Scoliosis in Children

What Is Scoliosis?

Scoliosis is a spine condition that causes the back to curve to the side (when viewed from the front). Scoliosis tends to worsen as children grow, for example during puberty. Thus, mild and moderate scoliosis rarely progresses once adolescents (teens) stop growing (girls up to 15 years old, boys up to 17 years old).

What Causes Scoliosis?

Over 80 percent of scoliosis cases are idiopathic. This means that there is no known cause. It occurs in otherwise healthy teens and preteens. Adolescent Idiopathic Scoliosis (AIS) is the most common type and affects children between the ages of 10 and 18. Progressive idiopathic scoliosis affects girls more often than boys.

However, scoliosis may be associated with other conditions that affect the muscles and nerves such as cerebral palsy and muscular dystrophy. Scoliosis isn’t poor posture and isn’t caused by carrying heavy objects (such as a back pack). A difference in leg lengths and tight hamstring muscles may be mistaken for mild scoliosis.

What Are the Symptoms of Scoliosis?

Each child may experience symptoms differently or have no symptoms at all. You may notice:

• Uneven shoulders (height of one shoulder seems higher, the other shoulder lower)
• One shoulder blade sticks out more than the other 
• The waist looks different on each side
• One hip appears higher than the other hip
• Differences in the way the arms hang beside the body when standing straight
• A prominence on one side of the back when bending forward
• Back pain 

How Is Scoliosis Diagnosed?

For a diagnosis of idiopathic scoliosis, a history and physical examination along with medical imaging (x-ray) needs to be completed. Your medical provider (physician, nurse practitioner or physician assistant) will take a complete medical history of your child. Next a physical exam includes checking the muscles and nerves work by testing strength and watching your child walk. Your child’s posture will be checked to see if their head, neck, shoulders, back, waist and pelvis (hips) are in symmetry (appear similar comparing the right and left sides). The spine will be examined with a forward bend test to check if the back ribs are even. This exam requires your child to bend at the waist, with their arms hanging loosely in front of them, so your provider can examine the spine and measure the asymmetry with a scoliometer (a tool that looks like a level is placed along the spine to note the area that has the most angle to it).

After the physical exam, x-rays are taken to determine the severity of the curvature. Standing x-rays of the entire spine (to include the neck to lower back) are obtained, with one view from back-to-front and one from the side. From these images, your provider can measure the curve (cobb angle), which is used to determine severity and treatment. On rare occasions, an MRI of the spine may be ordered if the provider notes neurologic abnormalities on exam or x-ray, if the curve is deemed atypical or if your child is experiencing significant pain.

Scoliosis curves can worsen during rapid periods of growth, such as during pre-puberty and puberty. On the x-rays of the spine the pelvis is usually included, so that the provider can determine (if visible) a Risser grade (changes in growth seen at the top of the hip bone which gives some information regarding bone maturity). An x-ray of the hand (typically includes the wrist), may also be used to determine your child’s maturity of the bones, or to predict how much growth is left. Females tend to grow until about 14 years of age, whereas males will grow up until 16 years of age (yet, sometimes longer).

How Is Scoliosis Treated?

• Observation
• Bracing
• Physical therapy
• Surgery

The treatment your child receives will depend on the severity of their curve and the amount of growth predicted. If your child has a mild curve, observation may be the best treatment plan. This includes regular repeat visits, typically every four to six months as determined by your health care provider. Each visit includes a health history, a physical exam, and possibly x-rays. As a pediatric and adolescent specialty healthcare center, we make every effort to minimize radiation exposure including using lose-dosage x-ray techniques.

Bracing is a common treatment choice for children and adolescents who have a moderate spinal curve — particularly if their body is still growing. Bracing is meant to decrease the chance of the curve getting worse as the patient grows, though it generally doesn’t reverse scoliosis. A brace is made custom (specific to your child’s body and curve pattern) by an orthotist. The brace is worn under clothes, and should be worn 16-18 hours a day to be effective. 

In both mild and moderate scoliosis, physical therapy (PT) may be recommended. Physiotherapy scoliosis-specific exercises, in addition to observation and bracing, can be useful for your child. A PT regimen can help provide some physical benefit, such as core strengthening and symptom relief.

Children with severe scoliosis curves are often considered for surgery. Spinal fusion is a surgical procedure to correct and stabilize the spine permanently. Implants are placed along the spine to stabilize the curve.

Scoliosis Surgery

How Can You Prepare for Surgery?

Before surgery, we recommend your child be in the best physical condition possible, such as eating healthy and taking vitamins and iron supplements. Also, your child should maintain good aerobic function and capacity, and exercise for strength and endurance. Preparing to be in a good frame of mind and thinking positively is very important as well. Lastly, speaking with other patients who have undergone spinal fusion surgery is helpful to prepare for what is ahead.

What Is Recovery Like After Surgery?

Hospital Stay

After surgery patients typically spend three to five days in the hospital, about four weeks recovering at home, and then for the following six months while back at school are restricted from gym class, participating in sports and some activities.

Activity Restrictions

There are some guidelines (rules) put in place after surgery. These rules followed by your child will maintain the spine in a neutral position and helps with the healing process. Using these rules, your child is expected to move and walk for their activity and helps their muscles and body to feel better. It is possible that your child may also be required to wear a brace after surgery to help support the spine.

Physical therapy may play an important part in your child’s full recovery. A physical therapist will work with your child typically one day after surgery in the hospital until your child transitions home.

Pain Management   

Following spinal fusion surgery, pain management is highly effective. At Lurie Children’s, pain specialists and a team manage your child’s experience with post-surgery pain. We take a multimodal approach to pain care to ensure your child feels comfortable, which will aid in their recovery. Your child may receive a combination of these medications after surgery:

• Epidural - continually delivers anesthetic, non-narcotic medication
• Patient controlled analgesic (PCA) - delivers pain medicine through an IV
• Oral pain medicine - for specific types of pain a PCA or epidural may not help with

Your child likely will be transitioned to a combination of oral pain medications in preparation for discharge home. Other strategies to ease the pain are also encouraged including distraction techniques with relaxation and activities such: as reading, doing puzzles, playing board games, watching television.

Continuing Care

Your child will also be scheduled for periodic follow-up appointments after surgery (which will include a physical exam and x-rays each visit). Follow-up visits are necessary to ensure their recovery is on track and their spine is stable.  These routine visits may continue annually up to five years.

What Are the Outcomes After Surgery?

In the cases involving healthy children with severe curves, corrective spinal fusion surgery with instrumentation is a procedure that corrects scoliosis. After surgery a normal healthy outcome is expected, with a stable corrected spine and satisfactory appearance for a lifetime.

What Are the Long-term Effects of Scoliosis?

If the scoliosis is mild or moderate by the time an adolescent is nearly grown, worsening is very unlikely, though they will continue to have a curvature. There is little medical evidence that mild to moderate scoliosis increases the risk of future health problems such as pain, arthritis, or other back problems.

If the scoliosis is severe, some patients may function at or near normal levels but may have pain, self-image concerns or decreased function. For severe untreated scoliosis, the curves can worsen over time. It is extremely rare to die from cardiac or pulmonary failure as a result.