Abnormalities in the curvature or shape of the spine can indicate scoliosis and spinal deformity. Jason Lowenstein, MD, medical director of Atlantic Health System’s Scoliosis and Spinal Deformity Center, joined a Community Conversation to explain how scoliosis is diagnosed and why early identification is the key to treating spinal deformity. The discussion was held June 8, 2021 on Facebook Live.
What are scoliosis and spinal deformity?
Dr. Lowenstein explained that when the spine is viewed from the front, it should look straight. When viewed from the side, there should be two curves, called the thoracic kyphosis and the lumbar lordosis, that form a gentle “S.” If there is a deviation from these normal curves and shapes, an exaggeration in the “S”, or a prominent hump in the back, that may be a sign of scoliosis or an underlying spine deformity.
How are these conditions diagnosed?
Children and adults are diagnosed differently, Dr. Lowenstein said. Children are typically screened by a school nurse, a pediatrician or a parent for abnormalities including ribs that are more prominent on one side of the body, one shoulder higher than the other or folds in the back that appear asymmetrical. If these signs are present, a young patient is generally referred to a physician for further evaluation. Adults often seek a diagnosis if they feel imbalanced or experience pain or numbness that travels into the buttocks or legs.
Is scoliosis more common in children?
A person can develop scoliosis at any age. The most common type of scoliosis that occurs in children is called idiopathic scoliosis, which simply means there is no underlying diagnosis that creates the scoliosis. According to Dr. Lowenstein, curves can develop, often in predicable patterns, that can progress into adulthood. Early diagnosis is important so that treatment can begin to prevent further progression of the abnormality.
Adults can develop idiopathic scoliosis, but they can also develop what is known as degenerative scoliosis. As we age, the discs and the normal structures in the spine can wear out asymmetrically, causing abnormal curves. Adults should also seek early treatment to prevent the condition from getting worse.
What treatment options are available for children with scoliosis?
Dr. Lowenstein emphasized that the approach to treatment is different for spines that are “immature” in children and those that are fully developed in adults.
If a child has a small curve, a physician will keep it under observation to make sure that it is not changing. But if a curve measures between 20 to 40 degrees and the child still has growth ahead of them, a brace is a typical treatment option.
Dr. Lowenstein said that bracing has been shown to be incredibly effective at preventing the progression of scoliosis and can sometimes be the main treatment.
“There are a lot of different studies out there, but braces can be up to 90% effective in preventing the progression of scoliosis in the immature growing spine. So that could be a huge option to try to treat and an opportunity to stop them from having more issues as adults,” he said.
What do the braces look like and how do they function?
There are different types of braces, but most tend to be made of rigid, thin plastic and offer three-point bending, according to Dr. Lowenstein. He said the goal is to push the spine straight, not necessarily to reverse the scoliosis, but to prevent it from getting worse. The more the patient wears the brace, the more effective it can be. It is recommended that most patients wear their brace for approximately 20 hours a day to get the maximum benefit.
Beyond bracing, are there other treatment options?
Children can do exercises that strengthen their spine and help prevent an abnormal curve from growing and getting worse, Dr. Lowenstein said.
If a curve goes beyond 45 degrees, then surgery may be an option. He said that the latest surgical option is called a tether. A tether is placed during a minimally invasive surgery, where a surgeon goes through the chest with a camera to put screws into the front of the spine.
“Instead of putting a rod to connect the screws, you put in a tether, which is a flexible cord. So you're trying to correct the scoliosis, but it’s a non-fusion … mobile type of surgical correction so patients hopefully retain their motion and they can still go back to all their normal activities afterwards,” he said.
Are braces used for adults?
Bracing is not usually used for adults to correct scoliosis or prevent it from getting worse, primarily because the spine is finished growing and can’t be modulated in the same way, Dr. Lowenstein explained. If adult patients with scoliosis experience back pain, braces may be offered for short-term use to help alleviate their symptoms.
“But we don’t use it to try to correct the scoliosis or to prevent the curve from getting worse the way we do in kids,” he added.
How successful are surgical treatments?
Most scoliosis patients whose condition has progressed to the point that they need to have surgery are able to go back to normal activity and can live normal lives afterward.
“It’s an incredibly transformative procedure and experience for them. And they just go back to being normal kids and normal adults.”
Helping his patients return to normal activities is particularly rewarding for Dr. Lowenstein.
“When you’re a child and you’re living with this deformity, whether it creates a cosmetic problem or pain or an inability to do the normal activities that you see your friends doing, by fixing this and allowing them to go back to their normal everyday routine, it’s very wonderful to see that happen,” he said.
What is diffuse idiopathic skeletal hyperostosis (DISH)?
Diffuse idiopathic skeletal hyperostosis (DISH) is when a person’s spine becomes stiff and loses its range of motion. DISH is sometimes accompanied by spinal stenosis, which is a narrowing of the space available for the spinal cord nerve roots. Spinal stenosis can cause pain and paresthesias or weakness in your legs. DISH can also create a spinal deformity.
Dr. Lowenstein explained that once your spine starts getting stiff, you can lose some of those normal contours. And oftentimes you get kyphosis.
What is kyphosis?
Kyphosis is an increased curvature of your back, usually in the thoracic spine. It is usually indicated by a humpback, a dowager back or a prominent curve.
“You lean forward with the inability to stand up straight. Sometimes you try to compensate by bending your hips and knees to try to get yourself straight, but you can only be in that position for so long without your legs fatiguing, and then you wind up falling forward again,” he stated.
It can also happen in conjunction with something called sagittal imbalance, which occurs when the head is in front of the pelvis.
“Typically, when you stand up straight, your head is supposed to be directly above your pelvis when you look at yourself from the front and from the side. If your head is way forward, that’s a sagittal imbalance.”
He explained that sagittal imbalance can also happen along with kyphosis and create tremendous disability, pain, and fatigue.
“Your muscles have a very hard time being that position, which is why some people start using a walker or cane to try and help support them. They put it in front of them to help balance themselves when they’re leaning forward.”
What are the treatment options for patients with DISH?
Depending on the condition, including kyphosis or the inability to stand up straight because of DISH, there are complex procedures that can be performed to correct the abnormality, Dr. Lowenstein said.
“They’re called a pedicle subtraction osteotomy, or a three-column osteotomy, where you basically take a wedge of bone out of the spine and you close the wedge to try to create the curvature, the lordosis that you’ve lost because of the DISH … it’s complicated, but it’s doable,” he explained.
If you are diagnosed with scoliosis as an adult, what can be done to mitigate the pain and other symptoms?
There is a spectrum of scoliosis diagnosis, from mild to severe, Dr. Lowenstein explained. Mild scoliosis is very common.
“What happens is that as we get older, our discs and our motion segments will wear out, almost like you wear out the tires on your car. And as it wears out, if it wears out asymmetrically, you start developing a curvature,” he said.
If there is a mild curve, and the patient is asymptomatic, there is nothing special to do beyond normal cardiovascular health and exercise.
If the curve is progressing or changing, or the patient develops symptoms such as back pain, buttock pain, leg pain, numbness, or weakness, these are warning signs that spinal stenosis or pressure on the nerves may be developing. Those patients should consult a primary care physician or a spine specialist for an evaluation.
“And then typically we follow you. We just try to make sure that the curve isn’t changing as you’re getting older, because progression of scoliosis is a warning sign that we want to catch early and try to either treat or ultimately be able to arrest the progression of the curve before it gets out of control.”
Should patients with scoliosis avoid any activities?
Common sense should prevail, Dr. Lowenstein said.
“You have to listen to your body. If you exercise and it doesn’t create pain or symptoms, it’s probably okay. If every time you start to do an activity and it starts bothering you, then you may want to back off of that.”
If a person is overweight, does that make the condition worse?
Scoliosis can affect anyone, whether they are overweight or not and it is not dependent on lifestyle. However, the more weight on a person’s spine, the more stress it will experience. Scoliosis can be exacerbated by weight, but not caused by weight.
If a person hears a popping sound while exercising, is that a cause for worry?
The sound itself is not cause for concern, Dr. Lowenstein said. He likened it to cracking your knuckles.
“The spine is the same way. Your facet joints can pop and make sounds, which are the joints in the back of your spine. However, if you do have a spinal instability, something called a spondylolisthesis, where one bone is shifted on the other, you might hear popping and clicking when you move. And if that popping and clicking is happening in conjunction with back pain, or you feel a sharp stab in the lower back or leg, that’s a little bit more concerning because there may be abnormal motion. I would get that checked out.”
Is the Scoliosis and Spinal Deformity Center designed for adults as well as children?
People of any age can develop a spinal deformity and can be evaluated and treated by the experts at Atlantic Health System’s Scoliosis and Spinal Deformity Center.
Adults with prominent curves that are getting progressively worse or those who are experiencing back pain are offered numerous treatment options, including physical therapy, core-strengthening exercises, Pilates and yoga. The center has pain management doctors who can offer medical treatment to alleviate pain. For those with more severe deformities or ongoing symptoms, such as weakness, numbness and paresthesia (a burning or tingling sensation), surgery is also offered as an option.
What is the Schroth Method and is it an alternative to wearing a brace?
The Schroth Method is a type of physical therapy developed in Germany at the turn of the 20th century to treat patients with polio, Dr. Lowenstein explained. The technique uses specific exercises to try to strengthen the muscles around the spine to correct scoliosis.
Anecdotally, many parents of children with scoliosis embrace this method because children may be able to avoid wearing a brace for 20 hours a day. However, Dr. Lowenstein said it is a relatively new treatment method for scoliosis and can be time-intensive.
Bracing, he maintains, is “incredibly effective in trying to slow the progression and treat scoliosis.”
He added, “I wouldn’t do Schroth in lieu of doing bracing. And certainly, if you’re seeing a spine specialist and they’ve recommended a brace, I would certainly take the recommendation and do that.”
What degree of curve makes a child a candidate for tether surgery?
A child may be a candidate for a tether procedure if the child has a curve between 40 and 65 degrees. A curve less than that angle would benefit from bracing, according to Dr. Lowenstein.
Where can I find more information about the Scoliosis and Spinal Deformity Center?
Scoliosis and Spinal Deformity Center offers comprehensive care for patients of all ages. Learn more >