Many children today are screened for scoliosis at school or at annual visits with their pediatricians. Health care professionals look not only for sideward curves, but also for rotation of the spine, which often translates into a measurable curve. Physicians are also interested in family history because there is a slightly higher incidence of scoliosis in families—a risk that increases from one generation to the next.
The vast majority of children who are diagnosed with scoliosis will never require treatment unless there is progression of the curve or it becomes symptomatic, according to Shyam Kishan, MD, an associate professor of orthopedics at Indiana University School of Medicine who specializes in treating pediatric spinal deformities at Riley Hospital for Children.
With juvenile and adolescent idiopathic scoliosis—two types that stem from a variety of unknown factors and aren’t congenital—so much depends on when the diagnosis is made, where the curve is and what happens as a child grows. Adolescence is the most common age group where idiopathic scoliosis is found, and it’s more common in girls than boys. It’s often noticed because it causes breast asymmetry due to the rotation of the chest.
"If there is a curve that measures between 25 and 45 degrees in a child who has more than two years of growth left, those are the children who will be started on treatment, beginning with bracing," says Kishan. For curves that measure above or below that range, he says bracing has not been shown as an effective treatment.
Once an adolescent patient is treated with bracing, Kishan says he evaluates them with X-rays every six months to see what is happening through growth. The critical size of the curve for the thoracic (chest) spine is 50 degrees; 40 to 45 degrees for the lumbar spine. "If the curve gets to those numbers, then there is a real possibility that it will progress through life," he says. "It's a tipping point where we will begin to think about surgical options for those adolescent children."
Even at that point, Kishan says he will observe patients for another six months to a year to establish whether the curve is progressing before he suggests surgery, which is usually a fusion that acts as an internal brace. The location and number of curves can also determine which are fused and which are left alone. Curves are corrected with metal screws and rods, and bone graft on each vertebra to encourage bone growth between the fused vertebra and those above and below them, forming a solid mass of bone.
Kishan says thoracic (chest) fusions put very few limits on children afterwards. "All my patients get back to pretty much everything they did before within three months of the surgery," he says. "It all depends on how good the fixation is, how strong the bone is and how fit they were before the surgery." Lumbar (lower back) fusions can be much more restrictive because so much bending and twisting comes from the lower body.
For children who are past the critical growth periods of five to eight years old but not quite to adolescence, Kishan may explore bracing or surgical options including non-fusion or growth techniques. "The simplest technique uses a flexible tether on the convex side of the spine that lets the concave side straighten as the child grows," he says. In other cases, metal growing rods are inserted, but that requires follow up surgery every six to nine months to stretch the spine.
What is common to both these treatments is that neither is FDA-approved. "We use the implants only after we explain this to families, but there aren't many choices. There's no sense in watching that curve progress to the point that it affects the function of the lung and heart," Kishan says.