Orthopedics: Conditions

Scoliosis Town Hall: Scoliosis Patients Share Their Success Stories Post-Surgery

Scoliosis is defined as a side to side deviation or curvature of the spine when viewing the body from the front or back. It is normal for people to have some curvature of the spine. Mild spinal curvatures allow us to have rounded shoulders and a mild amount of swayback to our lower spine. Scoliosis is an abnormal curvature to the spine that causes the spine to both curve and twist. Scoliosis may occur at any age and in many different types of people.

Typically, other than the above mentioned congenital scoliosis and neuromuscular scoliosis, most scoliosis is called idiopathic scoliosis. About 80% of scoliosis is termed “idiopathic” which means that no cause can be found. There are 4 classifications of idiopathic scoliosis based on the age of the patient.

• Children 0-3 years old – Infantile Scoliosis
• Children 4-10 years old – Juvenile Scoliosis
• Adolescents 11-18 years old – Adolescent Scoliosis
• Patients over 18 years old – Adult Scoliosis

Curves appearing earlier in life may be more likely to progress as there is more time and growth potential prior to skeletal maturity, which may slow curve progression. Later in life, degeneration may occur in the spine due to age or unusual stresses on the spine, and previously mild and undiagnosed scoliosis may progress and become symptomatic. This is referred to as degenerative scoliosis.

Curvature may be mild to severe, and treatment is varied depending on severity and response to conservative means. Generally a mild curve of less than 10 degrees is considered spinal asymmetry not scoliosis. Curves larger than 10 degrees are often watched for progression by X-ray measurement over time. If the patient is skeletally immature as determined by the pelvic growth plate on X-ray, bracing may be helpful in controlling progression. Not all cases are candidates for bracing as this depends on the type and severity of curve. Bracing is not always considered until curves reach 20-25 degrees or show rapid progression in skeletally immature individuals. Most scoliosis is not very painful during childhood and younger adulthood, but it may cause more significant problems as people age.

The cause of scoliosis, in most cases, is unknown. Severe curve progression has an increased incidence in the female population. Some known causes include congenital malformation of the spinal column, neuromuscular scoliosis caused by cerebral palsy or spina bifida, genetic anomalies, and other conditions.

Scoliosis can arise from a number of causes, including neurological disorders such as cerebral palsy or spina bifida, underlying genetic syndromes such as spinal muscular atrophy or skeletal dysplasias, or congenital abnormalities of the spine which we are born with. Scoliosis does not come from carrying heavy things, athletic involvement, sleeping/standing postures, or minor leg length abnormalities.

Typically, pediatric scoliosis is found during a routine pediatric evaluation or in a school screening. Sometimes it is picked up by family or friends at the pool. When found, it generally is referred to an orthopedic or spine surgeon. General physical evaluation, looking at the individual's spinal alignment both in the frontal and side planes will help ascertain the severity of the curve. Also evaluated are the alignment of shoulders, scapulae, hips, and pelvis. The forward flexion test familiar to most people from school screenings is invaluable in ascertaining the significance of the spinal rotation.

The mainstay in evaluating scoliosis is the standing 36-inch X-ray in the front and side view. A standing X-ray is critical because gravity will show the scoliosis at its worst, whereas a supine or lying down film may lessen the severity of the curve. Also, full-length views are important to determine spinal balance, or where the head appears in space in relationship to the pelvis. The goal of treatment, whether it is conservative or surgical, is to maximize the alignment of the head over the pelvis.

Generally, low-degrees curves are watched and re-evaluated every 6-12 months depending on the potential for growth and progression of scoliosis. If growth and progression are both ongoing, bracing may be recommended with a TLSO or thoracolumbar sacral orthosis, a hard plastic clamshell type brace, which may help limit progression of the curve. Sometimes these braces are worn 24 hours a day or just at night, depending on the condition and surgeon preference. If bracing does not slow or stop curve progression and curve magnitude is approaching the 40 to 50 degree range, surgery may be recommended. There is no absolute number of degrees that require surgery; rather, it is more a function of growth potential, skeletal maturity, and rate of progression.

In the mature spine, a progression of 2 or 3 degrees a year may not sound like a large progression, but if you have a 40 degree curve with a 2 degree per year progression, in 15 years you have a 70 degree curve, which is a significant problem. Therefore, sometimes follow up X-rays may be needed into adult life to make sure there is no progression of the scoliosis. Once this is determined, the patient is generally released from follow up with instructions to return if loss of height or change in shape occur or new onset pain begins that may indicate a change in the scoliosis.

Generally scoliosis is not a problem for individuals throughout their lives, and patients are encouraged to remain active and maintain a weight close to ideal body weight to avoid extra stress on the spine. Women generally have no trouble bearing children but sometimes do have back pain with the additional stress of carrying 30 to 40 pounds of extra weight during pregnancy. Continued back pain after child birth should be evaluated for potential progression of the scoliosis.

Surgical procedures used to treat scoliosis at Emory include:

Extreme Lateral Interbody Fusion (Xlif) or Direct Lateral Interbody Fusion (Dlif)

Serial Casting as a Delay Tactic in the Treatment of Moderate-to-severe Early-onset Scoliosis

Fletcher ND, McClung A, Rathjen KE, Denning JR, Browne R, Johnston CE 3rd
J Pediatr Orthop. 2012 Oct-Nov;32(7):664-71.

Early Onset Scoliosis: Current Concepts and Controversies

Fletcher ND, Bruce RW
Curr Rev Musculoskelet Med. 2012 Jun;5(2):102-10

Reliability Analysis for Manual Radiographic Measures of Rotatory Subluxation or Lateral Listhesis in Adult Scoliosis

Freedman BA, Horton WC, Rhee JM, Edwards CC 2nd, Kuklo TR
Spine (Phila Pa 1976). 2009 Mar 15;34(6):603-8. doi:

The Effect on Anterior Column Loading Due to Different Vertebral Augmentation Techniques

Ananthakrishnan D, Berven S, Deviren V, Cheng K, Lotz JC, Xu Z, Puttlitz CM
Clin Biomech (Bristol, Avon). 2005 Jan;20(1):25-31