal alignment, shoulder height, and rib cage symmetry. The Adam's forward bend test is commonly used to screen for scoliosis.
• X-rays: To measure the degree of spinal curvature (Cobb angle) and assess the type and severity of scoliosis.
• MRI or CT scan: May be used if neurological symptoms are present, or to assess underlying spinal abnormalities, particularly in congenital scoliosis.
• Bone density scan (DEXA): Recommended in older adults with degenerative scoliosis to assess bone health.

Management

Primary Care Management

• Observation: In mild cases, particularly in children and adolescents with idiopathic scoliosis, regular monitoring is recommended to assess the progression of the curve.
• Bracing: For moderate scoliosis in growing children and adolescents, bracing may be recommended to prevent further curvature progression. It is most effective when used consistently during periods of growth.
• Pain management: NSAIDs or other analgesics may be used to manage back pain associated with scoliosis.
• Physical therapy: Referral to a physiotherapist for exercises to improve posture, strengthen back muscles, and maintain spinal flexibility.
• Education and support: Providing information to patients and families about the nature of scoliosis, its potential progression, and the importance of adherence to treatment, such as bracing.

Specialist Management

• Referral to an orthopaedic specialist: For patients with significant curvature (Cobb angle >25-30 degrees), rapid progression, or symptoms that affect daily activities.
• Surgical intervention: Indicated for severe scoliosis (Cobb angle >40-50 degrees), particularly if the curve is progressing or causing significant symptoms. Spinal fusion surgery is the most common procedure to correct and stabilise the spine.
• Management of complications: Addressing any complications related to respiratory or neurological function due to severe scoliosis.
• Long-term monitoring: Regular follow-up to monitor curve progression, particularly in growing children and adolescents, or in adults with degenerative scoliosis.

References

1. NHS (2024) Scoliosis. Available at: https://www.nhs.uk/conditions/scoliosis/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Scoliosis and Kyphosis in Children and Young People. Available at: https://cks.nice.org.uk/topics/scoliosis-kyphosis/ (Accessed: 24 June 2024).
3. British Medical Journal (2024) Scoliosis: Clinical Features, Diagnosis, and Management. Available at: https://www.bmj.com/content/350/bmj.h3400 (Accessed: 24 June 2024).
4. American Academy of Orthopaedic Surgeons (2024) Scoliosis. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/scoliosis/ (Accessed: 24 June 2024).

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