Scoliosis 129090 226034940 2008-07-16T15:16:16Z Ronz 7862 [[WP:UNDO|Undid]] revision 225998078 by [[Special:Contributions/90.185.55.112|90.185.55.112]] ([[User talk:90.185.55.112|talk]]) forum {{Refimprove|date=November 2007}} {{Infobox_Disease | Name = {{PAGENAME}} | Image = Wiki pre-op.jpg | Caption = A [[coronal plane|coronal]] [[X-ray]] of a person with [[thoracic vertebrae|thoracic]] dextroscoliosis and [[lumbar vertebrae|lumbar]] levoscoliosis. The X-ray is projected such that the right side of the subject is on the right side of the image, i.e. the subject is viewed from the rear. This projection is typically used by surgeons as it is how [[orthopedic surgeon|surgeon]]s see their patients when they are on the operating table. | DiseasesDB = | ICD10 = M41.0, Q67.5, Q76.3 | ICD9 = {{ICD9|737.3}} | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj = | eMedicineTopic = | MeshID = D012600 | }} '''Scoliosis''' is a medical condition in which a person's [[Vertebral column|spine]] is curved from side to side, and may also be rotated. It is an abnormal lateral curvature of the spine. On an x-ray, the spine of an individual with a typical scoliosis may look more like an "S" or a "C" than a straight line. It is typically classified as [[congenital]] (caused by vertebral anomalies present at birth), [[idiopathic]] (sub-classified as infantile, juvenile, adolescent, or adult according to when onset occurred) or as having developed as a secondary symptom of another condition, such as [[cerebral palsy]], [[spinal muscular atrophy]] or due to something like a car crash. ==Terminology== The condition can be categorized based on convexity, or curvature of the spinal column, with relation to the central axis: *'''Dextroscoliosis''' is a scoliosis with the [[convexity]] on the right side.<ref name=richardson>Richardson ML. Approaches to differential diagnosis in musculoskeletal imaging. Univ. of Washington School of Medicine. URL: [http://www.rad.washington.edu/mskbook/scoliosis.html http://www.rad.washington.edu/mskbook/scoliosis.html]. Accessed on: January 8, 2006.</ref><ref name=morningstar>{{cite journal | author = Morningstar M, Joy T | title = Scoliosis treatment using spinal manipulation and the Pettibon Weighting Systemtrade mark: a summary of 3 atypical presentations | journal = Chiropr Osteopat | volume = 14 | issue = | pages = 1 | year = 2006| pmid = 16409627. [http://www.chiroandosteo.com/content/14/1/1 Free Full Text] | doi = 10.1186/1746-1340-14-1}}</ref><ref name=cpr>Chief Pediatric Resident. Scoliosis. Univ. of Chicago. URL: [http://pediatrics.uchicago.edu/chiefs/documents/Scoliosis-Gina.pdf http://pediatrics.uchicago.edu/chiefs/documents/Scoliosis-Gina.pdf]. Accessed on: January 8, 2006.</ref> *'''Levoscoliosis''' is a scoliosis with the [[convexity]] on the left side.<ref name=richardson/><ref name=morningstar/><ref name=cpr/> *'''Rotoscoliosis''' (may be used in conjunction with dextroscoliosis and levoscoliosis, e.g. levorotoscoliosis) refers to scoliosis in which the rotation of the vertebrae is particularly pronounced, or is used simply to draw attention to the fact that scoliosis is a complex 3 dimensional problem.<ref>http://www.emedicine.com/orthoped/topic504.htm</ref>. == Cause == In the case of the most common form of scoliosis, adolescent idiopathic scoliosis, there is a clear [[Mendelian inheritance]] but with incomplete [[penetrance]]. Various causes have been implicated, but none has consensus among scientists as the cause of scoliosis. Scoliosis is more often diagnosed in females and is often seen in patients with [[cerebral palsy]] or [[spina bifida]],{{Fact|date=April 2007}} although this form of scoliosis is different from that seen in children without these conditions. In some cases, scoliosis exists at birth due to a [[congenital vertebral anomaly]]. Occasionally, development of scoliosis during [[adolescence]] is due to an underlying anomaly such as a [[Tethered spinal cord syndrome|tethered spinal cord]], but most often the cause is unknown or [[idiopathic]].{{Fact|date=April 2007}} Some therapists like the referenced Hanna Somatic therapist believe that [[Physical trauma|trauma]] to an adult can cause, not just asymmetry but an actual curve to the spine visible on x-ray, although no documentation is offered in her article. <ref>http://www.somatixinfo.com/hse/scoliosis.pdf</ref> Scoliosis often presents itself, or worsens, during the adolescence growth spurt.<ref>http://www.ucihealth.com/news/uci%20health/win01scoliosis.htm Scoliosis</ref> In April 2007, researchers at Texas Scottish Rite Hospital for Children identified the first gene associated with idiopathic scoliosis, CHD7. The medical breakthrough was the result of a 10-year study and is outlined in the May 2007 issue of the American Journal of Human Genetics.<ref name=tsrhc>Texas Scottish Rite Hospital for Children Research: [http://www.tsrhc.org/default.asp?contentID=39 Scoliosis Research] </ref> == Prevalence == Scoliotic curves greater than 10° affect 2-3% of the population of the United States.<ref>[http://www.scoliosis.org/info.php National Scoliosis Foundation<!-- Bot generated title -->]</ref> The prevalence of curves less than 20° is about equal in males and females. Curves greater than 20° affect about one in 2500 people. Curves convex to the right are more common than those to the left, and single or "C" curves are slightly more common than double or "S" curve patterns. Males are more likely to have infantile or juvenile scoliosis, but there is a high female predominance of adolescent scoliosis. == Symptoms == Pain is often common in adulthood, especially if the scoliosis is left untreated.{{Fact|date=August 2007}} Scoliosis surgery is often performed for cosmetic reasons rather than pain alone as the surgery cannot guarantee pain loss but it can stabilize a curvature and prevent worsening therefore improving ones quality of life. Pain can occur because the muscles try to conform to the way the spine is curving often resulting in muscle spasms. The symptoms of scoliosis can include: * Uneven musculature on one side of the spine * A [[rib]] "hump" and/or a prominent [[shoulder blade]], caused by rotation of the ribcage in [[thoracic]] scoliosis * Uneven [[hip]] and [[shoulder]] levels * [[Asymmetric]] size or location of breast in females * Unequal distance between arms and body * Clothes that do not "hang right," e.g. with uneven hemlines * Slow nerve action (in some cases) == Associated conditions == Scoliosis is sometimes associated with other conditions such as [[kyphosis]], [[cerebral palsy]], [[spinal muscular atrophy]], [[familial dysautonomia]], [[CHARGE syndrome]], [[Friedreich's ataxia]], [[proteus syndrome]], [[Spina bifida]]s, [[Marfan's syndrome]], [[neurofibromatosis]], [[connective tissue disorder]]s, [[congenital diaphragmatic hernia]], and craniospinal axis disorders (''e.g.'', [[syringomyelia]], [[Arnold-Chiari malformation]]). A statistical correlation has been demonstrated between this condition and bipolar disorder. <ref> AJ Giannini, AE Slabr, JP Gianetti, K. Wagamon. Correlates on physical examination of bipolar patients. Turkish Journal of Biology and Medicine. 2(1):23-30,1991</ref> However, few people with adolescent scoliosis suffer from pain or other abnormalities. == Investigation == [[Image:Scoliosis cobb.gif|thumb|right|150px|[[Cobb angle]] measurement of a levoscoliosis.]]Patients who initially present with scoliosis are examined to determine if there is an underlying cause of the deformity. During a physical examination, the following is assessed: * [[Skin]] for [[Café au lait spot|café au lait]] spots indicative of [[neurofibromatosis]] * The feet for [[Pes cavus|cavovarus deformity]] * Abdominal reflexes * Muscle tone for [[spasticity]] During the exam, the patient is asked to bend forward (Adam's Bend Test). If a hump is noted, then scoliosis is a possibility and the patient should be sent for an x-ray to confirm the diagnosis. The patient's [[gait analysis|gait is assessed]], and there is an exam for [[sign (medicine)|sign]]s of other abnormalities (''e.g.'', [[Spina bifida]] as evidenced by a [[dimple]], hairy patch, [[lipoma]], or [[hemangioma]]). A thorough [[neurological examination]] is also performed. It is usual when scoliosis is suspected to arrange for weight-bearing full-spine AP/coronal (front-back view) and lateral/sagittal (side view) xrays to be taken, to assess both the scoliosis curves and also the kyphosis and [[lordosis]], as these can also be affected in individuals with scoliosis. Full-length standing spine [[X rays]] are the standard method for evaluating the severity and progression of the scoliosis, and whether it is congenital or idiopathic in nature. In growing individuals, serial radiographs are obtained at 3-12 month intervals to follow curve progression. In some instances, [[MRI]] investigation is warranted. The standard method for assessing the curvature quantitatively is measurement of the Cobb angle, which is the angle between two lines, drawn perpendicular to the upper endplate of the uppermost vertebrae involved and the lower endplate of the lowest vertebrae involved. For patients who have two curves, Cobb angles are followed for both curves. In some patients, lateral bending xrays are obtained to assess the flexibility of the curves or the primary and compensatory curves. ;Mass-screening for scoliosis using posture photos It has been suggested that entire populations be examined, for early detection. For example, in the 1940s, American psychologist [[William Sheldon]] proposed mandatory physical examinations that included nude photographs of each person being examined. One purpose of these photographs was the detection of rickets, scoliosis, and lordosis. His approach was implemented at a number of [[ivy league]] schools in which all freshmen were examined ([[Ivy League nude posture photos]]). A similar program was implemented in Boston's prison system. <ref>http://www.crimelibrary.com/criminal_mind/psychology/crime_motivation/6.html</ref> ==Prognosis== The prognosis of scoliosis depends on the likelihood of progression. The general rules of progression are that larger curves carry a higher risk of progression than smaller curves, and that thoracic and double primary curves carry a higher risk of progression than single lumbar or thoracolumbar curves. In addition, patients who have not yet reached skeletal maturity have a higher likelihood of progression. ==Management== The traditional medical management of scoliosis is complex and is determined by the severity of the curvature, [[Bone age|skeletal maturity]], which together help predict the likelihood of progression. The conventional options are, in order: # Observation # Bracing # Surgery Bracing is only done when the patient has bone growth remaining, and is generally implemented in order to hold the curve and prevent it from progressing to the point where surgery is necessary. Bracing involves fitting the patient with a device that covers the torso and in some cases it extends to the neck. The most commonly used brace is a [[TLSO]], a corset-like appliance that fits from armpits to hips and is custom-made from plastic. It is usually worn 22-23 hours a day and applies pressure on the curves in the spine. The effectiveness of the brace depends a lot on how much the person wears it. Typically braces are only used for idiopathic curves that are not grave enough to warrant surgery, but they may also be used to prevent the progression of more severe curves in young children, in order to buy the child time to grow before performing surgery which would prevent further growth in the part of the spine affected. Bracing may cause emotional and physical discomfort. Physical activity may be more difficult because the brace presses against the stomach making it very difficult to breathe. Children may lose weight from the brace, due to inceased pressure on the abdominal area. In infantile, and sometimes juvenile scoliosis, a plaster jacket applied early may be used instead of a brace. It has been proven possible <ref>{Growth as a corrective force in the early treatment of progressive infantile scoliosis, Journal of Bone & Joint Surgery,Vol.87-B, No.9,(Br.) September 2005}</ref> to permanently correct cases of infantile idiopathic scoliosis by applying a series of plaster casts (EDF-elongation, derotation, flexion) applied on a specialized frame under corrective traction, which helps to "mould" the infant's soft bones and work with their infantile growth spurts. This method was pioneered by UK scoliosis specialist Min Mehta. [[Chiropractic]] and [[physical therapy]] have some degree of anecdotal success in treating scoliosis that is primarily neuromuscular in nature, however non-surgical approaches will not address severe bone deformities associated with many cases of scoliosis. [[Chiropractors]] utilize joint mobilization techniques and therapeutic [[exercise]] to increase a scoliosis patient's flexibility and strength, theorizing that this better enables the brace to influence the curvature of the spine. [[Electronic Muscle Stimulation]] (EMS) is another therapeutic modality commonly utilized by chiropractors and physical therapists to reduce muscle spasms and strengthen atrophied muscles. There is limited published scientific research to evaluate the efficiency of treatment programs that include a combination of bracing along with physical therapy. While much debate remains in the scientific community about whether or not chiropractic and physical therapy can influence scoliotic curvature, there may well be palliative benefit from them in scoliosis patients who experience back pain either directly as a result of their deformity or indirectly from wearing an uncomfortable brace for the vast majority of the day. A non-invasive treatment for idiopathic scoliosis used successfully in Europe since the 1920s {{Fact|date=March 2008}}. Originally developed in Germany by scoliosis sufferer Katharina Schroth, this method is now taught to scoliosis patients in clinics specifically devoted to Schroth therapy in Germany, Spain, England, and, most recently, the United States. Physical therapists who do not specialize exclusively in Schroth therapy but who have received Schroth certification through the clinics in Spain and Germany offer Schroth therapy throughout Europe, parts of the Middle East, and the United States. ==Surgery== Surgery is usually indicated for curves that have a high likelihood of progression, curves that cause a significant amount of pain with some regularity, curves that would be cosmetically unacceptable as an adult, curves in patients with [[spina bifida]] and [[cerebral palsy]] that interfere with sitting and care, and curves that affect physiological functions such as breathing. Surgery for scoliosis is usually done by an [[Orthopedic surgery|orthopaedic surgeon]] who specializes in spine surgery. For various reasons it is usually impossible to completely straighten a scoliotic spine, but in most cases very good corrections are achieved. ===Spinal fusion with instrumentation=== [[Image:Wiki post-op.jpg|thumb|150px|right|[[Coronal]] [[X-ray]] of the above spine after having undergone successful fusion and instrumentation.]] [[Spinal fusion]] is the most widely performed surgery for scoliosis. In this procedure, bone (either harvested from elsewhere in the body [autograft], or donor bone [allograft]) is [[Bone grafting|grafted]] to the vertebrae so that when it heals, they will form one solid bone mass and the [[vertebral column]] becomes rigid. This prevents worsening of the curve at the expense of spinal movement. This can be performed from the anterior (front) aspect of the spine by entering the [[Thoracic cavity|thoracic]] or [[abdominal cavity]], or performed from the back (posterior). A combination of both is used in more severe cases. Originally, spinal fusions were done without metal implants. A [[Orthopedic cast|cast]] was applied after the surgery, usually under [[Traction (orthopedics)|traction]] to pull the curve as straight as possible and then hold it there while fusion took place. Unfortunately, there was a relatively high risk of [[pseudarthrosis]] (fusion failure) at one or more levels and significant correction could not always be achieved. In 1962, Paul Harrington introduced a metal spinal system of instrumentation which assisted with straightening the spine, as well as holding it rigid while fusion took place. The original, now obsolete [[Harrington implant|Harrington rod]] operated on a ratchet system, attached by hooks to the spine at the top and bottom of the curvature that when cranked would distract, or straighten, the curve. A major shortcoming of the Harrington method was that it failed to produce a posture where the skull would be in proper alignment with the pelvis and it didn't address rotational deformity. As a result, unfused parts of the spine would try to compensate for this in the effort to stand up straight. As the person aged, there would be increased wear and tear, early onset arthritis, disc degeneration, muscular stiffness and pain with eventual reliance on painkillers, further surgery, inability to work full-time and disability. "Flatback" became the medical name for a related complication, especially for those who had lumbar scoliosis.{{Vague|date=March 2008}} Modern spinal systems are attempting to address [[sagittal]] imbalance and rotational defects unresolved by the Harrington rod system. They involve a combination of rods, screws, hooks and wires fixing the spine and can apply stronger, safer forces to the spine than the Harrington rod. This technique is known as the Cotrel-Dubousset instrumentation, currently the most common technique for the procedure. Modern spinal fusions generally have good outcomes with high degrees of correction and low rates of failure and infection. Patients with fused spines and permanent implants tend to have normal lives with unrestricted activities when they are younger, it remains to be seen {{Vague|date=March 2008}} whether those that have been treated with the newer surgical techniques will develop problems as they age. They are able to participate in recreational athletics, have natural childbirth and are generally satisfied with their treatment. The most notable limitation of spinal fusions is that patients who have undergone surgery for scoliosis are ineligible for military service in the United States. In cases where scoliosis has caused a significant deformity resulting in a rib hump, it is often possible to perform a surgery called a costoplasty (also called a thorocoplasty) in order to achieve a more pleasing cosmetic result.{{Vague|date=March 2008}} This procedure may be performed at any time after a fusion surgery, whether as part of the same operation or several years afterwards. As stated before, it is usually impossible to completely straighten and untwist a scoliotic spine, and it should be noted that the level of cosmetic success will depend on the extent to which the fused spine still rotates out into the ribcage. A rib hump is evidence that there is still some rotational deformity to the spine. Specific weight training techniques can be used to influence this rotational deformity in the unfused parts of the spine.{{Vague|date=March 2008}} This leads to a marked decrease in pain and to some improvement in organ function depending on the person's particular case and is to be recommended over any cosmetic surgical procedure {{Fact|date=January 2008}}. ===Alternatives=== Recently, new implants have been developed that aim to delay spinal fusion and to allow more spinal growth in young children. These include rods that are extendible and allow growth while still applying corrective forces and vertebral stapling which is a method of retarding normal growth on the convex side of a curve, allowing the concave side to "catch up." For the youngest patients, whose thoracic insufficiency compromises their ability to breathe and applies significant cardiac pressure, ribcage implants that push the ribs apart on the concave side of the curve may be especially useful. These Vertical Expandable Prosthetic Titanium Ribs (VEPTR) provide the benefit of expanding the thoracic cavity and straightening the spine in all three dimensions while allowing the spine to grow. Although these methods are novel and promising, these treatments are only suitable for growing patients. Spinal fusion remains the "gold standard" of surgical treatment for scoliosis. There are now non-surgical ways to help treat scoliosis, as mentioned above in the management section. ==List of notable people known to have scoliosis == * [[James Blake]] * [[Melanie Blatt]] * [[Brooke Brodack]] * [[Steve Caballero]] * [[Liz Claman]] * [[Kurt Cobain]] * [[America Ferrera]] * [[Sarah Michelle Gellar]] * [[Kristin Kreuk]] * [[Jeanette Lee (pocket billards)]] * [[Michael McCary]] * [[Tracy McGrady]] * [[Gillian McKeith]] * [[Mohanlal]] (Malayalam movie actor) * [[Catherine Oxenburg]] * [[Georgie Parker]] * [[Sarah Polley]] * [[Rebecca Romijn]] * [[Eleanor Roosevelt]] * [[Hrithik Roshan]] * [[Isabella Rossellini]] * [[Chloe Sevigny]] * [[Elizabeth Taylor]] * [[Lauren Brady]] * [[Sophie Wilson]] * [[Rita Simons]] * [[Princess Eugenie of York]] * [[Gisele Bundchen]] == References == {{reflist}} *{{cite|author=Gylys, Barbara A. and Mary Ellen Wedding|title=Medical Terminology Systems|publisher=F.A. Davis Company|date=2005}} *Canale: Campbell's Operative Orthopaedics, 10th ed., Copyright © 2003 Mosby, Inc. == See also == *[[Alexander Technique]] ==External links== *[http://www.scoliosis.org National Scoliosis Foundation of America] {{Diseases of the musculoskeletal system and connective tissue}} {{Congenital malformations and deformations of musculoskeletal system}} [[Category:Orthopedics]] [[Category:Skeletal disorders]] [[bg:Сколиоза]] [[ca:Escoliosi]] [[cs:Skolióza]] [[da:Skoliose]] [[de:Skoliose]] [[es:Escoliosis]] [[fa:اسکولیوز]] [[fr:Scoliose]] [[it:Scoliosi]] [[he:עקמת]] [[la:Scoliosis]] [[lv:Skolioze]] [[ms:Skoliosis]] [[nl:Scoliose]] [[pl:Skolioza]] [[pt:Escoliose]] [[ru:Сколиоз]] [[sq:Skolioza]] [[sk:Skolióza]] [[fi:Skolioosi]] [[sv:Skolios]] [[tr:Skolyoz]]