What is adolescent scoliosis?
Like all forms of idiopathic scoliosis, the exact cause of AIS is unknown. Like other forms, there have been a large number of possible causes suggested – one of the leading theories is a genetic link, although more research is required before we are able to make a definitive conclusion. There is also some evidence that AIS may be associated with certain activities which stress and pull the spine away from its normal aligned position – for example, research indicates a higher incidence of scoliosis in ballet dancers and gymnasts.
Whereas infantile and younger Juvenile scoliosis cases are more common on boys, 80% of all AIS cases are girls. It is usually noticed around 11-12 years of age in girls and slightly later when diagnosed in boys. AIS is estimated to affect between 3 and 4% of teenagers. In most cases, AIS begins to develop noticeably at the initial onset of puberty and becomes more apparent as is worsens during growth spurts.
AIS can be highly progressive, so it is important that the right sort of monitoring and treatment is sought as soon as the condition is noticed. When not appropriately treated it may result in significant deformity, physical disability and psychological issues – but when treated with effective modern approaches, such as bracing with calibrate, the long term prognosis is very good indeed.
How is adolescent scoliosis diagnosed?
In the UK there is no formal screening program for AIS (nor for any other form of scoliosis) – although it is provided through some private schools and via sports and activity clubs, such as ballet schools, where there is known to be a higher rate of scoliosis sufferers. Typically, adolescent scoliosis is first noticed by the affected individual, a family member, teacher or sports coach.
A simple test, known as the “Adam’s Test” is routinely performed to test for scoliosis – here, the individual is asked to bend forwards from the waist and then hips, the shape of the spine and ribs is then observed. If one side of the rib cage or lower back is noticeably more prominent or humped, the test is regarded as positive and the individual should be seen by an appropriately trained health care professional. This hump can be measured by a specialist tool called a “Sociometer” which can measure the degree of rotation from one side to the other.
Scoliosis is typically diagnosed by a combination of tests, such as the Adams test – but can only be confirmed and fully understood by taking an x-ray, and measuring the degree of tilt and rotation of the vertebra involved. A “cobb angle” of over 10 degrees is diagnosed as scoliosis.
What are the symptoms of adolescent scoliosis?
Typically, AIS is without obvious symptoms, however unlike in younger children, it is not uncommon for adolescents with large curves or curves that progress quickly to complain of some back pain or discomfort.
The visual signs of adolescent idiopathic scoliosis include:
• Uneven hips
• A shorter leg
• A high shoulder
• A prominent shoulder blade
• A uneven waist, where one side is straight and the other more rounded
• Lack of symmetry in the chest
How is Adolescent Idiopathic Scoliosis Treated?
When deciding on which approach to take towards treating scoliosis, we must first consider the risk of curve progression. This largely depends upon the curve size and the maturity of the patient, as well as the amount of growth left in the spine at the time od diagnosis. When curves are large and there is still significant growth left, curve progression is inevitable. Even once growth has stopped, large curves will progress throughout adulthood, but small and medium curves can often be completely corrected with the right treatment. Even in very large curves, the right treatment can help to avoid surgery.
One way of determining the amount of growth left, is to assess the amount of cartilage left on the hip crests before it ossifies to the pelvis. This is known as the Risser sign and can be seen on a pelvic x-ray. The lower the Risser score number (0-5) the higher the risk of progression. Typically, the younger the person the more amount of growth left – this is why Juvenile typically has a worse long term prognosis than adolescent scoliosis.
Historically, observation or “Watchful Waiting” was often recommended for AIS however today some form of conservative treatment will usually be recommended by any scoliosis expert. The larger the curve as well as the greater the family history of scoliosis, the less appropriate observation is. For example, a 15° curve in a 11 year old girl with a family history of scoliosis will have a high risk of progression, whereas a 25° curve in a 15 year old with no family history has a lower risk of progression, but is already substantial. In either instance, it is important to remember it is easier to treat a small curve with bracing and scoliosis specific exercise than it is a large curve, meaning simply allowing the curve to continue to develop is almost never the right approach.
In curves between 10-20°, physiotherapy scoliosis specific exercises are typically recommended as a first line treatment, while bracing may also be used as a preventative measure in the long term, or as a more convenient alternative to exercise based approaches.
In curves over 20-25° with a moderate to high risk of progression, scoliosis bracing must be used in conjunction with scoliosis specific exercise. In Dr Stuart Weinstein’s landmark BrAIST study, bracing was shown to be effective in reducing the progression to the surgical threshold of 50° by the end of growth in 72% of cases compared to 48% of those who were purely observed. What is important to remember, is that those who wore the brace for more than 13 hours per day actually had a 90% success rate.
In curves 45-50°, conservative treatment becomes far more difficult. In older adolescents when a curve is less likely to rapidly progress, an aggressive rigid brace may be used and combined with intensive scoliosis specific exercise. This may help to improve body aesthetics and reduce the curve size when surgery is not recommended.
In large curves in younger adolescents with a high risk of progression, bracing may be used to slow curve development. This way surgery can be delayed until growth has finished so multiple surgeries are not required.
When curves are large and the risk of progression is high, surgery may be the only option. Surgery is recommended not purely on curve size, but also on curve location, future progression, loss of postural balance and when bracing has been unsuccessful.
When surgery is required, the spine is fused into a straightened position. The techniques for this do vary and may involve utilisation of bone grafts or surgical rods to straighten the spine. Surgery is obviously not without risks, but patients will normally return to school in 4-6 weeks and most if not all of their normal activities and non-contact sports over the following 12 months.