Scoliosis: What It Is, Diagnosis, & Treatment

What is Scoliosis

Scoliosis is defined as a complex three-dimensional rotational deformity of the spine and trunk, which appears in healthy individuals and can progress due to various factors during any period of a child’s development or later in life. The etymology of the word comes from the ancient Greek word “skolios,” meaning crooked. Scoliosis is a condition that affects all three planes of movement. It causes a lateral curvature in the frontal plane, axial rotation in the horizontal plane, and changes in the normal curvatures of the sagittal plane (kyphosis and lordosis), usually reducing thoracic kyphosis and causing the so-called “Flatback.”

Scoliosis can be either structural, where a lateral tilt of the spine coexists with vertebral rotation and deformation, or functional, caused by external factors such as leg length discrepancies or muscle spasms.

Diagnosis

The diagnosis of scoliosis is based on clinical and radiological examination. According to the SRS (Scoliosis Research Society), scoliosis is confirmed when an X-ray shows a lateral tilt of the spine with a Cobb angle greater than 10 degrees, along with simultaneous rotation of the spine. However, for a valid diagnosis and to distinguish between structural and functional scoliosis, a positive Adam’s test is required. The criteria for a positive Adam’s test include a lateral tilt of the spine, a rib hump on the convex side of the curve, and the interruption of the normal kyphotic curve in thoracic scoliosis during the forward bending test.

Clinical Examination

Depending on the type and degree of scoliosis, some minor or more noticeable changes in the clinical picture of the adolescent may be observed, such as:

• A change in shoulder position, with one shoulder being higher than the other.
• A change in pelvic position, with a shift to one side or even rotation or lateral tilt.
• Body shift to one side, especially in scoliosis with only one main curve.
• Scapular prominence, where one shoulder blade protrudes more than the other, mainly due to spinal rotation.
• Rib hump on the back during the forward bending test, where one side of the back rises higher than the other.

Radiological Examination

For a scoliosis diagnosis, there must be a lateral tilt of more than 10 degrees (Cobb angle), axial rotation of the vertebrae, and deformation of the vertebral bodies.

The BSPTS Radiological Criteria for scoliosis diagnosis include:

• Positive Adam’s test, with:
  1. Lateral tilt of the spine.
  2. Rib hump on the convex side of the curve.
  3. Interruption of the normal kyphotic curve in thoracic scoliosis.
• Any lateral tilt of the spine (even less than 10 degrees) with simultaneous vertebral deformation.
• Axial rotation of the vertebrae.

Epidemiology

Scoliosis affects approximately 2-3% of the global population, with a significantly higher incidence in girls for unknown reasons. The progression of scoliosis is also greater in girls. The ratio of occurrence compared to boys is about:

• 1.3:1 for scoliosis of 10-20 degrees.
• 5.4:1 for scoliosis of 20-30 degrees.
• 7:1 for scoliosis over 30 degrees.

Research suggests that scoliosis incidence rates may also depend on geographic location.

In 20% of cases, scoliosis occurs due to another underlying condition, making it of known etiology. Examples include congenital scoliosis, which is due to vertebral malformations (hemivertebrae or block vertebrae) at birth, or neuromuscular scoliosis, which follows neurological conditions such as cerebral palsy, or microbial scoliosis caused by infections or tumors of the spine. In idiopathic scoliosis, which makes up the remaining 80% of cases, the cause remains unknown.

Sports and Scoliosis

There are certain sports with high rates of scoliosis occurrence, though this does not mean they necessarily cause or influence its progression. These include swimming, rhythmic gymnastics, artistic gymnastics, ballet, and tennis, which require flexibility and frequent torso rotations, often putting the spine in extreme positions. Generally, scoliosis patients are encouraged to engage in sports for their overall health benefits, but no sport should be recommended as a form of scoliosis treatment.

Treatment

Scoliosis treatment depends on several factors, the most important being the size of the scoliosis curve and the child’s stage of growth. Other factors that must always be considered include the type of scoliosis, the radiological rotation and deformation of the vertebrae, the rotation of the trunk, body asymmetry, family history, the onset of a girl’s first period, reduced thoracic kyphosis, and more. Therefore, treatment decisions should be made by specialists to avoid undertreatment or overtreatment.

The general recommendation from international scientific communities like the SRS (Scoliosis Research Society) and SOSORT (Society on Scoliosis Orthopaedic and Rehabilitation Treatment) is that scoliosis below 25 degrees should be treated with Physiotherapeutic Scoliosis Specific Exercises (PSSE). The most widely known and scientifically supported method is the Schroth method. Contrary to what some doctors believe, exercises can indeed help prevent scoliosis progression, and numerous high-quality studies confirm that PSSE can significantly reduce the likelihood of scoliosis worsening, often avoiding the need for a brace.

In cases where a brace is necessary, SRS and SOSORT guidelines recommend it when scoliosis exceeds 25 degrees and the child still has considerable growth remaining (Risser sign 0-3). However, each case should be individually assessed.

Surgery is recommended for scoliosis above 40-45 degrees, but this does not mean that every patient with scoliosis over 45 degrees should undergo surgery. A well-designed brace combined with Schroth exercises can offer significant improvements, and many adults manage to stabilize or even improve large curves with PSSE. Therefore, surgery is not the only option, and patients should be fully informed of all available treatments.

References:

• Christa-Lehnert Schroth, The Schroth Method: Three-dimensional Treatment for Scoliosis, 2006, Edition 7th
• Hawes M, O’Brien J, The Transformation of Spinal Curvature into Spinal Deformity: Pathological Processes and Implications for Treatment, Scoliosis 2006, Mar 31; 1(1):3
• Negrini et al, 2011 SOSORT Guidelines: Orthopaedic and Rehabilitation Treatment of Idiopathic Scoliosis During Growth, Scoliosis 2012, 7:3.
• Weiss HR, Moramarco M, Scoliosis-Treatment Indications According to Current Evidence, OA Musculoskeletal Medicine 2013.
• Weiss HR et al, Indications for Conservative Treatment of Scoliosis (Guidelines) Scoliosis 2006.