Scoliosis (Spine Curvature)
What is Scoliosis (Spine Curvature)?
Scoliosis is a sideways bending of the spine greater than 10 degrees. In a normal and healthy spine, the vertebrae extend in a straight line from top to bottom, that is, in the neck, back and waist regions when viewed from the back. In scoliosis, the vertebrae change position to the right or left and at the same time rotate around their own axis. Therefore, it is defined as a three-dimensional deformity.
Due to scoliosis, besides the spine, shifts occur in the hip, rib cage and shoulder blades, and posture and visual deformities occur. In developing children, this situation causes abnormal loading in the developing and growing spine and thus results in deformities in the vertebrae. The incidence of scoliosis varies between 0.2 - 6%. Among girls, it is more common and the progression is greater. It is observed in 1.5% of school children and it is estimated that at least 150,000 children in Turkey have scoliosis.
This disorder, which is frequently seen in boys in the pre-school period, is 3-5 times more common in girls in adolescence, depending on the rate of growth. Scoliosis, which does not cause a strong complaint in the early period, is mostly detected incidentally as a result of school screenings or X-rays taken for any reason. On the other hand, the deformity in the child's posture is one of the most important reasons for families to consult a doctor. Symmetry disorders in the shoulders, shoulder blades, breast level and waist folds are the first striking findings. This condition may be accompanied by back and neck pain. As the degree of curvature increases, respiratory distress may also occur.
What are the symptoms of scoliosis?
Scoliosis may not show any symptoms in the early stage. Even if the symptoms of scoliosis appear, in nost cases no action is taken because it does not cause many complaints in the individual. Even if there are complaints, they are very few. For this reason, it is detected incidentally, either as a result of school scans or on x-rays taken for other reasons. The first symptom that takes the family to the physician is usually a deformity in the appearance. The first symptom of scoliosis of unknown origin is one shoulder being higher than the other. Asymmetry in the shoulder blades, breast level, waist folds or torso are the first noticeable deformities in the appearance. Back and low back pain are present in 40% of the cases. Curvatures above 50 degrees can cause respiratory distress.
How is scoliosis (curvature of the spine) diagnosed?
The diagnosis of scoliosis can be made by examining the child. Asymmetry in the midline can be noticed when looking at the bare spine from the front. When the child leans forward, a bending on one side and curvature of the ribs on the other side are noticeable. This appearance is called a rip hump. This image may be difficult to notice in some cases of "balanced scoliosis".
In the diagnosis of scoliosis, first x-ray is taken. The aim is to confirm the curvature of the spine, to determine its size and location, and to determine whether there is a concomitant hereditary defect of bone structure. X-rays should be taken at six-month intervals and the scoliosis should be followed up. On the other hand, other imaging tests such as bone scintigraphy, computerized tomography (CT) or magnetic resonance imaging (MRI) can be applied to patients with neurological disorders or those who will undergo surgery.
Diagnosis is easily confirmed by direct radiographs taken with the suspicion of scoliosis. Very rarely, an MRI is required. Since radiological examination is frequently used in the follow-up and diagnosis of scoliosis, great care should be taken to protect the ovaries and breasts with lead plates in these developing children.
Scoliosis curves are defined as major and minor curves. The place where the curvature is most angled, that is, the vertebrae that rotate the most in the vertical axis and move the most away from the midline, is called the apex. Scoliosis is also named according to the level of the spine where the apex is located. It is called cervical scoliosis if the apex is in the neck region, lumbar scoliosis in the lumbar region, and thoracic scoliosis in the back. Sometimes it can be seen in more than one region at the same time: For example, when it is both in the back and waist, it is defined as thoracolumbar scoliosis. It is more common in the back (thoracic) region.
The form and degree of scoliosis are determined on the radiographs. The most commonly used method for this is the Cobb angle. Scoliosis is followed up with Cobb angle and age of growth, and appropriate treatment methods are decided. The Cobb angle is measured with the help of lines drawn from the upper border of the spine where bending begins and the lower border of the spine where bending ends. The angle between the perpendiculars drawn on these lines (that is, the axis of the vertebra where the curvature begins and the axis of the vertebra where it ends) is the Cobb angle.
How is scoliosis treated?
Scoliosis can rarely regress on its own. In case of scoliosis which occurs at the beginning of the age of development, it is not possible to predict what kind of progression will happen. Some studies in recent years show that children with certain gene traits may show progression. Important follow-up criteria are used to determine the chosen treatment for scoliosis. But in some cases, progression is very frequent and thus treatments are less successful.
High degree of curvature at the time of first diagnosis
Double curvature at both the back and the waist
Severe contracture and muscle shortening
Considering these factors and the risk of progression of the spinal curvature, a decision is made on the type of treatment to be applied. The accepted treatment methods in the treatment of scoliosis are:
Monitoring and continuous follow-up
The use of Braces
Scoliosis exercises and special rehabilitation programs
Specialist follow-up is usually recommended if there is a Cobb angle of less than 15 degrees in children in whom growth has not started. Special scoliosis exercises and rehabilitation programs should be continued in those with a Cobb angle of 15-20 degrees. Intensive scoliosis rehabilitation programs should be applied for children with a Cobb angle greater than 25 degrees.
In the adolescence period we should be extremely careful, when the first signs of growth namely hair growth, voice changes, increase in height, breast development in girls or menstruation are seen, children should start the treatment. Since the speed and risk of bending are higher in these children, the risk of progression or development of the disease should be considered as the priority to the degree of Cobb angle, and treatments should be planned accordingly. Children with high risk of progression should definitely use braces in addition to physiotherapy and rehabilitation applications. Brace treatment should be continued between 16 hours and 23 hours a day until the growth is complete, depending on the state of growth and the degree of bending.
Surgical treatment can be applied if the Cobb angle is above 50 degrees in the above-mentioned individuals with a high risk of progression and for whom brace treatment has failed. In scoliosis surgery, the spine is taken to the midline with plates and screws, and sometimes these metals remain in their bodies in these children. It should also be known that surgery will create problems in the long term.
The Place of Brace Treatment in Scoliosis and the Efficacy of Braces with Different Features on the Treatment
The most controversial issue in scoliosis is brace treatment. Experts who embrace different concepts have different perspectives on the effectiveness of brace treatment. The most important reason for this is that the controlled braces which are determined according to the type of scoliosis and are correctly designed, are not sufficiently known in every country, thus are not applied. Another reason is that children in the developmental age show resistance to wearing braces.
As in all matters, technology has advanced a lot in this area as well. Now, mistakes that can be made while producing braces with classical techniques have been eliminated. It is possible to produce braces designed and produced with the help of computers, with very successful results.
The braces commonly used in scoliosis are called TLSO (Thoracic Lumbar Sacral Orthosis). These braces can be produced in different types and models. Determining and applying the appropriate brace model to the patient with scoliosis also requires additional expertise. The brace model should be determined by a specialist physician, and additional corrections should be applied in a timely manner and support should be increased during follow-ups at frequent intervals. Of course, one of the most important factors is the participation of Technicians who produce braces according to the correct instructions and rules, and who have expertise and experience in this field, in the medical team. Evidently scoliosis treatment requires a team effort. Physicians, technicians and physiotherapists, family and child should act together in the process of treatment, and every stage of the treatment should be monitored.
It may be possible to stop scoliosis with exercise programs. These exercise programs are very effective, especially in children from the age of 7 with scoliosis greater than 15 degrees. In addition, scoliosis exercises give good results in patients with scoliosis above 40 degrees.
In addition to techniques such as “Bobath”, “Vojta”, “Katharina Schroth”, classical stretching and strengthening exercises can also be applied in exercise programs. Considering that psychological factors play an important role in the rehabilitation of scoliosis, intensified exercise programs have significant effects on adolescents. Young people who act with group psychology have a high level of communication with their peers who share their problems.
Physical Therapy and Rehabilitation Applications in Scoliosis
Scoliosis rehabilitation programs are applied with or without a brace, depending on the period, in children at the age of development with a Cobb angle of 20-30 degrees. Adults with 30-40 degree angles and those with pain also benefit from these programs.
There are many physiotherapy approaches that stand out in the treatment of scoliosis. Like Vojta therapy, acupuncture practices, and the most studied Schroth therapy. The details of physical therapy should definitely be explained to children and families in detail, and necessary cooperation should be ensured regarding what needs to be done. Some of these programs can be applied intensively, or they can be continued with sessions of 3-4 days a week.
Intensive Scoliosis Rehabilitation-YSR (Scoliosis Intensive Rehabilitation-SIR)
The purpose of the intensified special exercise program, which is planned according to the direction of the curvature and the individual; It is a three-dimensional scoliosis treatment based on sensorimotor and movement principles. With these special exercises, it is aimed to correct the patient's asymmetrical posture and to help them contain a proper posture during daily life activities.
Patients referred to the center from various places participate in an intense exercise program for 4-6 weeks and 4 hours a day. In group exercises, patients with similar curvature directions, degrees and ages are trained in the same groups. Individual programs are also carried out for patients when necessary. On the basis of the exercises, there are breathing exercises, learning and maintaining the correct posture with proprioceptive stimulus, different balance and movement exercises and correction of the curvature side and restoring balance and normal movement.
Surgical treatment in scoliosis is applied in advanced cases. It is also applied in cases where an increase in the degree of scoliosis continues or is predicted to progress despite exercise and brace treatment. In other words, if the Cobb angle increases and exceeds 50 degrees despite conservative approaches, scoliosis surgery may be required. Surgery should be decided not only by looking at the angle in the radiograph, but also by evaluating the patient's psychological and sociocultural status. Because scoliosis occurring during adolescence, usually does not reach the point where it can damage the heart and lung functions. Basically, two approaches are adopted in scoliosis. These are posterior interference and anterior interference. The dorsal region is used in posterior intervention.
Surgically, the aim is to follow up all patients in the early period, to stop the progression, to eliminate cosmetic problems, and to eliminate pain and neurological findings, if any. If necessary, it may be possible to restore the spine with early interventions and simple surgical procedures in patients. At this stage, the most important point is to perform the right surgery at the right time, to protect the spinal cord while correcting the spine and bone structure. With the imaging devices used during scoliosis surgery and special tools to prevent spinal cord and nerve damage, its success rates have reached extremely high levels. It should not be forgotten that the treatment of scoliosis requires a long-term follow-up, as the patient and his family will be in contact with their physicians for many years.
After scoliosis surgery, the mobility of the spine is decreased. In the front approach, intervention is made by lifting the thorax from the underarm area. The disadvantage of this operation is that it requires the use of a brace after the operation. Its advantages are ensuring that the spine remains more mobile, and that the suture marks remain under the arm, thus making it look more aesthetic.
There are some matters that the patient should pay attention to after undergoing a scoliosis surgery. As every surgery has risks, scoliosis surgeries also have certain risk ratios. This rate is around 5%. If no complications occur, the patient can be discharged within 14 days. The undesirable results that can be observed after the surgery are as follows:
Infections, which can be controlled with the use of antibiotics.
Respiratory distress after bleeding, which can be relieved by blood drainage.
Separation or loosening of screws or breaks in instrumentation, which requires a second surgery.
Nerve paralysis observed in less than 1% (usually reversible)
What are the considerations to be taken after scoliosis treatment?
Standard practice after scoliosis surgery in children and young adults (with some limited exceptions) is as follows:
- The patient is mobilized in a controlled manner by standing up on the day after the surgery (1st day).
- Day 2 serums and other connections are greatly reduced and independent mobilization is encouraged.
- When the patient becomes self-sufficient (going to the toilet, getting out of bed, etc.) (on the 3rd or 4th day), they are taken home from the hospital.
- After the 3rd week, the patient can leave the house in a controlled manner.
- The patient can go to school in a controlled manner after the 4 th week.
- From the 4th week, light body exercises (pilates band, light weight) can be done. They can walk unlimitedly, swim in the pool or the sea to cool off.
- The patient can use public transportation (including school bus) from the end of the 2nd month.
- From the end of the 3rd month, they can continue their normal daily life without restrictions (except for home and school activities, sports), and can do light individual jogging and swimming for sports.
- As of the end of the 6th month, running and other individual sports (racquet sports, etc., not for competition purposes) can be done and unlimited cycling can be done without the purpose of competition.
- After the 1st year (last routine checkup), the patient is no longer limited, except for combat sports and especially dangerous activities, like parachuting, bungee jumping, etc.
Why should I choose the Memorial Health Group for scoliosis treatment?
Memorial Health Group Spine Centers provide world-class services. In our spine centers, we have competent spine surgeons who can successfully treat specific spine diseases. At the same time, our centers contain operating rooms equipped with the latest technological equipment. In our center, where experienced hands meet with technological tools, the treatment for all spinal problems including scoliosis has a high rate of success.