Dr. Michael Paloski, a pediatric orthopedic surgeon at OrthoCarolina, sheds light on the complexities of pediatric scoliosis. While everyone's spine has natural curves, once the curvature surpasses 10 degrees, it is classified as scoliosis, varying in severity. Dr. Paloski delves into types, treatments, and common concerns, providing valuable insights for individuals and families.

Understanding Scoliosis

Scoliosis is essentially defined as a lateral, or sideways, curvature of the spine that deviates from the normal straight vertical line. This condition occurs in the coronal plane, which divides the body into front and back sections. It becomes a significant medical concern when the curvature exceeds 10 degrees. To measure this deviation accurately, medical professionals use a method known as the Cobb angle. This technique involves taking an X-ray of the spine and drawing lines perpendicular to the top of the uppermost tilted vertebra and the bottom of the lowest tilted vertebra involved in the curve. The angle at which these two lines intersect is measured, and if it's more than 10 degrees, the condition can be formally diagnosed as scoliosis.

Though everyone's spine has natural curves that serve to absorb shock and help us move, a slight curvature in the spine is quite normal and doesn't necessarily indicate a problem. However, once this curvature passes the threshold of 10 degrees, it is no longer considered a slight variation but instead classified under the term 'scoliosis'. When scoliosis is present, the severity of the curve can vary widely from person to person, and the greater the angle, generally the more severe the condition. Depending on how much the spine is curved, scoliosis can have varying effects on posture, and mobility, and may lead to other health issues if left untreated.

Types of Scoliosis

The most common form idiopathic scoliosis, is often seen in adolescents. The cause is unknown yet believed to be linked to genetics. Other types include congenital scoliosis, arising from spinal bone deformities during development, and neuromuscular scoliosis, associated with muscular imbalances in conditions like cerebral palsy. Idiopathic scoliosis is further categorized based on age: infantile (0-3 years), juvenile (4-9 years), and adolescent (10-18 years).

Treatment varies depending on age, skeletal maturity, and the degree of curvature:

1. Physicians often observe curves under 25 degrees.
2. They continually monitor curves between 25 and 45 degrees without remaining growth.
3. Bracing is an option for curves between 25 and 45 degrees with remaining growth.
4. Surgeons consider posterior spinal fusion for curves exceeding 45 degrees.

Scoliosis Treatment

Monitoring through regular X-rays, lifestyle modifications, and bracing are integral parts of managing scoliosis. For adolescents with significant growth remaining, surgeries like vertebral body tethering or minimally invasive deformity correction offer alternatives to the traditional fusion method. These procedures aim to correct the curvature while allowing for continued growth, presenting a more tailored approach to scoliosis management. The field continues to explore new options, challenging the conventional gold standard and broadening the horizons of treatment for those affected by this spinal condition.

Scoliosis FAQ:

We asked Dr. Michael Paloski a handful of questions we received about Scoliosis. The following are his answers:

Question: We found out my daughter had mild scoliosis last year from an MRI. Since being involved in high school volleyball, she has begun to have lower back pain. So could this be from her scoliosis?

If you read books on scoliosis, doctors say scoliosis isn't painful. What that means is, as the spine curves, kids don't feel the spine curving and say, "My spine really hurt today. My curve must have gone up 10 degrees." However, as the spine does have a curve, and sometimes as these muscles get asymmetric because of the scoliosis, they can put strain on the back right where the curve is or even in other places. So it's not always 100% of the time that scoliosis causes the pain, but there probably is some causative connection between the two. Typically, when I see kids like this that have scoliosis, you can't always blame the scoliosis. The best way to treat that lower back pain typically is stretching, or doing some kind of core exercise, because even if it is the scoliosis affecting it, it's usually a muscle imbalance causing the pain. So stretching, core exercises, sometimes topical analgesics like Aspercreme, Biofreeze, heat to that low back area, and even a massage, and working with a chiropractor, too, can be helpful. But if you notice that it's not getting better just with those activities, and even sometimes backing off of volleyball, which could be the hardest thing to do for the kids, then if it's persisting, that's when having one of us check her out and see if there's anything else going on that could be affected.

Question: What is recommended for severe scoliosis for a child age two with no other issues at the moment?

At age two, that's much younger on the spectrum than we typically see; usually, these kids present with scoliosis in their teenage years. This falls into the infantile scoliosis group. First, we want to know if there's another cause of it. Is it congenital? Is there a vertebra causing it? Or is it truly idiopathic? If it is idiopathic, in other words, they have a curve in their spine, is it genetic? Things that we could do include casting. So sometimes putting on a cast while the children are asleep, we put a cast around their body and mold that. Bracing is also an option for kids aged two. For some of those surgical options, you want to wait as long as you can, but sometimes casting or bracing can be done at age two to help slow down progression or get the kids old enough where they can have one of those other growing types of implants placed in if needed.

Question: What are typical recommendations for mild thoracic scoliosis due to a limp, causing intermittent pain despite physical therapy?

Okay, so typical recommendations for mild thoracic scoliosis. Physical therapy is crucial to balance out those muscles around the apex of the curve. Also, follow-up observation is recommended. If the curve is in the bracing range, sometimes bracing can be considered for angles between 25 to 40 degrees.

Physical therapy is crucial, and sometimes topical analgesics, heat, massage, making sure backpacks are light, and even dietary considerations are essential. Checking weight and keeping a healthy lifestyle can contribute to managing the pain associated with scoliosis.

Question: My daughter is 14 and has had checks for scoliosis. I recently took her to the chiropractor after consistent complaints of lower back pain. The bottom half of her back is curved. Is it possible not to have scoliosis but still have curvature of your back that causes pain?

That's correct. We have big muscles that go from our butt up to our neck called our paraspinal muscles, and they give us our posture, give us our support. Sometimes these muscles on either side of the spine can become imbalanced. If one side is a little stronger than the other, it could clinically make the child look like they have asymmetry in their back and make them look like they have scoliosis. So yes, it is possible to have the appearance of scoliosis purely driven by muscle imbalance but not have a greater than 10-degree curve in the spine.

Question: Does a brachial plexus injury at birth increase your chance of getting scoliosis later in life due to one side of your body always dropping down?

I would say no. That wouldn't cause scoliosis per se in terms of an idiopathic cause, nor does it cause the spine to deform. If you're constantly drooping down on one side, that's going to cause an apparent curvature or apparent scoliosis, but it's not going to cause your spine to stay that way throughout life. If you do have a brachial plexus injury and have a curve, is there something else that happened neurologically in the spine at the time of the injury that was causing the scoliosis too? But if it was just an isolated brachial plexus injury, we don't see that increasing the chances of having scoliosis.

Question: We started with the Rego brace and saw a 14-degree correction. Now with the generic brace, we are seeing regression. Any advice?

If you're getting good correction with the Rego brace, sticking with it would be my recommendation. The design of the brace can be different between the Rego and generic brace. If you've had success with the Rego brace and notice regression with a different generic brace, going back to what works would be a prudent choice. If the child still has significant growth remaining and has more than two years of growth left, a Rego-type brace may be recommended for optimal correction.

Question: We discovered my daughter has scoliosis from an MRI. She's 15 and has lower back pain often, especially during volleyball. Is this pain related to her scoliosis?

Very similar to the other question. It can be related to scoliosis, but if the curve is a bit higher and the pain is lower, a lot of times it's not directly related to the scoliosis. It could be related to volleyball or other activities. Most of the time, whether it is related to scoliosis or back pain in adolescence, it's muscular, greater than 80% of the time due to muscle imbalance. So keeping flexibility, doing physical therapy, and managing lifestyle factors can help alleviate the back pain.

Question: What is the maximum time for healing of the lumbar spine scoliosis after surgery? Surgery was more than two years ago, and I'm still sore.

Studies show that the body continues to adjust to a straighter spine even two-plus years after surgery. Having some soreness as your body is still adjusting is not uncommon. It should be less than what you had maybe a year ago and certainly less than when the surgery happened. If the pain is increasing more than before or after surgery, that might be a reason to get checked out again to ensure everything is okay with the implants and see if any other workup needs to be done.

Question: My 17-year-old son was just told at a child visit that he has mild scoliosis. Should I take him to an orthopedic doctor for a consult, or not worried because it is mild and he won't be growing much more?

Great question. At 17, boys typically grow until they're about 16 or 17, so he might be close to being done. Mild is subjective, so getting an x-ray to determine the actual degree of scoliosis would be beneficial. If it's 30 degrees or less, the prognosis is generally good. It's essential to check and monitor to guide the prognosis, and if it truly is mild and he doesn't have much more growing, there may not be a need to worry.

Question: My daughter has an S curve with a 47-degree curve on top and 41 on the bottom. She is almost done growing and is very crooked. We had physical therapy in addition to her night brace and are worried about tightness in her muscles. What can we do to be proactive about issues as she grows into an adult?

With an S curve, especially in that surgical range, it's crucial to consider whether surgery is an option, particularly if there's a significant imbalance or trunk shift. Maintaining an active lifestyle, keeping flexibility, and maintaining core strength are essential. If surgery is not the immediate plan, staying active and keeping the back strong are the best things to preserve the health of the spine.

Question: I have scoliosis and have two metal rods. I had the two rods placed in October 1998, I feel that scoliosis has returned, is this possible?

Depending on how long those rods are and how much of your spine was fused, it's possible that scoliosis can progress or return, especially if there was a limited fusion. If you feel there has been a shift or progression, getting X-rays to assess the instrumented area and the area that wasn't worked on is crucial. Routine radiographic maintenance follow-up every two to three years for those who had surgery is recommended.

Question: If a 13-year-old boy has fusion surgery, would you expect additional surgeries needed in his 40s, or 50s due to degradation of the surrounding unfused vertebrae?

The long-term prognosis of needing additional surgeries is generally low, but it depends on various factors, including how much was fused, how many unfused vertebrae are left, and the individual's activity level. If there's a larger fusion and the person puts a lot of miles on their back, there's a chance, but it's not a guarantee. Routine follow-up with x-rays and monitoring as he gets older is recommended. While the distinct percentage is tough to determine, additional procedures, if needed, would likely occur later in life rather than immediately after the initial fusion.

Next Steps for Scoliosis Treatment

Understanding scoliosis is crucial for informed decision-making regarding diagnoses and treatment. Whether exploring the diverse types of scoliosis, considering treatment options, or seeking long-term management strategies.

It is important to note that while this guide aims to provide helpful insights, it is not a substitute for professional medical advice. We encourage readers to use this resource as a means of gathering information before seeking professional help or when considering a second opinion.

If you need specialized care for scoliosis, our team of spine specialists is here to assist you. Our experts have extensive experience in diagnosing and treating scoliosis, and they are dedicated to providing personalized care tailored to your specific needs.

For personalized care, schedule an appointment with our pediatric spine surgeons to navigate your scoliosis journey.

This blog content was provided from our free webinar with Dr. Paloski which aired on December 13, 2023. You can watch the full webinar video here. Stay tuned to our social media and email newsletter for details on any upcoming free webinars.

This information is provided as an educational service and is not intended to serve as medical advice. If you are seeking specific orthopedic advice or assistance, please consult with your OrthoCarolina physician or locate one in your area through OrthoCarolina’s website at www.OrthoCarolina.com.