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Scoliosis, the Cinderella in the field of orthopaedics is the price paid by mankind because of the assumption of erect posture. Hippocrates in the fifth century BC described scoliosis for the first time. The names scoliosis, kyphosis, and lordosis were first used to characterise spinal deformities by Galen (131–201 AD). The apparent lateral curvature of the spine is referred to as scoliosis. In a true sense, it is a tri-planar deformity with lateral, anterior-posterior and rotational components.
Scoliosis is described as "a lateral curvature of the spine larger than 10° as determined by Cobb's method on a standing radiograph" by the Scoliosis Research Society (SRS). With a measurable but small curve, the incidence of scoliosis is approximately 2% to 4% in children aged between 10 and 16 years. In curves greater than 20°, there are more than 5 times as many girls as boys. Congenital and infantile idiopathic scoliosis have different natural histories of progression than idiopathic adolescent scoliosis. The behaviour of scoliosis caused by neurogenic disorders may also vary. This should be recorded in a systematic manner.
At the end of the clinical and radiological examination, the following information has to be gathered which is relevant in the planning of the treatment of scoliosis.
Factors to Consider While Planning the Treatment for Scoliosis
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Type of Scoliosis
At the time of primary evaluation, all attempts should be made to determine the underlying cause whether idiopathic, congenital, neurogenic or miscellaneous. Congenital and infantile idiopathic scoliosis have different natural histories of progression than idiopathic adolescent scoliosis. The behaviour of scoliosis caused by neurogenic disorders may also vary.
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Severity and Progression of the Curve
Curves less than 40 degrees can be treated non-operatively and should be followed up at regular intervals to determine their progression. Curves more than 40 degrees in adolescents during growth spurt progress rapidly and therefore may need surgical correction.
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The Pattern of the Curve
The deformity produced by various curve patterns is variable. The right thoracic and right thoracolumbar curves are progressing rapidly and may need early surgical intervention.
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Other Factors
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The Rigidity of the Curve
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Skeletal Age of the patient.
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Associated Anomalies especially in Congenital Scoliosis.
The type of scoliosis is the most important factor in the treatment and care of scoliosis care.
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Idiopathic Scoliosis
Various methods have been used to treat adolescent idiopathic scoliosis over the years, including physical therapy, manipulation, and electrical stimulation, but there is no scientific evidence supporting their effectiveness. The two non-operative methods for idiopathic scoliosis that are most commonly used are bracing and observation.
Observation Method For Treating Scoliosis
Young patients with minor curves of less than 20 degrees can typically have examinations every six to twelve months. Patients who are skeletally mature and have curves of less than 20 degrees usually don't need any more testing. A curve of more than 20 degrees in a patient who has not reached skeletal maturity needs more regular radiological examinations, often every three to four months. If the curve becomes more than 25 degrees (with a rate of 5 degrees or more in 6 months) orthotic treatment is to be considered.
Orthotic Treatment For Scoliosis
Originally designed to be worn for 23 hours per day, the orthoses are now only worn part-time due to concerns regarding compliance. The majority of part-time bracing methods demand wearing the brace for no more than 16 hours each day. Part-time bracing for roughly 16 hours may be considered wear if the curvature is less than 35 degrees and does not demonstrate severe spinal wedging. If significant progression of the curvature is noted during the use of the part-time protocol, full-time bracing has to be advised. Orthotic therapy for adolescent idiopathic scoliosis is appropriate for a flexible curve of 20 to 40 degrees in a developing child with a proven progression of 5 degrees or more. Although surgery usually is indicated for curves in the range of 40 to 50 degrees in growing children, orthotic treatment may be considered for some curves, such as cosmetically acceptable double major curves.
Surgical Management of Scoliosis
The following are the reasons for surgery in adolescents with idiopathic scoliosis:
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Curves more than 50 degrees and curves more than 40 degrees in skeletally immature patients.
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Progression of the curve (5 degrees per year) in spite of bracing.
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Patients who do not accept bracing.
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Other indications of surgery are pain, increasing respiratory insufficiency, neurological involvement, degenerative changes in the spine, spinal instability and cosmesis.
The following clinical and radiological aspects of the deformity may also be taken into consideration as signs that surgery is warranted:
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Sagittal alignment showing thoracic hyperkyphosis, thoracolumbar kyphosis and lumbar kyphosis.
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Rib hump more than 3 cm.
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Decompensated curve, trunk shift.
The primary goals of surgery include:
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To arrest the deformity, pulmonary dysfunction and pain.
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To achieve the maximum correction of the deformity with minimum risk of surgical complications.
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To obtain a balanced trunk.
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The achievement of the first three objectives should be as permanent as possible.
Pedicle Fixation Method
An increasingly common method of spinal fixation is the instrumentation that leverages the pedicle as a source of purchase for bone screws inserted from the posterior approach into the vertebral body.
Congenital Scoliosis
It is caused by the presence of vertebral anomalies that produce a longitudinal growth imbalance of the spine. Congenital scoliosis, among other forms of the condition, presents particular issues that require specific attention. It necessitates distinct modes of thinking about its natural history and treatment. Congenital scoliosis is a deceptive word since it implies that the curvature is present from birth. This might not always be the case. Even though the spinal abnormality that causes the deformity is present from birth, the curve itself frequently does not manifest until much later.
The main objective of congenital scoliosis treatment is to have the spine as straight as feasible before the end of growth without damaging the neurologic condition. However, when there is a marked imbalance, the result achieved may not be a perfectly straight spine. In these cases, for optimum results, a relatively straight, balanced spine can be accepted preserving the neurological function.
The key factors in achieving optimum results are:
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Early Diagnosis of the Anomaly
If detected early enough before any gross deformity becomes evident, prophylactic surgery may prevent a major problem later.
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Anticipation
Knowing the natural history of the deformity will help in anticipating the progression of the curve thereby instituting treatment earlier for the curves that have a tendency to progress faster.
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Prevention of Deterioration
Some deformities like a unilateral unsegmented bar with or without hemi vertebrae can be treated by surgery immediately on presentation irrespective of the age but others need to be observed at regular intervals of six months depending on the severity of the deformity at presentation. A simple operation to balance the growth is preferred to a complex multistage surgery later for correction.
Note on Screening of Scoliosis
Prevention of severe scoliosis is a major commitment of spine surgeons. The American Academy of Orthopaedic Surgeons (AAOS) and the Scoliosis Research Society (SRS) first formally supported the idea of school screening for the early detection of scoliosis in children in 1984. This is predicated on the presumption that non-operative treatment would be implemented in cases of early diagnosis in children at risk for deteriorating. Without treatment, many curves could be expected to worsen over time, with some of them eventually needing surgical intervention. Those children with significant scoliosis without other symptoms could be detected by clinical screening at a time when surgical treatment could be performed most effectively.
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