Tag: scoliosis

Reduction of Scheuermann’s deformity and scoliosis using ScoliBrace

New research just published by our partner ScoliCare has once again gone to show that the ScoliBrace, coupled with an appropriate exercise regime can be effective not only in reducing scoliosis, but also in treating Scheuermann’s Kyphosis.

Regular readers of the blog will know that a treatable case of Scoliosis is considered to exist when the cobb angle (the bend in the spine) exceeds 10 degrees. Scoliosis causes the spine to bend “from side to side”.  In Scheuermann’s Kyphosis there is a malformation of the spinal vertebrae – specifically, they are slightly shorter in height at the front than at the back, leaving them slightly wedge-shaped – This leads to a “forward hunching” curve in the spine. While both conditions can and do frequently present independently, it is entirely possible for both to be present.

With respect to treatment for Scheuermann’s kyphosis and scoliosis, a course of conservative (that is to say, non-surgical) therapy is recommended wherever possible, with surgical intervention reserved for those patients with severe pain and/or disability at the time of the initial consultation or for individuals who have not responded to conservative management attempts.  The research from 2019 provided a case study of a patient in which both conditions were present, and were managed successfully with ScoliBrace, and appropriate exercise.

Let’s take a look at the recent case study[1] – both because we can learn something about the way that ScoliBrace can be used to treat these cases, but also because many readers may recognise something of their own experience!

 

Scoliosis and Scheuermann’s, a case study

Initial X-ray, taken at the start of treatment

On the 22nd of February 2016, a 26-year-old Caucasian male presented to a chiropractic clinic suffering with from lower back pain and poor posture. He also had a previous diagnosis of Scheuermann’s kyphosis and adolescent idiopathic scoliosis. The patient reported difficulty with prolonged standing and sitting, dissatisfaction with his cosmetic appearance, and difficulty with leisure activities – all of which are common issues for sufferers of both conditions.

Interestingly, the patient in question had not left his spinal conditions untreated – on the contrary, at the age of 15, the patient was referred to the local Children’s Hospital and was prescribed a hospital made thoraco-lumbo-sacral orthosis (TLSO) (a brace) which he wore full-time (23 hours per day) between the ages of 15–17 years.  Unfortunately, the brace provided was not like ScoliBrace, in that it’s action was preventative, rather than corrective – meaning that its objective was simply to hold his curves in place to avoid progression of the scoliosis, rather than to reduce it. The brace also had no effect on the Kyphosis.

At the point of initial examination, the patient reported that he was significantly unhappy with his physical appearance and rated his back pain as 4/10 on average and 7/10 at worst.

Full spine radiographic assessment was performed which revealed a thoracic hyper-kyphosis measuring 79° Cobb (Fig. 1), and a 30° Cobb lumbar scoliosis and sacral obliquity (Fig. 2). A loss of disc height, vertebral wedging and endplate irregularities were noted at several levels in the mid-thoracic spine. A true leg-length discrepancy (short left leg relative to the right) of 6 mm was also noted during the radiographic examination.

Subsequently, he was prescribed a ScoliBrace custom spinal orthosis, a rehabilitation program and a 6 mm heel lift. The ScoliBrace, unlike the Boston brace the patient was previously provide with, is an over-corrective brace, which takes and active approach to correction – this means that rather than simply trying to stop scoliosis progressing, it actually works to reduce the curve. The patients home exercises were simple for him to perform and included a mixture of stretching and strengthening exercises designed to oppose both undesirable curvatures.

 

12 months with ScoliBrace, results!

Follow up X-ray

Since the entire ScoliBrace process is designed to be flexible, reactive and adaptable, patients are typically seen every 6 months or so to assess progress and make any necessary treatment changes. Our patients first follow-up assessment was performed 4.5-months after the initial assessment. After just 18 weeks, the patient reported that, on average, he had been pain-free, with his worst occasional pain being rated as 2/10 pain on occasion.  In terms of the spinal deformity, the hyper-kyphosis had reduced by 16°, from 79° down to 63°, and the lumbar scoliosis curve was reduced by 5°, from 30° down to 25°.

At a further follow-up, 12 and a half months after the initial consultation, another series of x-rays showed that the postural improvements had all been maintained. An analysis of follow-up radiographic images (Fig. 6) showed a maintenance of the original postural improvements. [2]

 

 

Treating Scoliosis and Scheuermann’s at the UK Scoliosis clinic

The above case study results are interesting, because fairly few studies have addressed the use of active correction braces in adults, and there is also very little research on the correction of both conditions simultaneously. This case study certainly suggests that ScoliBrace, coupled with targeted home exercise can indeed have a positive impact on these conditions.

Of note is also the fact that this is yet another study to indicate a link between scoliosis and pain. At the UK Scoliosis clinic, we have long observed that pain and discomfort are often associated with these conditions, even if research has yet to confirm this association in an absolute sense. It would be fair to mention on this point that much of the research that would go to establish the validity of bracing as an approach to pain reduction have been affected by low adherence of study participants to their prescriptions – which is a common issue for many studies in bracing.[3]

At the UK Scoliosis clinic, we also offer the Kyphobrace system (from the same developers as scolibrace) which is ideal for treating Kyphosis cases which occur without scoliosis. To learn more, click here.

 

 

[1] Christopher M. Gubbels, DC, Paul A. Oakely, DC, MSc, Jeb McAviney, MChiro, MPainMed, Deed E. Harrison, DC, Benjamin T. Brown, PhD,  Reduction of Scheuermann’s deformity and scoliosis using ScoliBrace and a scoliosis specific rehabilitation program: a case report, J. Phys. Ther. Sci. 31: 159–165, 2019

 

[2] Christopher M. Gubbels, DC, Paul A. Oakely, DC, MSc, Jeb McAviney, MChiro, MPainMed, Deed E. Harrison, DC, Benjamin T. Brown, PhD,

Reduction of Scheuermann’s deformity and scoliosis using ScoliBrace and a scoliosis specific rehabilitation program: a case report, J. Phys. Ther. Sci. 31: 159–165, 2019

 

[3] See for example Weiss HR, Moramarco K, Moramarco M: Scoliosis bracing and exercise for pain management in adults—a case report. J Phys Ther Sci, 2016, 28: 2404–2407.

Palazzo C, Montigny JP, Barbot F, et al.: Effects of bracing in adult with scoliosis: a retrospective study. Arch Phys Med Rehabil, 2017, 98: 187–190.

Is scoliosis a risk factor for mental health?

Like all reputable clinics, the UK scoliosis clinic focuses the majority of its time and effort on providing the best possible treatment for scoliosis cases. For the most part, this means keeping up with the latest research, bracing and exercise based techniques which can assist in controlling and reducing scoliosis, however, where we also concentrate a lot of time and attention is to the psychological aspects of living with and being treated for scoliosis.

 

Scoliosis and Psychological factors

Like any condition, Scoliosis can obviously cause distress and concern – but there are some specific factors associated with scoliosis which may make the condition especially difficult for many patients to cope with. The key areas include:

  • The fact that Scoliosis does cause physical deformity, and very often strikes at the most sensitive time in a young person’s life. It’s normal and expected for teens and young adults to experience stress and difficulty associated with physical changes in their body and the formation of their adult identity, even under typical circumstances – scoliosis can certainly complicate this.
  • Misinformation about scoliosis which is frequently repeated. Many still believe that a diagnosis of scoliosis necessitates surgery, which, ironically, can prevent some people from taking advantage of screening. It’s also commonly believed that scoliosis can impact on the ability to have children, take part in physical activity or even live a normal life. While it’s true that if left untreated scoliosis could lead to some of these outcomes, early treatment can often make such outcomes almost completely avoidable.
  • Concerns about bracing, and stigma associated with bracing. It’s certainly the case that “old style” braces such as the Boston brace were visible, clunky and certainly embarrassing for young people – but modern CAD/CAM braces, such as ScoliBrace, are virtually invisible under clothing.
  • Fear of being unable to participate in normal activities. Again, with modern bracing technology this is rarely if ever, an issue – today’s braces are so easy to put on and take off that they can simply be removed for exercise, although designs such as ScoliBrace are actually flexible enough to be left on.

With each of these concerns, the critical point to stress is that Scoliosis, if caught early enough can now usually be treated non-surgically and quite quickly, through bracing, exercise or a combination of both. The best possible way to detect scoliosis is through a routine screening, which can often allow the condition to be detected long before it has progressed to a significant degree.

 

Scoliosis and psychological health : scientific research

There has been some limited research which has sought to understand the impact that scoliosis can have on a young person’s psychological health – although it’s still fair to say that only a small part of the literature relating to scoliosis considers this angle, there is still sufficient a body of evidence for us to draw some meaningful conclusions.

One such study looked at adolescents with and without scoliosis in Minnesota who were 12 through 18 years of age. During the study, six hundred eighty-five cases of scoliosis were identified from the 34,706 adolescents. The prevalence was therefore 1.97%  (incidentally, this is slightly below the average figure). The researchers wanted to calculate the odds ratio of scoliosis to some common psychological issues.

Put simply, an odds ratio is a measure of how strongly related two items are – An odds ratio of more than 1 means that there are a higher odds of property B happening with exposure to property A, whereas an odds ratio of exactly 1 means that exposure to property A does not affect the odds of property B. An odds ratio is less than 1 is associated with lower odds of two factors being related. [1]

In the study, of the 685 adolescents with scoliosis, the odds ratio for having suicidal thought among adolescents with scoliosis, compared to adolescents without scoliosis, was 1.40 after adjustment for race, gender, socioeconomic status, and age. The odds ratio for having feelings about poor body development among adolescents with scoliosis was 1.82 compared with adolescents without scoliosis after adjustment for race, gender, socioeconomic status, and age. Scoliosis was therefore deemed to be an independent risk factor for suicidal thought, worry and concern over body development, and peer interactions.

In a 2019 study, which compared scoliosis treatment approaches, the SRS-22 (a standardised scoliosis quality of life screening form) was used to explore the impact which treatment had on psychological health.  Here, researchers noticed that self-image was significantly improved amongst patients treated with a scoliosis brace, especially at a follow up after 12 months of treatment, this was especially interesting given the negative self-image association which is sometimes linked to bracing

Researchers found a similar improvement in patients treated with an exercise methodology –  all the SRS-22 quality of life subsets showed a slightly larger improvement across the three visits than bracing, although the correction of scoliosis was less.[2]

 

Does scoliosis affect psychological health?

From the research which has been conducted, as well as our own experience at the clinic we feel it’s safe to say that scoliosis can be a significant risk factor for psychological health – especially in young people. While this certainly does not mean that everyone with scoliosis will struggle with mental health as a result, it’s clearly important that scoliosis clinicians are aware of the risk, and work to mitigate it.

At the UK Scoliosis clinic, we believe that properly researched information, coupled with effective treatment, applied as quickly as possible is the best possible way to address the psychological risks associated with scoliosis. It’s for this reason that we continue to recommend frequent screening throughout high risk years. It cannot be stressed enough that early detection, coupled with good information can go the majority of the distance in diffusing some of the  main concerns around a scoliosis diagnosis. We would caution parents and sufferers from relying on general advice or information pulled from the internet – the best option is by far a consultation with a scoliosis professional.

[1] Payne, William K. III, MD, et al. Does Scoliosis Have a Psychological Impact and Does Gender Make a Difference? Spine: June 15, 1997 – Volume 22 – Issue 12 – p 1380–1384

[2] Yu Zheng, MD PhD et al. Whether orthotic management and exercise are equally effective to the patients with adolescent idiopathic scoliosis in Mainland China? – A randomized controlled trial study SPINE: An International Journal for the study of the spine [Publish Ahead of Print]

Spinal surgery for scoliosis and degenerative disc disease

Scoliosis, if left untreated, tends to progress in most cases – and where this progression is significant enough it can result in significant disability and reduction in quality of life. For this reason, scoliosis is a condition which the medical profession has been keen to treat and treat as early as possible in affected individuals. Stopping scoliosis is the primary objective of any surgical procedure, but unlike non-surgical approaches, there are known complications with surgical interventions. One of the most common is Degenerative Disc Disease (DDD).

 

Treatment options for scoliosis

Today, the treatment options for Adolescent Idiopathic scoliosis include observation, bracing, exercise approaches and surgery, and the general goal is to keep curves under 50° at maturity[1]. Observation, while still recommended by some medical practitioners not specially trained in scoliosis management, is not truly a treatment for scoliosis, and instead simply allows the condition to progress. Non-surgical options, such as bracing and exercise are fast becoming the treatment of choice, with surgery usually preferred as a last resort.

There are three main approaches to scoliosis surgery – these are posterior spinal fusion (PSF), anterior spinal fusion (ASF), or a combination of both. In each case, the goal is to fuse the affected vertebra into the correct position – this results in the targeted vertebra being unable to move, instead fusing into a single unit, but also eliminates scoliosis. PSF remains as the gold standard for the treatment of thoracic and double major curves, which make up most scoliosis cases. ASF is indicated for thoracolumbar and lumbar cases having a normal sagittal profile. A combination of ASF and PSF could also be used for the management of large curves (> 75°) or stiff curves, young age, and to prevent the “crankshaft phenomenon” – a condition in which the posterior fusion of the spine cases a secondary curvature to form as the bones grow.[2]

Although the safety and efficacy of both techniques have been demonstrated[3], many patients and surgeons are increasingly concerned about the long-term outcome of an extensive fusion in terms of spinal function, the development of degenerative disc disease and pain[4]. Weiss et al. reviewed the long-term risks of fusion spinal surgery with respect to scoliosis to enable establishing a cost/benefit relation of this intervention. According to their study, average rate of complications was as high as 44% in adolescent cases, ranging from 10 to 78%. They concluded that long-term complications have not yet been fully evaluated and further studies are needed to address this concern adequately[5].

 

Post-operative complications – new research

Corrective surgery of AIS can result in several benefits for the affected patients including improvements in aesthetics, quality of life, disability, back pain, psychological well-being, and breathing function. This is especially the case for patients whose scoliosis has progressed beyond the range likely to be positively impacted by non-surgical approaches, such as bracing.

These points notwithstanding, surgery is also associated with a variety of complications whose long-term impact is currently poorly understood – these may include  neurological damage, loss of normal spinal function, strain on unfused vertebrae, curvature progression, decompensation and increased sagittal deformity, increased torso deformity, delayed paraparesis, and pseudarthrosis.[6] Degenerative disc disease is however considered one of the most common results of surgery (although it is also associated with scoliosis progression)  and its association with the severity of pain has been reported.[7]

The most recent study looking at this connection was published in 2018[8] and followed a total of 42 AIS patients who underwent PSF surgery. The participants were examined for a range of post-operative complications. The mean age of the surgery was 14.4 ± 5.1 years. The mean follow-up of the patients was 5.6 ± 3.2 years.

On the positive side, the study confirmed that complete fusion of the vertebra was observed in all cases, and no cases of failure of surgical implants were noticed – in this sense, the patient’s scoliosis cases were therefore addressed and halted, which was of course the primary objective. However, according to the most recent study, degenerative disc disease had developed in 6 out of 37 (16%) of the patients. This finding was roughly in line with previous research, which has suggested rates on average of 7%, although rates varied by study.[9]

More concerning however, was the fact that the observed post-operative disability tended to increase over time, a similar study by Upasani et al. also showed an increased pain at 5 years compared with 2 years after AIS surgical treatment[10], and with this in mind the study investigators suggest that possible progression of DDD and associated increases in pain be carefully considered before opting for a surgical procedure.

 

Treating scoliosis without surgery

While it’s clear that for some patient’s surgical intervention may be the best option, even if there is a risk of postoperative complications, recent advances in non-surgical approaches to scoliosis treatment mean that other options exist for far larger numbers of patients then ever before. Scoliosis bracing, for example, is not associated with any long-term complications, save for the possibility of a loss of muscle strength, which is easily mitigated with targeted exercises. While such approaches are necessarily slower to show results than a surgical procedure, the most modern “over corrective” braces (such as the ScoliBrace we offer at the UK Scoliosis clinic) can nonetheless offer a substantial correction, typically over a period of 6 to 12 months.

 

 

[1] Janicki JA, Alman B. Scoliosis: review of diagnosis and treatment. Paediatr Child Health. 2007;12:771–6.

Tari SHV, Mahabadi EA, Ghandehari H, Nikouei F, Javaheri R, Safdari F. Spinopelvic sagittal alignment in patients with adolescent idiopathic scoliosis. Shafa Orthop J. 2015;2(3):e739.

[2] Hasan Ghandhari, Ebrahim Ameri, Farshad Nikouei, Milad Haji Agha Bozorgi, Shoeib Majdi & Mostafa Salehpour  ,Long-term outcome of posterior spinal fusion for the correction of adolescent idiopathic scoliosis Scoliosis and Spinal Disordersvolume 13, Article number: 14 (2018)

[3] Wang Y, Fei Q, Qiu G, Lee CI, Shen J, Zhang J, Zhao H, Zhao Y, Wang H, Yuan S. Anterior spinal fusion versus posterior spinal fusion for moderate lumbar/thoracolumbar adolescent idiopathic scoliosis: a prospective study. Spine. 2008;33:2166–72.

[4] Bridwell KH, Shufflebarger HL, Lenke LG, Lowe TG, Betz RR, Bassett GS. Parents’ and patients’ preferences and concerns in idiopathic adolescent scoliosis: a cross-sectional preoperative analysis. Spine. 2000;25:2392–9.

[5] Weiss H-R, Goodall D. Rate of complications in scoliosis surgery—a systematic review of the Pub Med literature. Scoliosis. 2008;3:9.

[6] Weiss H-R, Goodall D. Rate of complications in scoliosis surgery—a systematic review of the Pub Med literature. Scoliosis. 2008;3:9.

[7] Buttermann GR, Mullin WJ. Pain and disability correlated with disc degeneration via magnetic resonance imaging in scoliosis patients. Euro Spine J. 2008;17:240–9.

[8] Hasan Ghandhari, Ebrahim Ameri, Farshad Nikouei, Milad Haji Agha Bozorgi, Shoeib Majdi & Mostafa Salehpour  ,Long-term outcome of posterior spinal fusion for the correction of adolescent idiopathic scoliosis Scoliosis and Spinal Disordersvolume 13, Article number: 14 (2018)

[9] Jones M, Badreddine I, Mehta J, Ede MN, Gardner A, Spilsbury J, Marks D. The rate of disc degeneration on MRI in preoperative adolescent idiopathic scoliosis. Spine J. 2017;17:S332.

[10] Upasani VV, Caltoum C, Petcharaporn M, Bastrom TP, Pawelek JB, Betz RR, Clements DH, Lenke LG, Lowe TG, Newton PO. Adolescent idiopathic scoliosis patients report increased pain at five years compared with two years after surgical treatment. Spine. 2008;33:1107–12.

Think Scoliosis Just effects children? Think again!

While it’s true that Scoliosis is a major issue for younger people, the fact that scoliosis only affects them, or even primarily affects them isn’t quite correct. Today, for example, we know that at least one child in every school class will develop scoliosis – bud did you know that as many as 1 in 3 people over the age of 60 also suffer from scoliosis ? This means that scoliosis, while often more serious in younger people due to the high risk of progression, is actually far more frequently seen in older individuals.

 

The overs 60’s get scoliosis?

De-Novo Scoliosis

The over 60’s are certainly at a high risk of scoliosis, but you’d be forgiven for being unaware of this fact. Over the last 10 years, there has been much more interest in the treatment of adolescent and juvenile scoliosis – prominent cases such as that of Princess Eugene have certainly contributed to this attention as have numerous other celebrities who have openly discussed their childhood scoliosis. What’s been much less discussed is scoliosis in adults – a condition which primarily affects the over 60’s.
Unlike scoliosis in juveniles and adolescents (the exact cause of which is still unclear) we do know that De novo (or “new”) scoliosis is caused by wear and tear to the spine. Adults scoliosis is also worsened by wear and tear but is primarily the development of existing scoliosis, rather than an entirely new occurrence. Although the cause might be different, the symptoms are the same – scoliosis sufferers often notice undesirable physical symptoms, such as the Rib cage sticking out on one side, hips or waist sticking out and being unable to stand up straight easily. Scoliosis is also frequently the cause of back pain and discomfort, ranging from moderate to acute. Many suffers also have to live with pain in the legs or pins and needles due to nerve root pressure. That annoying back pain might, in fact, be the early signs of De-Novo scoliosis.

 

Does scoliosis in adults matter?

De-Novo scoliosis

Just as with children, the key issue is the degree of scoliosis. A very small curve may present with few if any symptoms, but, if left untreated, scoliosis can progress to such an extent that normal physical function can be impaired – first making walking and moving about difficult, and then eventually even affecting breathing.
Many adults simply accept aches and pains as part of “getting older” – but no matter the case this isn’t a smart approach. The first reason for this is that small, but persistent, aches and pains can be the first sign of a more serious problem which requires treatment. The second and more important reason is that you do not need to live your life in pain! Pain itself, while once thought not to be correlated with scoliosis is now believed to have at least some link to the condition.
Where scoliosis isn’t painful, it may also cause difficulties with movement or a noticeable postural or physical deformation of the spine which for some people can be embarrassing and stressful. The overall result for most older adults is a reduction in their ability or desire to socialise, exercise and get about day to day. This is especially problematic given that research is increasingly showing that keeping fit and active is the key to ageing gracefully and enjoying a long and healthy life.

 

Can scoliosis in adults be treated?

The good news is that through the same treatment approaches which are being used to treat adolescent scoliosis today, its also possible to treat adult scoliosis. Historically, it was thought that only surgical treatment was effective in correcting scoliosis – so with many people unwilling to go under the knife, scoliosis has become a life-limiting factor for many of us. Today, however, conservative methods such as bracing and specialist exercise programs are a time, cost and risk effective way to treat the condition.
For smaller curves, a scoliosis-specific exercise program can be an ideal intervention but by far the best option is a customised scoliosis brace, designed to gently guide the spine back into the proper alignment. Far from the braces used many years ago, our cutting edge ScoliBrace is a low profile, comfortable brace which looks more like a piece of sports equipment than a medical device. Best of all, bracing has been shown to effectively reduce scoliosis and its symptoms, and in some instances can have a noticeable impact in a matter of weeks. Pain especially seems to be reduced through part-time bracing in older adults.

 

How can I get treatment for scoliosis?

While your GP might be the first stop for most conditions (and its certainly worth a visit to rule out anything more serious) there’s a limited amount that your GP can do for you through the NHS. Instead, speak with a spinal specialist, such as a Scoliosis Clinician. At the UK Scoliosis clinic, many of our patients are adult scoliosis sufferers – so if you suspect you may be suffering from adult scoliosis, why not give us a call today and arrange a consultation?

A Scoliosis Journey: Week 1

Welcome to this special series of articles from the UK scoliosis clinic. This month is scoliosis awareness month, and throughout June we will be covering a representational example of a scoliosis case, all the way from discovery to diagnosis, treatment to conclusion.  While this series necessarily presents a generalised view of scoliosis treatment as a whole, we hope it will provide a good overview of the treatment process, which will be similar for most cases.

It is scoliosis? It’s not always easy to tell without an x-ray

 

1 . Is that scoliosis?

Most people have never heard of scoliosis, although it’s much more common than you might think. Scoliosis affects about 3 or 4 per cent of children (about one in each class at school) and as many as 40% of the over 60s. Scoliosis is a condition of the spine which causes it to curve away from its natural (fairly) straight alignment when viewed from behind. When viewed from the side the spine does curve gently forwards and backwards – these curves are known as Kyphosis, and Lordosis, and are a normal and important part of the way your spine works. A small bend in the spine, less than 10 degrees is considered normal and not a cause for concern – but in cases which need treatment, curves can often exceed as much as 50 degrees, 5 times that “normal” figure.

While this is all great information, we can’t usually see our spines or our children’s spines – and unless you’ve had cause to have a chest x-ray or similar taken its unlikely that you ever would have, so how can we recognise scoliosis in the first place?

In many countries around the world, Scoliosis is a condition for which there is a national screening program. In the same way that many of our children receive immunisations through their school, if you happen to be born in the right country, you’ll also get a Scoliosis screening. Screening allows scoliosis to be spotted very early and therefore treated most effectively. In the UK however, there is no such program, so here most scoliosis cases are spotted by family members, friends, or (often in the case of teenagers) by the sufferer themselves.

Take our case here, patient X. Patient X is a 16-year-old female, who initially complained about what appeared to be poor posture. The ‘x’s marked on her back show exactly where each of her vertebrate is, but you can imagine that without these markings, it simply looks as if she is standing awkwardly, or, like many teenagers, has awful posture! As you can see from the X-ray on the right, however, this is, in fact, a fairly well-advanced scoliosis case.

 

So how do we spot scoliosis? The main points to ask yourself are –

  • Are the shoulder’s level or uneven?
  • Is the waist even on each side? Or is one side straighter and the other more rounded or prominent?
  • Does one side look like it’s folded down or have a large skin crease?
  • Are the shoulder blades level? Does one stick out more than the other?
  • With straight legs, bending forward from the waist and with the hands between the knees is one side of the rib cage higher than the other, or is the lower back more prominent than the other, if yes, this indicates scoliosis.

 

It wasn’t a scoliosis screening which highlighted this example – In-Patient X’s case, it was this poor posture, and some mild back pain which brought her in for a scoliosis screening – importantly, she also participated in ballet (research shows that ballet dancers have a higher incidence of scoliosis) and had a family history of scoliosis. While these facts probably didn’t seem relevant to her at the time, they sounded all too common to the scoliosis professionals. According to the patients’ mum, she had no major issues growing up and all major growth milestones passed without incident – but for the back pain and the fact that she noticed the poor posture, this case would have continued to progress. It’s hard to say when the case actually began, but it’s entirely possible it had been developing for several years, and early screening could have detected this.

 

2. So, its Scoliosis.

A scoliometer, which helps us to measure and understand a Scoliosis case

Thankfully, patient X was seen at a scoliosis clinic within just weeks of her initial diagnosis. A simple scoliosis screening, coupled with a measurement from a device known as a scoliometer revealed the presence of all the warning signs, and at her follow up appointment the above x-ray confirmed the presence of scoliosis.

But when we say “scoliosis” – what do we really mean? This is a complex question since each and every scoliosis case is different and occurs in 3D. While we typically define scoliosis as a curvature of the spine when viewed from the rear, the condition is always more complex than this explanation makes it sound. In addition to the curvature, the vertebra will usually be rotated to some extent and may also be subject to damage or malformations as a result, or even as a cause of the Scoliosis. Scoliosis cases can curve in different directions and the vertebra which is most displaced from the centreline will also vary. Some scoliosis cases consist of a single curve, whereas others consist of a major curve and an opposite “compensatory” or secondary curve.  Scoliotic curves can also develop in different regions of the spine, or more than one region.

Therefore, receiving the diagnosis of “scoliosis” is only the first step. Using a variety of sophisticated imaging technologies, it was possible to classify and understand patient x’s scoliosis – hers was a 33 degree, left thoracolumbar scoliosis with significant rotation of the vertebra in the lumbar spine, the condition was causing poor posture and had also become painful. There’s no question that this is a complex diagnosis and one which only 10 years ago would almost certainly have ended in surgery, but thanks to the advanced research in the field of scoliosis correction, it’s the kind of case that today we can successfully treat non-surgically.

What’s critical to appreciate, however, is the complexity of this and the vast majority of scoliosis cases. Patient X (as we will see in coming segments) was treated with great success, without surgery, and no longer suffers from scoliosis – but this result has been almost entirely attributable to the highly individualised, customised treatment plan she received. More about that, next week.

 

At what age am I at the greatest risk of scoliosis?

Scoliosis, like many conditions, is most common in certain age groups – and as a consequence, we recommend that these individuals be the most careful when checking for symptoms. The simplest answer to the question is that young adults are generally considered to be at the highest overall risk – but in fact, this question is a complicated one which is worth some discussion.

 

Scoliosis and age of diagnosis

Scoliosis is a difficult condition to diagnose – in large part, this is due to the complex nature of the condition and the fact it causes an individualised, three-dimensional shift in the spine. The rate at which scoliosis develops also varies, and is usually associated with growth spurts, rather than being steady.

One major challenge with scoliosis cases is estimating exactly when the condition began. Because scoliosis is very hard to detect (unless an individual is properly screened) until it has become large enough to cause visual distortions to the patient’s body, a diagnosis is often not made until the condition has existed for some time. Ideally, we would like to know when scoliosis began, as this has an impact on future prognosis – but in most cases, scoliosis is simply classified by the time it is diagnosed, not necessarily when it actually began.

 

Scoliosis in children is typically grouped into one of three types:

Infantile scoliosis – diagnosed in children from 0 -3 years old

Juvenile scoliosis – diagnosed in children from 4 – 10 years old

Adolescent scoliosis– Diagnosed in children and young people from 10 – 18 years old

 

Scoliosis first diagnosed in individuals older than 18 is classified as adult scoliosis and could be either a case of scoliosis which has progressed undetected throughout childhood (common in younger individuals) or a case caused by degeneration of the spine and supporting structures, known as de-novo scoliosis. (Very common in the over 60’s)

 

Which age group is most at risk?

While much of the literature on scoliosis focuses on scoliosis in younger people, the statistics are clear – the most affected group is actually the over 60’s, mainly from De-Novo scoliosis. While about 3 or 4 % of young people suffer from scoliosis, nearly 40% of the over 60’s have the condition.

Statically, Infantile scoliosis is the least common of all and comprises only about 1% of all idiopathic scoliosis in children. Unlike most forms of Scoliosis infantile scoliosis is more common in males – about 60% of patients are boys.

Juvenile scoliosis is less common than adolescent scoliosis but more common than infantile scoliosis – Juvenile scoliosis comprises approximately 10-15% of idiopathic scoliosis cases and is slightly more common in younger males and older females within this age range.

Adolescent scoliosis makes up the majority of cases in young people, somewhere between 80 and 85%. Whereas infantile and younger Juvenile scoliosis cases are more common on boys, 80% of all adolescent cases are girls. The very highest point for diagnosis is around 11-12 years of age in girls and slightly later in boys.

 

Risk of progression and severity – the key factors

If it’s actually older people who are most likely to suffer from scoliosis, why does most scoliosis treatment focus on the young? It’s an important question which goes to the heart of scoliosis itself and its treatment.

Scoliosis can vary hugely in its severity and its speed of progression – but in all cases, once scoliosis has started to develop, it generally does not stop until a young person has reached skeletal maturity. This means that the younger a scoliosis patient, the longer the condition has to develop to the point at which it becomes debilitating or requires major surgery to correct.  What’s more, scoliosis is closely linked to growth spurts – often worsening substantially over just a few months during a growth phase. Since younger children have much growth ahead of them, the risk of progression is significant.

It’s this risk of progression and the initial degree of the curvature which means cases in younger people are often considered as more serious – De-novo scoliosis, the form most commonly found in older adults, while a problematic condition, tends to be much less substantial in magnitude and much slower in progression. Addressing the problem can lead to a significant improvement in quality of life, but urgency is less of a factor.

By contrast, some research has demonstrated that Juvenile scoliosis greater than 30 degrees almost always increases rapidly and presents a 100% prognosis for surgery, whereas curves from 21 to 30 degrees are more difficult to predict but can frequently end up requiring surgery, or at least causing significant disability.[i]

Today, with modern bracing technology, it has been demonstrated that timely conservative treatment with a brace is highly effective in treating juvenile idiopathic scoliosis – and research has suggested drastically different outcomes. In one recent study of Juvenile 113 patients treated with bracing, the vast majority achieved a complete curve correction, and only 4.9% of patients eventually needed surgery.[ii]

While cases detected in adolescents do have less time to develop, they are often more severe once detected (they may well have began as a Juvenile anyway) and the high volume of cases in this age range means that this group are considered to be at the most risk. It’s thought that the changes which occur during puberty may be linked to the onset or progression of scoliosis, which may account for the spike in cases in this age range. If 3 or 4% of young people in this age bracket will develop scoliosis, that’s about one in each class at school and in most cases,  there will still be enough time for scoliosis to progress to the surgical threshold or at least cause significant disability.

 

So, who is at the greatest risk?

The answer to this question is simply that everyone should be aware of scoliosis, and take the simple steps needed to screen for the condition and address it early on. Our ScoliScreen tool is a great place to start.

Scoliosis in infants is certainly rare, but obviously presents the greatest possible opportunity for the condition to worsen over time. Juvenile scoliosis is also fairly uncommon, but the prognosis is not good if the condition is not treated early on. Most younger scoliosis patients are diagnosed as adolescents, meaning that children from 11-15, in particular, should be screened regularly.

Older individuals, while likely to develop a less severe form of scoliosis, have about a 4 in 10 chance of developing the condition over the age of 60.

If you are concerned about scoliosis, why not try out ScoliScreen tool, or get in touch today to arrange a professional consultation.

 

 

[i] Progression risk of idiopathic juvenile scoliosis during pubertal growth, Charles YP, Daures JP, de Rosa V, Diméglio A. Spine 2006 Aug 1;31(17):1933-42.

[ii] ‘Brace treatment in juvenile idiopathic scoliosis: a prospective study in accordance with the SRS criteria for bracing studies – SOSORT award 2013 winner‘ Angelo G Aulisa, Vincenzo Guzzanti, Emanuele Marzetti,Marco Giordano, Francesco Falciglia and Lorenzo Aulisa, Scoliosis 2014 9:3 DOI: 10.1186/1748-7161-9-3

I have Scoliosis – will my children have Scoliosis?

One of the questions which scoliosis sufferers often ask is as to whether they would be likely to pass scoliosis on to any children they may have. This is a good question since research does suggest that scoliosis (like most conditions) can run in families. Having said this, much more research is required before we can give a definitive answer, but here’s an overview of the latest thinking.

 

Is scoliosis genetic?

Before answering this question its important to remember that in children at least, 80% of all scoliosis cases are still considered idiopathic  – this literally means “without known cause” – so while we can make some useful observations on this topic, science is yet to form a complete conclusion, and that should be kept in mind.

It’s also important to be clear about the kind of scoliosis which is being discussed here – the causes of some forms of scoliosis are known. For example, de novo scoliosis in the over 60’s is caused by degeneration of the spine, while other genetic and neurological disorders (which certainly can be communicated to children) can also cause scoliosis. Here, we’ll be discussing the 80% of cases which are currently considered “idiopathic”.

One thing certainly has been established with clarity – results show that no ethnic group seems to be invulnerable to scoliosis, as is the case with some genetic conditions. Research suggests that whatever your heritage, scoliosis could be a risk.[1]

 

Scoliosis in twin studies

Perhaps the best way to study the importance of genetics in the inheritance of a certain condition is through the conduct of twin studies. Because of the unique relationship which twins have, they help researchers to examine the overall role of genes in the development of a trait or disorder.  Comparisons between monozygotic (MZ or identical) twins and dizygotic (DZ or fraternal) twins are conducted to evaluate the degree of genetic and environmental influence on a specific trait.  MZ twins are the same sex and share 100% of their genes.  DZ twins can be the same- or opposite-sex and share, on average, about 50% of their genes.

If MZ twins show more similarity on a given trait compared to DZ twins, this provides evidence that genes significantly influence that trait.  However, if MZ and DZ twins share a trait to an equal extent, it is likely that the environment influences the trait more than genetic factors.

So what do twin studies say about scoliosis? Such an approach has suggested that scoliosis may have a familial link since at least as early as 1922[2] and since then reports of multiple twin sets and twin series have consistently shown higher concordance (that is to say, similarity)  in monozygotic (MZ) compared to dizygotic (DZ) twins[3] – indicating a strong genetic link.  A meta-analysis of these clinical twin studies revealed 73% MZ compared to 36% DZ concordances[4]. Interestingly, in this series, there was a significant correlation with curve severity in monozygous twins but not dizygous twins. No correlation with curve pattern was found either, suggesting the importance of genetic factors in controlling susceptibility and disease course, but not necessarily disease pattern.

 

Will I pass scoliosis on to my children?

If research clearly shows that there may well be a genetic link, what are your chances of passing on scoliosis? One study[5] has tried to estimate the approximate chances, by comparing scoliosis prevalence with other common genetic diseases such as rheumatoid arthritis (RA), Crohn’s disease (CD), type 1 diabetes (T1D), or psoriasis vs the general population. The following table illustrates the findings and provides at least some broad context.

 

Calculated Sibling Risk Ratios for IS are Comparable to Other Well-Studied Complex Genetic Diseases

 

Disease Prevalence Risk ratio  
RA .01 2-17
CD .001 10
T1D .007 15
Psoriasis .02 4-11.5
IS (≥10°) .03 8
IS (≥20°) .005 23

 

The main message here is therefore that the more severe your scoliosis, the more likely you are to pass scoliosis on to your children – however, rheumatoid arthritis (RA), Crohn’s disease (CD), type 1 diabetes (T1D), or psoriasis are all more likely to be passed on than scoliosis resulting in a small curve, and scoliosis with a large curve is only fractionally more likely to be passed on than rheumatoid arthritis.

Therefore, research certainly suggests that if you have scoliosis, you do have a risk of passing it on to your children. Given the advances in treatment technologies however, this should not be a reason to put off having children in this day and age. Parents with scoliosis should of course be diligent with screening and monitoring for scoliosis, but in all fairness the same should go for all parents – not just scoliosis sufferers.

 

 

 

[1] Herring JA. Tachdjian’s Pediatric Orthopaedics. Philadelphia: WB Saunders; 2002. Scoliosis; p. 213.

[2] Staub HA. Eine skoliotikerfamilie.Ein Beitrag zur Frage der kongenitalen Skoliose und der Hereditat der Skoliosen. Z. Orthop. Chir. 1922;43:1

[3] Horton D. Common skeletal deformities. In: Rimoin DL, Conner MJ, Pyeritz RE, Korf BR, editors. Emery & Rimoins Principles and Practices of Medical Genetics. Amsterdam: Churchill Livingstone Elsevier; 2002. pp. 4236–4244

[4] Kesling KL, Reinker KA. Scoliosis in twins. A meta-analysis of the literature and report of six cases. Spine. 1997;22:2009–2014.

[5] ‘Understanding Genetic Factors in Idiopathic Scoliosis, a Complex Disease of Childhood’

Carol A Wise, Xiaochong Gao, Scott Shoemaker, Derek Gordon, and John A Herring, Curr Genomics. 2008 Mar; 9(1): 51–59. doi:  10.2174/138920208783884874

Does Scoliosis cause Neck pain?

For some time, it has been thought that common problems such as back and neck aches and pains were not a symptom of scoliosis. Even many scoliosis specialists did not necessarily consider pain to be an important indicator of a problem – however, over the last few years, various studies have demonstrated that back pain at least is correlated with scoliosis, and new research now also suggests that neck problems are a common issue.

 

Back pain and Scoliosis.

While it was once thought that back pain was not necessarily correlated with scoliosis (since scoliosis certainly can exist without pain) it has become increasingly clear that there is a link.

Indeed, research from the last few years has sown that spinal pain is, in fact, a frequent condition in scoliosis patients, further supporting the need for early detection and screening to minimise potential pain and suffering[1]. Furthermore, in one study of patients under 21 treated for back pain, scoliosis was the most common underlying condition (1439/1953 patients)[2] and in another of 2400 patients with AIS, 23% reported back pain at their initial contact[3].  Chronic nonspecific back pain (CNSBP) is frequently associated with AIS, with a greater reported prevalence (59%) than seen in adolescents without scoliosis (33%)[4], while patients diagnosed with AIS at age 15 are 42% more likely to report back pain at age 18.[5]

We also now know that part-time bracing in adult scoliosis cases can improve chronic pain[6] and that taken as a whole Scoliosis patients have between a 3 and 5 fold increased risk of back pain in the upper and middle right part of the back.[7]

At the very least, this evidence suggests we should reevaluate our view of the relationship between Scoliosis, and pain.

 

Scoliosis and neck pain.

Perhaps the most obvious common features of the studies just discussed is their focus on back pain. This certainly sensible, after all, scoliosis primarily affects the thoracic and lumbar spine – but this does beg the question – what about neck pain?

Studies examining scoliosis and neck pain are much more sparse, however, at least one 2017 study[8]does provide some useful insight.

The large scale study, conducted across the Karolinska University Hospital, Stockholm; the Skåne University Hospital, Malmö; the Sundsvall and Härnösand County Hospital, Sundsvall, and Sahlgrenska University Hospital, Gothenburg, sought to understand what if any correlation existed between scoliosis and neck problems.

One thousand sixty-nine adults with a mean age of 40 years, diagnosed with idiopathic scoliosis in youth, answered a questionnaire on neck and back problems. Eight hundred seventy of these answered the same questionnaire on a the second occasion in a mean of 4 years later. Comparisons were made with a cross-sectional population-based survey of 158 individuals. Statistical analyses were made with logistic regression or analysis of variance, adjusted for age, smoking status, and sex.

The results were telling – Individuals with scoliosis (either treated or untreated) had a higher prevalence of neck problems –  42% compared to 20% of the control group (non-scoliosis patients). Interestingly, the study also showed that there was no correlation between the methodology used to address the scoliosis, or by the age of onset of scoliosis; juvenile or adolescent – which suggests the risk is the same regardless of how you approach scoliosis treatment.

Given the prior interest in back pain and scoliosis, this study also provided some interesting information on the two as a combined issue  – if neck and back problems were taken together, then the percentage of scoliosis patients experiencing problems increased to 72% , while the control group rose to 37%.  Of the individuals with scoliosis having neck problems, 81% also reported back problems, compared to 59% of the individuals in the control group.

 

Conclusions

Given the research which has already taken place on back pain and with this 2017 study in mind, it seems fair to suggest that neck problems are more prevalent, and more often coexist with back problems in individuals with idiopathic scoliosis than in non-scoliosis patients – and indeed, many scoliosis patients seem to suffer from both of these issues.

For us as a clinic, this stands out as an area for further study and research – it perhaps telling that the current version of the widely used and validated Scoliosis Research Society (SRS)-questionnaire (at the time of writing) does not even include questions on neck pain.

At the UK scoliosis clinic, we do take pain into consideration when diagnosing and treating scoliosis – and as a broad-based clinic dealing with multiple complex postural issues, we have other screening tools on hand to assess and monitor neck pain, however, going forward it may well benefit the field for neck and back pain, to be considered with greater weight when diagnosing scoliosis.

 

[1] Back Pain and Adolescent Idiopathic Scoliosis: A Descriptive, Correlation Study’,
Theroux Jean, Le May Sylvie, Labelle Hubert [University of Montreal, Quebec, Canada; Murdoch University, Perth, WA, Australia]Spine Society of Australia 27th Annual Scientific Meeting (8-10 April 2016)

‘Back Pain Prevalence Is Associated With Curve-type and Severity in Adolescents With Idiopathic Scoliosis A Cross-sectional Study’
Jean Theroux, DC, MSc, PhD, Sylvie Le May, RN, PhD, Jeffrey J. Hebert, DC, PhD,and Hubert Labelle, MD : SPINE 153607

[2] Dimar 2nd JR, Glassman SD, Carreon LY. Juvenile degenerative disc disease: a report of 76 cases identified by magnetic resonance imaging. Spine J. 2007;7:332–7.

[3] Ramirez N, Johnston CE, Browne RH. The prevalence of back pain in children who have idiopathic scoliosis. J Bone Joint Surg Am. 1997;79:364–8

[4] Jean Theroux et al. Back Pain Prevalence Is Associated With Curve-type and Severity in Adolescents With Idiopathic Scoliosis Spine: August 1, 2017 – Volume 42 – Issue 15

[5] Clark EM, Tobias JH, Fairbank J. The impact of small spinal curves in adolescents that have not presented to secondary care: a population- based cohort study. Spine (Phila Pa 1976) 2016; 41:E611–7.

[6] Scoliosis bracing and exercise for pain management in adults—a case report
Weiss et al, J Phys Ther Sci. 2016 Aug; 28(8): 2404–2407.

[7] Sato T, Hirano T, Ito T, Morita O, Kikuchi R, Endo N, et al. Back pain in adolescents with idiopathic scoliosis: epidemiological study for 43,630 pupils in Niigata City. Japan Eur Spine J. 2011;20:274–9

[8] Christos Topalis, Anna Grauers, Elias Diarbakerli, Aina Danielsson and Paul Gerdhem, Neck and back problems in adults with idiopathic scoliosis diagnosed in youth: an observational study of prevalence, change over a mean four year time period and comparison with a control group Scoliosis and Spinal Disorders 2017 12:20

Is observation a treatment for scoliosis?

When first seeking treatment, many scoliosis sufferers are advised that they should “watch and wait” or  “wait and see” how their condition progresses, in the hope that their curve will remain small enough to avoid surgery.  Medically, this approach is known as “observation”.

 

Is observation ever the right choice?

The argument for observation was once much stronger than it is today – for much of recent history the consensus view has been that surgery was the only effective way to treat scoliosis and since surgery is obviously best avoided wherever possible, observation is the only other choice. Although surgical treatment was once the only option for scoliosis sufferers, this is no longer the case – today non-surgical approaches are highly effective, meaning that observation is probably never the right choice.

 

Avoiding surgery with non-surgical treatment

Today, non-surgical treatment from scoliosis consists of two major approaches, exercise-based and bracing. Scoliosis braces are the most effective non-surgical method for reducing cobb angle[1]. There are many different kinds of scoliosis brace and the way they work is different, however broadly speaking braces can be classified as active correction braces (which aim to reduce scoliosis by guiding the spine back to correct posture) and passive braces (which aim to prevent scoliosis from developing any further by holding the spine in its current position).

Exercise methods such as the Schroth method (remove comma) or SEAS focus on teaching the scoliosis sufferer to self-correct their scoliotic position. Schroth and SEAS can both be effective as a standalone treatment for smaller curves and is often paired with bracing for superior results.

In both cases, however, catching scoliosis early with screening, and then taking appropriate action to stabilise and correct the Cobb angle is the key to a successful outcome. Unfortunately, many medical professionals today are still unaware of the non-surgical options for treating scoliosis and how effective they can be – unlike 20 years ago, today the prognosis is a good one.

 

Why observation does not work

Simply put, Observation is not a treatment for scoliosis, it is simply the act of watching and waiting, hoping the condition does not worse – however recent research has shown that scoliosis almost never resolves without treatment.[2] While it was once thought that scoliosis would not always progress, modern research has demonstrated, for example, that Juvenile scoliosis greater than 30 degrees increases rapidly and presents a 100% prognosis for surgery. Curves from 21 to 30 degrees are more difficult to predict but can frequently end up requiring surgery, or at least causing significant disability.[i]

Because observation is not a treatment, it most often leads to the patient requiring surgery and does not promise any improvement. By contrast, modern bracing technology allows for highly effective treatment, such that it has now been demonstrated that conservative treatment with a brace is highly effective in treating juvenile idiopathic scoliosis. In one recent study of 113 patients, the vast majority achieved a complete curve correction and only 4.9% of patients needed surgery.[ii]

 

What should I do if I have been prescribed observation?

If you have been diagnosed with scoliosis but have been advised that observation or “wait and see” is the best approach, the best option is to book a consultation with a scoliosis specialist. Even if your condition is not serious enough to merit bracing, some targeted scoliosis specific exercise can, at the very least, help to prevent the curve from developing further rather than simply allowing it to increase.

 

 

 

 

 

[1] Yu Zheng, MD PhD et al. Whether orthotic management and exercise are equally effective to the patients with adolescent idiopathic scoliosis in Mainland China? – A randomized controlled trial study SPINE: An International Journal for the study of the spine (2018) [Publish Ahead of Print]

[2] Progression risk of idiopathic juvenile scoliosis during pubertal growth, Charles YP, Daures JP, de Rosa V, Diméglio A. Spine 2006 Aug 1;31(17):1933-42

[i] Progression risk of idiopathic juvenile scoliosis during pubertal growth, Charles YP, Daures JP, de Rosa V, Diméglio A. Spine 2006 Aug 1;31(17):1933-42.

[ii] ‘Brace treatment in juvenile idiopathic scoliosis: a prospective study in accordance with the SRS criteria for bracing studies – SOSORT award 2013 winner‘ Angelo G Aulisa, Vincenzo Guzzanti, Emanuele Marzetti,Marco Giordano, Francesco Falciglia and Lorenzo Aulisa, Scoliosis 2014 9:3 DOI: 10.1186/1748-7161-9-3

Does a having a short leg cause scoliosis?

Leg length discrepancy, commonly known as a short leg, and medically known as Anisomelia is a condition in which one leg is shorter than the other, resulting in a limping gait and often chronic lower back pain.  In fact, a small leg length discrepancy is not unusual and is frequently treated by specialists such as a chiropractor – however, Anisomelia is said to occur if there is a difference of over 1cm, and surgery can be necessary for differences over 2cm.[1]

A short leg can cause scoliosis

Leg length discrepancy (LLD) has been observed in between 3–15% of the population[2] and there are two possible types, apparent or true.

True LLD is where the shortening of one leg compared to the other can lead to scoliosis as the body tries to compensate. In this case, scoliosis will usually reduce when the LLD is treated.

By contrast, apparent LLD is a symptom of a problem, not the actual cause. Apparent LLD is a condition in which the legs are actually the same length but appear to be different due to an underlying pelvic or spine disorder. In this case, treating the pelvic and/or spine disorder resolves the LLD.

Because of these relationships, it has long been suggested that True LLD can cause or worsen scoliosis[3] – despite this, there had not been any definitive studies on the relationship between LLD and scoliosis until this year.

 

How common is LLD in scoliosis patients?

Despite  the fact that many health professionals see a link, information on the exact relationship of LLD to scoliosis has been difficult to obtain and studies have produced mixed results.  One study of 23 young adults[4] suggested that scoliosis was minor in patients with discrepancies of < 2.2 cm. At the other end of the scale, another study measuring the x-rays of 106  patients in a private chiropractic practice showed that those with LLD > 6 mm often (53% of the cases) had scoliosis and/or abnormal lordotic curves.

 

Does LLD cause scoliosis?

There has certainly been evidence to suggest that there may be a causal link between LLD and scoliosis. Although a direct link has not been established, it Is accepted that LLD causes pelvic obliquity.[5] Pelvic obliquity simply means that one side of the pelvis sits higher than the other.  Since we also know that 40% to 60% of children with lumbar scoliosis also have pelvic obliquity, it seems reasonable to suggest that LLD may indirectly lead to scoliosis.[6]

 

Pelvic Obliquity is common in scoliosis patients

LLD and Scoliosis, new research results

With this background in mind, a 2018 study[7] aimed to find out if there is a measurable association between pelvic obliquity, LLD and the scoliotic curve in an adolescent patient or not.  The researchers also wanted to discover whether scoliotic curve progression was linked to different amounts of leg length discrepancy

During the study, seventy-three patients with an average age of 13.3 years at initial examination were given an X-Ray and then had this compared with a later follow up. Scoliosis was confirmed in all 73 patients. At initial examination, pelvic obliquity appeared in 23 (31.5%) patients with scoliosis, and LLD was identified in 6 (8.2%) patients with scoliosis and pelvic obliquity. The majority of the patients in the study were under observation for their scoliosis, allowing the researchers to observe the relationship between scoliosis and leg length.

At a subsequent visit, at an average of 2.8 years later, no significant change in LLD was observed, but a statistically significant increase in scoliotic and pelvic deformity was found.  The study, therefore, concluded that in the adolescent patient population with thoracic or thoracolumbar scoliosis, the LLD remains stable with growth but both the scoliotic deformity and pelvic obliquity continue to progress.[8]

 

So what is the relationship between LLD and scoliosis?

This most recent study suggests that in adolescent patients at least, LLD stays stable and does not seem to have a direct association with the progression of scoliosis. Having said this, the small number (6 out of 73, 8.3%) of patients with LLD in this study suggests that a larger sample set should be explored before drawing any firm conclusions.

Perhaps most importantly, the authors suggest that future research could focus on younger patients less than 10 years with LLD to detect early-onset scoliosis prevalence and how it changes with growth and treatment since it is entirely possible that LLD may have a more significant impact at this early stage.

For now, it seems advisable to conclude that LLD is just one of a number of conditions which can be associated with scoliosis, and certainly with spinal disorders more widely. If you or a loved one have noticeable LLD, it is advisable to see a spinal specialist.

 

[1] Steen H, Terjesen T, Bjerkreim I, Anisomelia. Clinical consequences and treatment Tidsskr Nor Laegeforen. 1997 Apr 30;117(11):1595-600.

[2] Gurney B. Leg length discrepancy. Gait Posture. 2002;15:195–206.

[3] Steen H, Terjesen T, Bjerkreim I, Anisomelia. Clinical consequences and treatment Tidsskr Nor Laegeforen. 1997 Apr 30;117(11):1595-600.

[4] Papaioannou T, Stokes I, Kenwright J. Scoliosis associated with limb-length inequality. J Bone Joint Surg. 1982;64:59–62.

[5] Anderson M, Green WT, Messner MB. Growth and predictions of growth in the lower extremities. J Bone Joint Surg. 1963;45-A:1–14.

Asher MA. Scoliosis evaluation. Ortho Clin North Am. 1988;19:805–14.

Brady RJ, Dean JB, Skinner TM, Gross MT. Limb length inequality: clinical implications for assessment and intervention. J Orthop Sports Phys Ther. 2003;33:221–34.

Burwell RG, Aujla RK, Freeman BJ, Dangerfield PH, Cole AA, Kirby AS, et al. Patterns of extra-spinal left-right skeletal asymmetries in adolescent girls with lower spine scoliosis: relative lengthening of the ilium on the curve concavity & of right lower limb segments. Stud Health Technol Inform. 2006;123:57–65.

Cummings G, Scholz JP, Barnes K. The effect of imposed leg length difference on pelvic bone symmetry. Spine. 1993;18:368–73.

D’Amico M. Scoliosis and leg asymmetries: a reliable approach to assess wedge solutions efficacy. Stud Health Technol Inform. 2002;88:285–9.

[6] Schwender JD, Denis F. Coronal plane imbalance in adolescent idiopathic scoliosis with left lumbar curves exceeding 40 degrees: the role of the lumbosacral hemicurve. Spine. 2000;25:2358–63.

Walker AP, Dickson RA. School screening and pelvic tilt scoliosis. Lancet. 1984;2:152–3.

[7] Avraam Ploumis et al. Progression of idiopathic thoracic or thoracolumbar scoliosis and pelvic obliquity in adolescent patients with and without limb length discrepancy Scoliosis and Spinal Disorders 2018 13:18

[8] Specht DL, De Boer KF. Anatomical leg length inequality, scoliosis and lordotic curve in unselected clinic patients. J Manip Physiol Ther. 1991;14:368–75.