I want to remove some of the mystique around scoliosis and debunk some myths people potentially have heard about scoliosis that cause anxiety for patients and families.
Background on Scoliosis
About 7 million people in the US have scoliosis, so almost everyone knows someone in their family, at their school or in their friend group who has it, although you may not know it.
The official definition of scoliosis is an abnormal curvature of the spine. If the most tilted vertebra is more than a 10-degree angle, it’s officially scoliosis. We have traditionally thought of scoliosis as an S-curve in the back, but it’s really a three-dimensional deformity and the curve of the spine from the side also matters. A 3D view allows you to fully appreciate the curvature in scoliosis.
Types of Scoliosis
There are two common types of scoliosis, as well as a few less-common types not discussed here.
Adolescent Idiopathic Scoliosis
We often think of teenagers being diagnosed with scoliosis, usually girls from 10 to 18 years old. Most of the time it’s diagnosed at a school screening or by a pediatrician. You may have experienced or know about a common test, where you bend down towards your toes and the doctor or nurse looks for an asymmetry in the spine. The asymmetry is due to the rotation and curvature so one side is higher than the other. If scoliosis is suspected, the doctor or nurse will refer the student for x-rays and a visit to a spine surgeon.
As the teen grows the curve changes, and the goal is to stop the curve before it gets to the surgical range of about 45 to 50 degrees. If the curve is stopped, you don’t need to have surgery and can live your life normally. There are some adults who have adolescent idiopathic scoliosis, are not diagnosed as children or teens, and are diagnosed after an unrelated x-ray as an adult. The scoliosis has not affected their lives and while we may check it occasionally, they can continue to live their lives normally.
Some people do need to have scoliosis surgery as a kid, but that’s relatively rare.
Adult Degenerative Scoliosis
Adult degenerative scoliosis develops later in life, in your sixties, seventies or eighties. Unlike adolescent idiopathic scoliosis, adult degenerative scoliosis is painful due to nerve compression from disc degeneration and bone spurs in your spine. It can cause leg pain from the nerve compression.
In adolescent idiopathic scoliosis, patients tend to be well-aligned, with their head over their hips; from the front and the side, they have a curve in the middle. In adult degenerative scoliosis, you may start to tilt to the side or tilt forward because the spine, the scaffolding of your body, is moving from where it has been.
The adult version of scoliosis is very debilitating. It can be as debilitating as chronic diseases like heart failure or lung disease.
Scoliosis Myth 1: Scoliosis is Caused by Something Controllable
People worry that they may have done something to cause scoliosis. In adolescent idiopathic scoliosis, idiopathic is the key word. It is the word doctors use for “we don’t know what causes it”. Science has spent a lot of time and money trying to figure out what causes scoliosis, and we think mostly likely it’s an asymmetric growth in the spine that causes the curve. We know there’s some genetic component to it, as there are often many females in the family that have scoliosis if there’s a diagnosis, but we’ve never identified one specific gene that causes it.
People often wonder if slouching causes scoliosis, and there’s never been any association shown between posture and scoliosis. If slouching caused scoliosis, every teenager would have it because slouching is so common. It’s also not caused by carrying heavy backpacks, doing specific sports, or playing musical instruments.
Another common myth is that a leg length discrepancy causes scoliosis, but that myth goes back to thinking about scoliosis only in one plane. If you look at someone from the back when they have an S curve in their spine and one of their legs is higher, you can image that the leg length discrepancy may cause the spine to be curved. But if it’s a true scoliosis there is also rotation and sagittal plane issues that wouldn’t happen if there’s a leg length discrepancy.
Adult degenerative scoliosis is not caused by one specific thing like sitting for work, a sports injury, or a fall as a child. It’s usually from normal degeneration with time, which is a combination of genetics and what you’ve done in your life. Some people live very strenuous lives with minimal degeneration and a normal looking x-ray, while other people live very moderately or mildly strenuous lives and have a large curve due to severe degeneration. Adult degenerative scoliosis usually has a genetic component.
Scoliosis Myth 2: Scoliosis Will Significantly Change My Life
When people are diagnosed with scoliosis, they worry it will significantly change their life or will stop them from doing what they want to do. Especially with pediatric patients who don’t have pain, I emphasize they can do anything they want to do in life. There’s a professional female golfer on the LGPA tour who had a scoliosis surgery. Teens have scoliosis surgery and play football or dance.
Parents worry if scoliosis will impair their children’s future fertility, and scoliosis has no effect on anything in the process of having children. If someone with scoliosis gets an epidural, the anesthesiologist needs to be aware for proper positioning of the needle to get it into the spinal canal, but otherwise it shouldn’t affect anything in the process of having children.
Scoliosis Myth 3: Scoliosis is Painful
Adolescent idiopathic scoliosis isn’t very painful. Ninety-five to 99% of the teenage patients I see with a curve in the back don’t have any pain. If they have some discomfort, it’s usually the right scapula, and physical therapy or medications can help with the discomfort but it’s not painful.
Scoliosis surgery for teenagers is to halt the progression of the spinal curve, not for pain. If a teenager has scoliosis surgery they may have more pain than they had previously: if they did not have any pain before the surgery, they may have some pain after the surgery to stop progression of the curve. Scoliosis surgery for adolescents also may decrease some of the rotation to decrease some of the asymmetry of the trunk, so you may be slightly taller after the surgery. In cases of severe scoliosis, surgery may also improve lung function. However, most scoliosis curves in adolescents don’t affect lung function or your gastrointestinal system.
However, the adult version of scoliosis is painful. You may have leg pain from nerve compression and your muscles may become fatigued from compensating. If your scaffolding is crooked and your muscles are trying to have you stand up straight, it may be painful and tiring. People may need to use a walker or cane to stand up straight.
Scoliosis Myth 4: Scoliosis Always Requires Surgery
Most of the time scoliosis does not require surgery. The size of the curve determines if surgery is necessary. Most patients are in the 10-to-30-degree range, which does not require surgery. A larger curve, such as 45 or 60 degrees, may need a discussion of surgery.
For adolescents with scoliosis, bracing is a very effective nonsurgical treatment. Approximately 30,000 kids receiving bracing for scoliosis every year. Bracing is effective for kids with 20-to-25-degree curves who are still growing and helps ensure the curve does not get worse.
The other treatment that has been studied but is not proven yet is Schroth physical therapy. Regular stretching and strengthening physical therapy has not been shown to decrease progression of scoliosis curves, but Schroth therapy is currently being studied to potentially decrease the progression of curves.
If your curve is in the bracing range, you must brace to decrease your risk of surgery. Schroth physical therapy may be added as an adjunct treatment to strengthen the core muscles and potentially decrease the risk of surgery.
Unfortunately, adult curves are not as easily braced, since braces are designed to stop progressing in growth. For adult degenerative scoliosis, you’d have to wear a brace essentially through your entire body to keep it straight and you can’t stop the degeneration.
However, we have many non-surgical methods to help deal with the pain including physical therapy, medications, epidural injections, and activity modification. Surgery is always a last resort: only when you’ve exhausted every other option and you’re still having pain or you’re still debilitated enough is it worth the risk of surgery.
Scoliosis Myth 5: Surgery is Scary
If you have adolescent idiopathic scoliosis, you’ll be able to live your life normally and do anything you want. While you may need a brace, most of the time you won’t need surgery.
Adults who had scoliosis as an adolescent may have a slightly increased risk of back pain in their lives, but almost everyone has back pain at some point and it’s difficult to know what back pain you may have had anyway and what back pain comes from scoliosis. People who had idiopathic scoliosis are relatively normal and active.
Adult degenerative scoliosis is more debilitating, but we have many techniques both surgical and nonsurgical that will hopefully help you improve your quality of life.
Frequently Asked Questions
If a child has been diagnosed with scoliosis, when should they see an orthopedic spine surgeon?
Go ahead and see an orthopedic spine surgeon if there’s any question at all. We’ll get a full-length x-ray to see, and we’ll be able to do a standardized assessment of scoliosis and answer all your questions as fully as you want them to be answered. Just because you’re going to see a surgeon doesn’t mean that we’re going to be discussing surgery.
If someone has adult degenerative scoliosis and bone-on-bone arthritis in their hip, should they have a hip replacement or fix their back first?
This question has been a topic of study and discussion in the spine and hip replacement communities over the last decade. Right now, we’re learning more toward doing the spine surgery first.
If you had back surgery and have bad hip arthritis, it will be difficult to recover from the back surgery because of the hip pain and difficulty walking. Conversely, a big part of degenerative scoliosis is changes in the overall alignment of the spine and pelvis and the position of the pelvis may change. A surgeon may put a hip replacement into what they think is the perfect position, but a subsequent scoliosis surgery may change that position. After the spine surgery, the hip replacement may be not be positioned as well to replace the hip and may be more prone to dislocations.
Once a child completes the required time in a brace while they’re growing, what is the follow-up care?
We stop bracing when the patient is done growing. We measure if they’ve finished growing by taking an x-ray of the hand. There are growth plates in every bone in the hand, and we can tell from that x-ray when the patient is about done growing.
After bracing, the child can live their life completely normally. If they’re having pain, they can do therapy and things that deal with the pain. If they want to continue Schroth physical therapy to keep their core strong and keep their spine as healthy as possible, they may continue. They’ll be checked again via x-ray in a few years to make sure there isn’t any abnormal progression we weren’t expecting.
Does having scoliosis make you more susceptible to osteoporosis?
No, it does not. Osteoporosis is low bone density. While there are many risk factors for osteoporosis, including being a post-menopausal female, genetic causes, smoking, certain drugs, and family history, osteoporosis and scoliosis are not related. If you have osteoporosis and you have a fracture in your back from weak bones it could potentially cause an abnormal curvature, but having scoliosis does not affect your bone density at all.
Is it safe to have surgery for other spine issues when you have mild scoliosis?
It’s usually safe. Your spine surgeon will have x-rays and imaging that will show them the anatomy of your spine, and they may need to take into account the curve when they’re doing surgery. If they’re doing a surgery to decompress the nerves or take out a disc herniation, the scoliosis won’t have much effect. Spinal fusion is slightly more complex to make sure that the correct biomechanical alignment is preserved when fusing. It’s safe to have surgery in those situations.