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Scoliosis in Children
Adolescents are the most common age group to have idiopathic scoliosis, and it usually begins between the ages of 10 and 14. While it occurs about equally in both boys and girls, girls are much more likely to have a progression of the curve that requires treatment. Still, only about 10% of children with scoliosis require corrective treatment bracing or surgery. The rest 90% will not require treatment and will have no long lasting effects or symptoms from the curve.
Idiopathic scoliosis can also much less commonly be found in young infants infantile scoliosis, and children 4 to 10 years of age juvenile scoliosis. Younger children should be seen by a pediatric orthopedic specialist, even if they have a small curve.
Scoliosis is usually discovered during routine screening with the forward bend test Adams test, either at school or as part of a childs regular well child visits with their Pediatrician. During this exam, the child takes of his or her shirt girls can leave their bra on, and stands up straight, with feet together. The examiner will first check that the shoulders, scapulae shoulder blades, and hips are level uneven shoulders can be a sign of scoliosis and the spine is straight. Next the child will bend forward at the hips, with the arms loosely extended and the palms held together. In children with scoliosis, bending forward will reveal an asymmetry of the back or posterior chest wall causing an elevation of one side of the back, or a rib hump.
If your child was identified as having scoliosis during a routine school screening test, then you should see your Pediatrician for a confirmatory exam. Not all children with a positive test at school really have a curve.
Since most children with scoliosis do not have symptoms scoliosis is usually painless, and they can develop compensatory curves that keep the shoulders level and give the appearance that the back is straight, it is very important that all children between the ages of 10 and 14 have yearly scoliosis screening, especially if they are at high risk, including having another family member with scoliosis.
Once a child is identified as having scoliosis, they should have an xray to determine the degree of curvature of the spine. These xrays usually consists of a standing PA posteroanterior and lateral xray of the spine. From these xrays, the physician usually a radiologist or orthopedic specialist can determine the degree of curvature of the spine by measuring different angles along the curve Cobb method. The xrays expose your child to a minimal amount of radiation.
The degree of curvature helps to determine what needs to be done next. For children with mild or small curves, usually less than 20 degrees, no treatment is generally required. Your physician will just observe your child with serial xrays every 46 months. Repeating the xrays is important to see if the curve is progressing. If the curve is progressing slowly 510 degrees over 23 years and has not reached 20, then your Pediatrician may just continue to do serial xrays until your child has reached full skeletal growth or maturation. This is usually about two years after a girl has her first period menarche or when boys are about 17 or 18. With skeletal maturation, the scoliosis progression will usually slow or end, except for the most severe curves, which can progress into adulthood.
Children with curves that progress very rapidly more than about 5 degrees in 46 months, or that progress past 20 degrees, should be evaluated by an orthopedic specialist that cares for children with scoliosis.
An exception to the 20 degree rule is children under 12, who should be referred to a specialist even if their curve is under 20. Since the curve progresses as your child grows, a child with scoliosis at a young age has much more time for the curve to grow, in contrast to a 14 or 15 year old who only has a few more years of growing ahead of them.
Also important is the location of the curve, which can occur in the thoracic, thoracolumbar, or lumbar regions of the spine, its pattern single vs double, and direction right vs left. Double curves are more likely to progress than single curves and single thoracic curves are more likely to progress than single curves in the lumbar region.
For children with rapidly progressive curves, or with curves that are above 30 degrees, treatment will likely be necessary. The main treatments are bracing and surgical correction, although surgery is usually reserved for children with curves over 45 to 50 degrees, or which dont respond to bracing.
Bracing is usually necessary for children with rapidly progressive curves, or curves between 30 and 45 degrees, although it also depends on the childs age and degree of skeletal development. Younger children may need treatment with a smaller curve than older children, because they have more room to grow and for the curve to progress. While a brace will not fix the curve or make the spine straight, it can help to prevent the curve from progressing anymore or worsening.
The most commonly used brace to treat children with scoliosis is the thoracolumbosacral orthosis TLSO, which is custom molded, fits beneath clothing, and is worn for most of the day and night. Another type of brace is the Charleston bending brace, which is worn at night only. The Charleston brace is usually used for single lumbar curves. The Milwaukee brace extends up to the neck and isnt used very much anymore.
For children who do not respond to bracing, who have a very large curve over 4550 degrees, or who are having symptoms, including physical deformities, pain, and compromise in their heart or lung function, then surgery will probably be needed. The most common surgical procedure is a posterior spinal fusion, with correction of the curve and the use of implanted internal metal fixation rods until the bone fusion heals. The rods are usually permanently placed and are not removed, but they usually do not cause any problems and will not set off airport metal detectors.
Alternative treatments for scoliosis which are not thought to work to slow or stop scoliosis from progressing include chiropractic manipulations and electrical stimulations.
Although much less common than idiopathic scoliosis, children can also have congenital scoliosis, which is often associated with genitourinary abnormalities, congenital heart disease, and other defects of the spinal column. These children should be closely followed by an orthopedic specialist to monitor the progression of their curve. Only about 25% of children with congenital scoliosis do not require treatment.
Scoliosis can also be associated with certain types of neuromuscular disorders, such as cerebral palsy, muscular dystrophies and spinal muscular atrophy SMA. Iannellis new book