What is Scoliosis?
Scoliosis is defined as a curvature of the spine deviating 10 degrees or more to the right or left, instead of being aligned in a straight line, as seen in a front-facing X-ray of the spine.
What Types of Scoliosis Exist in Children and Adolescents?
There are basically three types of scoliosis:
- Idiopathic Scoliosis: This is the most common type of scoliosis. The exact cause is unknown, but genetic factors are believed to play a role.
- Congenital Scoliosis: This type of scoliosis develops due to congenital spinal abnormalities present from birth.
- Neuromuscular Scoliosis: This type of scoliosis develops as a result of neuromuscular problems such as muscle diseases or nervous system disorders.
What is Idiopathic Scoliosis? What Causes It?
Idiopathic scoliosis is a type of scoliosis whose cause is unknown and cannot be explained by any disease, medication, improper body use, harmful foods, radiation, or heavy sports and activities that could cause deformities in the body or bones. However, GENETIC FACTORS ARE BELIEVED TO PLAY A ROLE in its development.
At What Ages and in Whom is Idiopathic Scoliosis Most Commonly Seen?
Idiopathic scoliosis is categorized into four groups based on the age at which it is observed:
- Infantile period (0-2 years)
- Juvenile (3-9 years)
- Adolescent period (10-17 years) (Adolescent Idiopathic Scoliosis)
- Adult period (18 years and older)
Idiopathic scoliosis is most commonly seen during the adolescent period, i.e., during puberty, and it is most prevalent in girls.
Can Scoliosis Be Detected at an Early Age? What is the Importance of Early Detection?
Scoliosis can indeed be detected at an early age. If diagnosed early, the progression of the condition can be controlled with bracing and physical therapy in progressive cases, and non-surgical treatment can be achieved for some patients.
Should Screening Methods Be Applied for Early Detection?
Examining and taking X-rays of children who show no symptoms for scoliosis is a debated topic due to costs and radiation exposure.
However, raising awareness among families about scoliosis is essential. It is recommended that children of families with a history of scoliosis or with visible signs of scoliosis be examined by a spinal surgery specialist, even if they do not show any symptoms. It is advised that girls be examined between the ages of 10-13 and boys between 13-17.
What are the Symptoms of Scoliosis?
Typical symptoms of scoliosis include:
- Difference in shoulder height
- Height difference between the shoulder blades
- Asymmetry between the right and left waist indentations
- Leaning of the torso to one side
- Height difference between the right and left sides of the pelvis
- Deviation of the spine from the midline when bending forward and sometimes a hump on one side of the back
Is There Pain in Scoliosis?
Pain may accompany scoliosis in some patients. This is independent of the degree of scoliosis, meaning that pain can be present in both high-angle and low-angle scoliosis.
How is Scoliosis Definitively Diagnosed?
The definitive diagnosis of scoliosis is made through an X-ray that shows the entire spine. The curvature (Cobb angle) of the spine is measured on the X-ray. A diagnosis of scoliosis is made if the curvature is 10 degrees or more.
How is the Cobb Angle Measured?
The Cobb angle is the sum of the angles that the uppermost and lowest vertebrae involved in the curvature make with the horizontal plane. It is important to distinguish the topmost and lowest vertebrae involved in the curvature and to measure from the same vertebrae during follow-up.
Is the Treatment of Idiopathic Scoliosis Based on the Cobb Angle, or Degree of Curvature?
Yes, this is the most important factor. However, the child's growth potential also determines the type of treatment.
How is the Child's Growth Potential Assessed?
In boys, the rapid growth phase typically occurs between the ages of 13-17, while in girls, it usually happens earlier, between the ages of 10-13. The rate of curvature progression increases during the rapid growth period. Some physical signs appear in children during adolescence, including voice deepening, pubic and underarm hair growth, and breast development. In girls, the onset of menstruation (menarche) generally occurs towards the final stages of growth.
However, in scoliosis patients, growth tracking is done objectively through radiological examinations. The most commonly used radiological assessments are hand X-rays and pelvic X-rays. The Risser classification and Sanders classification can largely predict how much more growth potential a child has.
How is Treatment Determined in Scoliosis Based on Cobb Angle and Growth Potential?
In the Risser classification, which involves the radiological examination of the pelvis (the Risser classification is made from the pelvis on the scoliosis X-ray taken during normal follow-up; no extra X-ray is needed), a Risser score of 0-1 indicates that the child is in the early growth phase and still has significant growth potential. For children with a Risser score of 0-1 and a curvature angle between 10-20 degrees, only physical therapy and radiological examination every 6 months are sufficient.
However, if the curvature is between 20-40 degrees, brace treatment must be added. Radiological examination should still be done every 6 months. For a Risser score of 2-3, the treatment plan remains the same: physical therapy for curvatures of 10-20 degrees and brace treatment for those between 20-40 degrees. A Risser score of 4-5 indicates that the child's growth has slowed or stopped, and the rate of curvature progression has also stopped. Brace and physical therapy are debated at this stage. Brace treatment can still be applied in very selective cases where it is thought that there is still a small amount of growth potential. For scoliosis with a Risser score of 4-5 and a curvature under 40 degrees, annual X-ray follow-up is deemed sufficient.
Generally, surgical treatment is appropriate for scoliosis cases with a curvature angle over 40-45 degrees.
Is Brace Treatment Effective in Scoliosis?
Brace treatment is effective when performed by experienced orthotist teams at suitable curvature angles during the growth period. An important point here is the child's compliance with the treatment. It is recommended that the brace be worn for at least 16 hours a day.
Is Exercise Therapy Effective in Scoliosis?
Studies have shown that exercise therapy is particularly effective in cases of low-angle scoliosis. Exercise alone is prescribed for curvatures between 10-20 degrees, while exercise therapy is added to brace treatment for curvatures between 20-40 degrees if the child is at an age where they can handle it physically and psychologically. Since most of these children are in pre-adolescence and adolescence, resistance and non-compliance with brace treatment can be an issue. Therefore, discussing all these aspects with families and managing the treatment without putting the child under excessive psychological stress is the best approach.
Which Scoliosis Patients Require Surgical Treatment?
Generally, surgical treatment is recommended for scoliosis patients with a curvature angle over 40 degrees, regardless of the Risser score. There are exceptions to this. For example, in some cases, 35-degree lumbar curvatures that show progression during follow-up may require surgery, while 45-degree thoracic curvatures that remain stable and do not progress can be monitored without surgery. Social and psychological factors, brace non-compliance, and cosmetic concerns can also influence the decision for surgery.
What Techniques Are Used in Adolescent Idiopathic Scoliosis Surgery?
Two different surgical techniques are used in scoliosis surgery:
1. Fusion Surgeries:
In this type of surgery, implants called pedicle screws are placed in the vertebrae within the curvature, and the correction is made using rigid metal rods attached to these screws. These rods are usually made of cobalt-chromium or titanium. The goal of this surgery is to correct the curvature using the rods and achieve fusion (joining) of the vertebrae within the curvature.
This procedure is typically performed through a posterior approach, meaning incisions are made along the back or lumbar region (posterior side) of the patient. The muscles surrounding the vertebrae are separated from the bone using a cutter called a cautery. Some surgeons place screws in all vertebrae within the curvature, while others only place screws in selected vertebrae to perform the correction. Both methods are valid.
However, the most important factor is selecting the correct top and bottom vertebrae and applying the correction maneuvers accurately. Incorrect selection can lead to repeated surgeries. Preoperative planning is as important as the surgery itself.
2. Non-Fusion Surgeries:
Non-fusion surgeries have become increasingly common recently, and scientific articles have begun to publish results extensively. Although fusion surgeries remain the gold standard, the advantages of non-fusion surgeries have offered promising options for scoliosis patients.
First published in 2010, the results of vertebral body tethering (tethered scoliosis surgery) are especially preferred in flexible curvatures and in growing children. Not every type of curvature is suitable for this surgery. Problems may arise, particularly with accompanying upper thoracic curvatures and curvatures associated with kyphosis (hyperkyphosis).
If the curvature is in the thoracic region, the surgical procedure is performed on the convex side of the curve through 4-5 cm incisions or multiple 1-2 cm incisions using the thoracoscopic method with camera assistance, depending on the surgeon's experience. During the procedure, the lung on the surgical side is deflated to prevent damage. Screws are placed on the side of the vertebral bodies, similar to fusion surgery.
In both fusion and non-fusion surgeries, the patient's neurological status must be monitored throughout the procedure using a device called neuromonitoring, performed by experienced neurologists and neuromonitoring technicians. After the screws are placed, they are connected by a strong tethering system and tightened to perform the correction. After the correction is made, a chest tube drainage system is placed to remove accumulated blood and fluids around the lungs.
If the curvature is in the lumbar region (lower back), a small 8-10 cm incision is made to access the side of the vertebral bodies by pushing the intestines forward. The other steps continue as described above.
Is Early Return to School Possible After Scoliosis Surgery? When Can Sports Activities Begin? Which Sports Can They Play?
After surgeries performed with both techniques, returning to school can typically be possible within a short period, around 2-3 weeks. However, returning to contact sports such as football, basketball, and volleyball usually occurs about 1 year after fusion surgery and approximately 3-6 months after tethered scoliosis surgery. Some surgeons do not recommend contact sports after fusion surgeries.
However, this is not based on evidence-based scientific data. Since the main philosophy behind tethered scoliosis surgery is to preserve movement, and there is no expectation of fusion between the vertebrae, early movement and return to sports are permitted. In fusion surgery, the main reason for limiting movement for a certain period is to prevent any negative effects on the fusion process and to avoid potential wear on the discs of the non-instrumented vertebrae due to excessive load.
Do the Tethers Used in Tethered Scoliosis Surgery Break?
Yes, they can break. However, this does not mean that the surgery has failed. If the tether can control the curvature within the desired period and lasts until the curvature is stabilized, significant worsening is not expected.
If the tethers break in the early period, they need to be replaced. Recently, to solve this issue, a system has been developed where each vertebra is fitted with two screws and two tethers, particularly in lumbar and sometimes thoracic curves.