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SCOLIOSIS

Definition 
   Scoliosis is a side-to-side curvature of the spine.

Description 
   - When viewed from the rear, the spine usually appears 
     perfectly straight. 
   - Scoliosis is a lateral (side-to-side) curve in the spine, 
     usually combined with a rotation of the vertebrae. 
     (The lateral curvature of scoliosis should not be confused 
     with the normal set of front-to-back spinal curves visible 
     from the side.) While a small degree of lateral curvature  
     does not cause any medical problems, larger curves can cause 
     postural imbalance and lead to muscle fatigue and pain. 
   - More severe scoliosis can interfere with breathing and lead 
     to arthritis of the spine (spondylosis).
   - Approximately 10% of all adolescents have some degree of 
     scoliosis, though fewer than 1% have curves which require 
     medical attention beyond monitoring. Scoliosis is found in 
     both boys and girls, but a girl's spinal curve is much more 
     likely to progress than a boy's. Girls require scoliosis 
     treatment about five times as often. The reason for these 
     differences is not known.

Causes & symptoms 
   - Four out of five cases of scoliosis are idiopathic, meaning 
     the cause is unknown. 
   - While idiopathic scoliosis tends to run in families, no 
     responsible genes had been identified as of 1997. 
   - Children with idiopathic scoliosis appear to be otherwise 
     entirely healthy, and have not had any bone or joint disease 
     early in life. 
   - Scoliosis is not caused by poor posture, diet, or carrying 
     a heavy bookbag exclusively on one shoulder.

Idiopathic scoliosis 
   classified according to age of onset: 
	 Infantile 
          - Curvature appears before age three. 
          - This type is quite rare in the United States, but 
            is more common in Europe. 
	 Juvenile 
	  - Curvature appears between ages 3 and 10. 
          - This type may be equivalent to the adolescent type, 
             except for the age of onset. 
	 Adolescent 
          - Curvature appears between ages of 10 and 13, near 
            the beginning of puberty. 
          - This is the most common type of idiopathic scoliosis. 
	 Adult 
          - Curvature begins after physical maturation is 
            completed. 

Causes are known for three other types of scoliosis: 
 	 Congenital scoliosis 
          - due to congenital birth defects in the spine, often 
            associated with other organ defects. 
	 Neuromuscular scoliosis 
          - due to loss of control of the nerves or muscles which 
            support the spine. 
          - The most common causes of this type of scoliosis are 
            cerebral palsy and muscular dystrophy. 
	 Degenerative scoliosis 
          - may be caused by degeneration of the discs which 
            separate the vertebrae or arthritis in the joints 
            that link them. 

Diagnosis 
- Diagnosis for scoliosis is done by an orthopedist. 
- A complete medical history is taken, including questions about 
  family history of scoliosis. 
- The physical examination includes determination of pubertal
  development in adolescents, a neurological exam (which may 
  reveal a neuromuscular cause), and measurements of trunk 
  asymmetry. 
- Examination of the trunk is done while the patient is standing, 
  bending over, and lying down, and involves both visual 
  inspection and use of a simple mechanical device called a 
  scoliometer.
- If a curve is detected, one or more x rays will usually be 
  taken to define the curve or curves more precisely. 
- An x ray is used to document spinal maturity, any pelvic tilt 
  or hip asymmetry, and the location, extent, and degree of 
  curvature. 
- The curve is defined in terms of where it begins and ends, 
  in which direction it bends, and by an angle measure known as 
  the Cobb angle. 
- The Cobb angle is found by projecting lines parallel to the
  vertebrae tops at the extremes of the curve; projecting 
  perpendiculars from these lines; and measuring the angle of 
  intersection. To properly track the progress of scoliosis, 
  it is important to project from the same points of the 
  spine each time.
- Occasionally, magnetic resonance imaging (MRI) is used, 
  primarily to look more closely at the condition of the spinal 
  cord and nerve roots extending from it if neurological problems 
  are suspected.

Treatment 
- Treatment decisions for scoliosis are based on the degree of 
  curvature, the likelihood of significant progression, and the 
  presence of pain, if any. 
- Curves less than 20 degrees are not usually treated, except 
  by regular follow-up for children who are still growing. 
- Watchful waiting is usually all that is required in adolescents 
  with curves of 20-30 degrees, or adults with curves up to 40 
  degrees or slightly more, as long as there is no pain. 
- For children or adolescents whose curves progress to 30 
  degrees, and who have a year or more of growth left, bracing 
  may be required. 
- Bracing cannot correct curvature, but may be 
  effective in halting or slowing progression.
- Bracing is rarely used in adults, except where pain is 
  significant and surgery is not an option, as in some elderly 
  patients.
- Two general styles of braces are used for daytime wear. 
- The Milwaukee brace consists of metal uprights attached to pads 
  at the hips, rib cage, and neck. The underarm brace uses rigid 
  plastic to encircle the lower rib cage, abdomen, and hips. 
- Both these brace types hold the spine in a vertical position. 
- Because it can be worn out of sight beneath clothing, the 
  underarm brace is better tolerated and often leads to better 
  compliance.
- A third style, the Charleston bending brace, is used at night 
  to bend the spine in the opposite direction. Braces are often 
  prescribed to be worn for 22-23 hours per day, though some 
  clinicians allow or encourage removal of the brace for exercise.
- Bracing may be appropriate for scoliosis due to some types of 
  neuromuscular disease, including spinal muscular atrophy, 
  before growth is finished. 
- Duchenne muscular dystrophy is not treated by bracing, 
  since surgery is likely to be required, and since later 
  surgery is complicated by loss of respiratory capacity. 

- Surgery for idiopathic scoliosis is usually recommended if: 
	 The curve has progressed despite bracing 
	 The curve is greater than 40-50 degrees before growth 
          has stopped in an adolescent 
	 The curve is greater than 50 degrees and continues 
          to increase in an adult 
	 There is significant pain. 
- Orthopedic surgery for neuromuscular scoliosis is often done 
  earlier. 
- The goals of surgery are to correct the deformity as much as 
  possible, to prevent further deformity, and to eliminate pain 
  as much as possible. 
- Surgery can usually correct 40-50% of the curve, and sometimes 
  as much as 80%. Surgery cannot always completely remove pain.
- The surgical procedure for scoliosis is called spinal fusion, 
  because the goal is to straighten the spine as much as possible,
  and then to fuse the vertebrae together to prevent further 
  curvature. 
- To achieve fusion, the involved vertebra are first exposed, 
  and then scraped to promote regrowth. Bone chips are usually 
  used to splint together the vertebrae to increase the 
  likelihood of fusion. 
- To maintain the proper spinal posture before fusion occurs, 
  metal rods are inserted alongside the spine, and are attached 
  to the vertebrae by hooks, screws, or wires. Fusion of the 
  spine makes it rigid and resistant to further curvature. 
- The metal rods are no longer needed once fusion is complete, 
  but are rarely removed unless their presence leads to 
  complications. 
- Spinal fusion leaves the involved portion of the spine 
  permanently stiff and inflexible. While this leads to some 
  loss of normal motion, most functional activities are not 
  strongly affected, unless the very lowest portion of the spine 
  (the lumbar region) is fused. Normal mobility, exercise, 
   and even contact sports are usually all possible after spinal 
   fusion. Full recovery takes approximately six months.

Alternative treatment 
- Although important for general health and strength, 
  exercise has not been shown to prevent or slow the development 
  of scoliosis. 
- It may help to relieve pain from scoliosis by helping to 
  maintain range of motion. Good nutrition is also important 
  for general health, but no specific dietary regimen has been  
  shown to control scoliosis development. 
- In particular, dietary calcium levels do not influence 
  scoliosis progression.

Chiropractic treatment 
- may relieve pain, but it cannot halt scoliosis development, 
  and should not be a substitute for conventional treatment of 
  progressing scoliosis. 
- Acupuncture and acupressure may also help reduce pain and 
  discomfort, but they cannot halt scoliosis development either.

Prognosis 
- The prognosis for a person with scoliosis depends on may 
  factors, including the age at which scoliosis begins and 
  the treatment received. More importantly, mostly unknown 
  individual factors affect the likelihood of progression and 
  the severity of the curve. 
- Most cases of mild adolescent idiopathic scoliosis need no 
  treatment and do not progress. Untreated severe scoliosis 
  often leads to spondylosis, and may impair breathing.

Prevention 
- There is no known way to prevent the development of scoliosis. 
- Progression of scoliosis may be prevented through bracing or
  surgery.





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