Scoliosis in Children
- Exercises for Pediatric Scoliosis
- Bracing for Pediatric Scoliosis
- Casting for Pediatric Scoliosis
- Traction for Pediatric Scoliosis
- Pediatric Scoliosis Surgery
Scoliosis in children, also referred to as Pediatric Scoliosis or Juvenile Scoliosis, is a condition in which the spine is curved sideways in the child. The Scoliosis Research Society defines pediatric scoliosis as a curved spine in a child measuring 10 degrees or greater. Juvenile idiopathic scoliosis is a spinal curvature that is first diagnosed between the ages of 3 and 10. The word “Idiopathic” is a medical term which means the exact cause is unknown.
There are 3 categories of pediatric scoliosis of unknown cause: Infantile (birth – 3 yrs), Juvenile (3 – 10 yrs) and Adolescent (10 + yrs). Each category is based on the age when the child’s spinal curvature was first diagnosed.
|It is possible that a child who developed scoliosis at an earlier age (Juvenile Scoliosis) but was not diagnosed until later would be misclassified as Adolescent Scoliosis.|
Mild Scoliosis in Children
A curve size of less than 20 degrees is considered a mild scoliosis in a child. The typical medical approach to treating a mild scoliosis is to be under doctor supervision until the curves progresses further. The chart below shows why the younger the child is when the scoliosis is first diagnosed, the more dangerous it is for the child. The chart below shows that a mild scoliosis in a child, is very likely to become larger as they reach full growth (labeled as “R5” or Risser 5 on the bottom right side of the graph).
Scoliosis causes the bones of the spine to twist or rotate. Instead of a straight line down the middle of the back, the spine looks more like the letter “C” or “S.” Scoliosis curves can occur only in the upper and middle back (thoracic scoliosis). They can also develop only in the lower back (lumbar scoliosis). Many times the curvature will occur in both the upper and lower parts of the spine known as a double major scoliosis. Scoliosis that involves both the middle and lower back can also be called thoracolumbar scoliosis in children.
Unfortunately many small curves go unnoticed and even moderate size curves may not be noticed by the child’s family and may be first detected during a school screening or at a regular check-up with their pediatrician.
Scoliosis causes pain in approximately 35% of children, other symptoms can include:
- Tilted, uneven shoulders, with one shoulder blade sticking out more than the other
- Prominence of the ribs on one side
- Uneven waistline
- One hip higher than the other
- Uneven leg length
Juvenile idiopathic scoliosis comprises about 10% to 15% of all idiopathic scoliosis in children. At the younger end of the age range, boys are affected slightly more than girls and the curve is often angled to the left. This shape of scoliosis is referred to as “levoscoliosis”. Towards the upper end of the age range, the condition is more like adolescent idiopathic scoliosis, with a larger percentage of girls and right-sided curves referred to as “dextroscoliosis”.
Although doctors do not know the exact cause of idiopathic scoliosis, they do know that it is NOT related to specific behaviors or activities — like carrying a heavy backpack or having poor posture. Research shows that in most cases genetics play a role in the development of scoliosis. Approximately 30% of patients with adolescent idiopathic scoliosis have a family history of the condition.
Other less common types of Pediatric scoliosis include:
- Neuromuscular scoliosis. This type of scoliosis is caused by medical conditions that affect the nerves and muscles, such as muscular dystrophy or cerebral palsy, and can lead to scoliosis. These types of neuromuscular conditions can cause imbalance and weakness in the muscles that support the spine.
Specific medical syndromes can be associated with the development of scoliosis. These medical conditions are associated with weakness of the connective tissues of the body. The more common syndromes that will often have scoliosis are Marfans, Prada-Willi, Ehlers-Danlos, Trisomy 21, Retts, and Beale’s syndrome.
Juvenile scoliosis curves are at high risk of worsening without treatment. As stated above, in a typical medical practice, pediatric scoliosis treatment usually begins with no actual treatment, but only observation. The physician will first wait up to 6 months to determine if the curvature is progressing–or getting worse. While a small percentage of children will have a curvature of the spine that is stable and unchanging, the large majority of children with a curve size above 20 degrees will have a curve that rapidly gets worse.
The standard medical approach with juvenile scoliosis (children between 3 and 10 years of age) is to see the child every 4-6 months and have new front-view X-ray taken to measure the curves and compare them with the previously taken films. The large majority of orthopedics will refuse to give the young patient scoliosis exercises! When the curve progresses, the medical specialist will cast, brace or operate the patient… something that may have been totally avoidable if they had started an effective exercise program at the earliest opportunity!
Without effective bracing and a scoliosis specific exercise program, nearly 95% of juvenile cases go on to require surgical treatment.In infantile cases (birth to 3 years) scoliosis under 20 degrees many spontaneously resolve. However, because of the very real risk of rapid progression, it is vital to keep a close eye on the child! This means taking the child to a scoliosis professional every 3 months to be evaluated for progression.
The chart above shows the extremely high rate of growth in young children. It is this high growth rate that explains why a scoliosis in a young child can rapidly become worse.
Scientific studies demonstrate a positive long term outcome for curves treated nonsurgically by scoliosis specific individually designed exercise programs. The best results using only these special exercises are seen in smaller curve sizes (below 30 degrees). For larger curves above 40 degrees, the scoliosis exercise program must be accompanied by 3D over corrective bracing for the best results.
Research has shown that children aged 6-7 years old and older can effectively use exercise to treat their scoliosis. Kids below that are are just too young to understand what needs to be done to effectively perform the exercises.
For curves above 30 degrees OR in those cases at high risk of progression, scoliosis bracing is often used to manage scoliosis in children.
There are many named and unnamed scoliosis braces available. Like all modern technology, things have changed greatly in brace materials and designs in the past 75 years.
- The most commonly used brace is the outdated design called the Boston brace. It was developed in 1972 and is most commonly supplied as an off the shelf “clam shell” type brace that uses pads inside the brace to push the curve. While custom Boston Braces are available, they are seen much less frequently and still suffer from many of the design limitations of the original “off the shelf” product (opening at the back making it difficult for the child to get in and out of the brace without adult assistance, lack of correction of lost “normal” curves, older design 3 point pressure)
- The Milwaukee brace, was first developed in 1946 for bracing after surgery. This brace uses a neck lifting strut and is rarely used today because of the jaw and neck problems that resulted from the brace design.
- The Charleston brace and Providence brace are night use only braces and are prescribed for eight hours a day, only during the hours of sleep. While this sounds like a great alternative to full time bracing, research has shown that these night braces are only effective for the smaller curve sizes and so are not used by most scoliosis specialists.
- The Cheneau brace was developed in 1979 as an alternative to casting. This is the earliest of the “modern” brace designs. This is a true 3D brace whose design works to achieve maximum reduction of the twist in the spine while also assisting in restoring normal lordosis.
- Over the last 40 years the Cheneau design has been modified by several later orthotists who added their name to the Cheneau design. These include Rigo, Gensignen, Woods and others.
In 2002 the next evolution in bracing concept called ScoliBrace was brought to treatment. This is called 3D over corrective bracing and uses CAD CAM technology to create as perfect a fit as possible resulting in a more comfortable, effective brace. This brace uses all the benefits in the Cheneau design, and adds an over-corrective element that enhances the ability of the brace to reduce the curve size.
In most juvenile cases the ScoliBrace can quickly reduce the curve. This means that after the first 6 months of treatment juvenile patients can often continue to wear the ScoliBrace part-time or at night until they reach their adolescent growth spurt. The child would be refitted every 6 months or so as they grow. All braces need to be redesigned each time the child grows more than 2-3 cm in height.
Yes, it is more expensive to have to replace the brace at regular intervals rather than replacing a plaster cast as the child grows, but the infantile ScoliBrace can be removed to allow the child some time out of the brace for washing and playtime.
The use of repeatedly larger plaster casts applied to young children was the standard of care until recent advances in plastic brace materials and design have made casting no longer necessary. Since a cast can not be removed, it can be considered a 24 hour full-time brace. Issues with casting include muscular atrophy and hygiene issues due to the case becoming soiled by the child.
Placement of the cast on the child may require general anesthesia to increase flexibility of the curve and make the child hold still during the application of the plaster. The cast is generally changed every six months, usually under an additional general anesthetic.
Treatment for patients with a progressive deformity who are not a candidate for bracing can be more difficult, for example those with weakness, skin or chest wall intolerance, mental retardation, or with large and stiff curves that do not correct much during serial casting. In these instances, halo-gravity traction is a method to achieve deformity correction, and indirectly, improve respiratory mechanics.
A halo (metal ring around the head) is applied under general anesthesia. Multiple pins attach the ring to the patient’s skull. The halo is not painful and is well tolerated after the patient becomes accustomed to its presence. Traction is applied the following day with the use of ropes, pulleys, and weights or springs that can be applied to the child’s bed or a wheelchair. Some patients can be treated as outpatients if the family is comfortable. The children are followed with serial X-rays after successive increases in the weight of the traction. Once the spine has shown the maximal amount of improvement, the next phase of treatment will usually be surgical fusion of the scoliotic curve.
An operation is sometimes necessary to address spinal deformity in young children, and the decision to do these procedures is based on many factors. If the child’s curve has shown progression despite conservative care like scoliosis exercises, bracing or casting, something will need to be done. The dilemma faced by the surgeon is how to stop the progression of a curve without adversely affecting future growth. Sometimes this is unavoidable, as most operations work by stopping abnormal spinal growth with a procedure called spinal fusion.
In Situ Spinal Fusion in Children
Spinal fusion is a procedure performed to stop growth of the spine. It is a common procedure in surgical correction of large scoliosis curves. Fusion can be done from the back (posterior) or through the chest (anterior). Bone grafts are placed over the spinal joints; when the bone heals there will be one solid piece of bone. Once they’re fused, they no longer move like they used to. The goal is for the many vertebrae of the spine to become one segment and stop growing crooked. In situ fusion means that the curve will be fused “where it is” with little or no correction of the spine.
Sometimes instrumentation (rods, hooks, and screws) may be placed to help straighten the spine slightly and act as an internal brace for the bone graft that will form the fusion. When implants are not used, usually in young children, the child may need to wear a brace following the operation. The goal of an in situ spinal fusion is to address the problem early, before it becomes a serious deformity. For example, if a pediatric spine surgeon sees a very young child with a 40 degree curve that has a poor prognosis (high risk to progress), they may elect to perform a limited spinal fusion to prevent the curve from getting any bigger. It is generally a safer procedure than those more extensive procedures that reduce the curvature of the spine. The results of a procedure to reduce the curve at a young age can be unpredictable, as continued growth of the spine in other areas can cause the curve to progress further in the unfused areas and rotate (twist around).
Growing Rods for Juvenile Scoliosis
Most operations that address spinal deformity in young children work by stopping growth. This may have unfavorable effects on growth of the thorax, lung development, and the size of the trunk. The theory of the growing rod operation is to allow for continued controlled growth of the spine. This is done through the back of the spine. In general, the curve is spanned by one or two rods under the skin to avoid damaging the growth tissues of the spine. The rods are then attached to the spine above and below the curve with hooks or screws. The curve can usually be corrected by up to fifty percent at the time of the first operation. The child then returns every six months to have the rods “lengthened” approximately 1 cm to keep up with the child’s growth. This is usually an outpatient procedure performed through a small incision.
Most children will have to wear a brace to protect the instrumentation. When the child becomes older and the spine has grown sufficiently, the doctor will remove the instrumentation and perform a typical spinal fusion operation. In the past, this procedure had a very high complication rate, most of which were related to the instrumentation (hook dislodgement, rod breakage). Newer techniques are more promising, such as rods that are expanded with a magnet placed on the patient’s back in an outpatient clinic and do not require scheduled expansions in the operating room. However, treatment with growing rods remains a long and difficult therapy for the child.
Instrumentation and Fusion
The most invasive (and most commonly used) spinal fusion is performed to stop all growth of the spine and thus achieve permanent reduction of the scoliosis. This treatment becomes appropriate only when the patient has achieved enough spinal length and chest size that the growth stoppage from the surgery will not prevent the full use of the lungs. When exactly it might be appropriate to use this more invasive approach is controversial, but in general, patients who have reached age 10 have completed a large enough amount of their spinal and rib cage growth to be candidates for the final stage of full spinal fusion to complete their surgical scoliosis treatment.
Posterior fusion provides permanent stabilization in the corrected position and is achieved by removing the joints between the vertebrae to be fused, usually all the vertebrae which are involved in the curve. Bone graft – either from the pelvis, ribs, or from the bone bank (allograft) – is placed in each joint space which has been removed. Over time (4-6 months), the graft incorporates to the vertebral bone, and the operated portion of the spine heals into a solid block of bone which cannot bend, thus eliminating further progression of the curve. Typically in a child who has reached an appropriate age for scoliosis fusion surgery, rods,screws, hooks and wires will also be placed when the fusion is performed. This instrumentation rigidly fix the spine internally, so that the reduced curve size is preserved while the fusion takes place over a 4-6 month period.
In selected cases, an anterior (front) fusion of the spine may also be appropriate. This will prevent curve progression due to continued growth of the vertebrae after posterior (rear) fusion. Known as the “crankshaft phenomenon”, curves sometimes continue to grow by rotating around the original surgical fusion. This is known to happen when children under the age of ten undergo fusion surgery and can be prevented by performing an anterior fusion at the same time as the initial full fusion has been completed (or shortly before or after).
Obviously the additional surgery required to prevent crankshaft curve progression is best not done at all if it is not necessary, the decision depends on the age of the child at the time of surgery. Delaying the final full fusion surgery is the best option, if that delay can be accomplished while maintaining control of the curve through non-operative means (conservative scoliosis care consisting of scoliosis exercises and 3D bracing).
The goal of non surgical (conservative) care in a juvenile case is expressly to delay the need for a full fusion surgery as long as possible. In selected cases the child would never require surgery. The conservative route of exercise (if the child is old enough to learn and perform them) along with a series of custom designed 3D overcorrective braces is the best path to take in the beginning. Always start with the least invasive approach and only advance to more aggressive treatment options as necessary.
If you are considering treatment, have questions, or would like an information packet, contact our office!
+1 (845) 624-0010