Scoliosis in Children and Adults: Causes, Manifestations and Treatment

Scoliosis is the medical term for a sideways curvature of the spine. It is a condition of pathological misalignment, which can be caused by faulty posture, but also by other health problems.

We most often encounter this term into adolescence and as scoliosis in children. However, people of any age can be affected.

Greek: skolios = bend, curved. 
Galen Claudius described scoliosis as the first spinal deformity between 130 and 200 AD.

This type of spinal deformity reportedly affects approximately 3% of the population.

Scoliosis is also present under physiological conditions. However, only to a certain extent. Transient spinal misalignment is caused when a unilateral load is applied, for example, while carrying a shopping bag in one hand.

The spine has its physiological curvature

The spine is an important part of the musculoskeletal and support apparatus of the human body. This means that it has an important movement and support function. In addition, it is significant in terms of protecting the spinal cord, which passes through the spinal canal.

The spine is composed of vertebrae. There are between 33 and 34 of these.

The spine is divided into several sections:

• cervical spine - 7 vertebrae = from C1 to C7
• thoracic spine - 12 vertebrae = from Th1 to Th12
• cervical spine - 5 vertebrae = from L1 to L5
• sacral spine - 5 or 6 = from S1 to S5 (S6), together forming the sacrum - os sacrale
• coccyx - 4 or 5 vertebrae = Co1 - Co4 (Co5)

Latin names for the vertebrae: 
C - vertebrae Cervicales 
Th - vertebrae Thoracicae 
L - vertebrae Lumbales 
S - vertebrae Sacrales
Co - vertebrae Coccygeae 

From the head to the pelvis, the spine makes up approximately 35% of the length of the human body.

Latin name: Columna vertebralis.

The vertebrae form the spinal canal through which the spinal cord (medulla spinalis) runs, from the head to approximately the second cervical vertebra - L2.

The spine is a unit made up of vertebrae, together with the intervertebral discs (disci intervertebrales), intervertebral joints, ligaments and muscles, it belongs to a perfect functional unit. The interplay of all the structures and the specific shape guarantee us mobility.

The mobility is different in each section.

Mobility is greatest in the cervical region.
The thoracic spine is reinforced with ribs, which limit the range of motion to some extent.
The lowest rate of movement is in the lumbar region.

The cruciate part is immovable. The tailbone has a limited ability to move forward and backward.

The movements of the spine are divided into:

1. anteflexion - bent or curved forwards
2. retroflexia - bent or curved backwards
3. lateroflexion - bent or curved to the side
4. rotation - turning around a centre or an axis, torsion
5. circular movements - by mutual combination
6. translation - also important in shock absorption, it is provided by discs

The spine is naturally (physiologically) curved in several sections.

The spine is naturally curved.

This S-shaped curvature is significant from both a support and movement function. Within a certain range, the curvature is normal = physiological.

It is referred to as lordosis and kyphosis.

A. Lordosis is forward curvature - cervical and lumbar. The apex is in the cervical regions C4 - C5 and lumbar regions L3 - L4.

B. Kyphosis is backward curvature - thoracic and sacral part. Its peak is in the region of the chest Th6 - Th7.

They alternate in the following order:

cervical lordosis >

thoracic kyphosis >

lumbar lordosis >

sacral kyphosis.

The spine can be affected by various conditions, one of which is scoliosis.

However, scoliosis is also present to some extent in every person. It is most noticeable in the region of vertebrae Th3 - Th5. It is transiently accentuated when standing on one leg, but also when carrying a load in one hand.

Read also: 
Hyperlordosis
Hyperkyphosis

Scoliosis is...

The definition of scoliosis states that it is a condition of morbid sideways deviation of the spine from the frontal (anterior, frontal) plane by more than 10 degrees.

In addition to the buckling, there is also a component of rotation (torsion). It is therefore a three-dimensional deformity of the spine. 

There are several classifications of scoliosis. These take into account, for example, the side, extent or location of the curve of the buckling. A further important division is according to the aetiology, i.e. the origin of the scoliosis. 

Table: classification according to curve localization

Another form divides it according to scope. In this case, the Cobb-Lippmann classification into 4 basic stages is applied.

Table: 4 degrees of scoliosis according to Cobb-Lippmann

Subsequently, curvatures such as kyphoscoliosis or lordoscoliosis are also known. In these cases, states of deformity in the sense of kyphosis and lordosis are also associated. Scoliosis most often occurs together with kyphosis at thoracic level.

Hypo - kyphosis = deficient; less than normal / reduction of spinal curvature
or
hyper - kyphosis = overly / too much - excessive kyphosis.

In terms of the age at which the curvature disorder is detected, it is also assessed as:

• infantile - in children under 3 years
• juvenile - in children between 3 and 10 years of age
• adolescent - in children over 10 years of age

And not to make the subject simple, there is also a division based on the structural changes present. It is then that structural and non-structural scoliosis is discussed.

In the case of the former, damage (deformities) of the structure of the vertebral body, intervertebral disc and surrounding soft parts are present. They are either major, which are always structural, or, on the contrary, minor, or compensatory (structural deformities may not be present).

Scoliosis, or curvature of the spine, can be C-shaped, in which case it is referred to as large-arch scoliosis, but it can also be referred to as single-curve scoliosis. This form is rarer.

Another case is S-shaped (compensatory), also referred to as double-curve scoliosis. The curvatures are in the thoracic spine, at the transition of the thoracic to the cervical spine or in the shaft.

There is also scoliosis with multiple curves. In this form, there are multiple curves, up to three or four.

What are the causes of scoliosis?

Various causes are given for this spinal deformity. These classify it into different forms.

Table: forms of scoliosis by cause

As the table indicates, the cause of scoliosis may not be known. There are some risk factors that, especially during childhood, can provoke the onset of spinal deformities.

In scoliosis, there are some risk factors:

• genetic predisposition
• sex
• more common in girls during adolescence
  • the possible influence of hormones is assumed
• sexual maturity
• height
• incorrect posture
• poor postural habits
• muscle imbalance
• different length of the lower limbs
• sports activities, especially unilateral loading
  • tennis
  • golf
• injury
• playing a musical instrument
• Obesity

Girls are 5 to 10 times more likely to have scoliosis greater than 30 degrees. 
Children sit for too long a time, do not move enough.

Today's modern age brings many advantages, on the other hand, also disadvantages.

Children have adopted a sedentary lifestyle, they lack movement.

Sitting weakens the muscles of the back, abdomen and therefore the whole body core. This generally has a negative effect on the child's musculoskeletal system and organism.

Sufficient movement in children promotes muscle strength, balance, correct posture. Therefore, it is important to lead children to a healthy lifestyle, to sports activities, such as swimming, running, football or karate.

Physical activity has a positive effect on the healthy development of the child,

not only on the musculoskeletal system, but also on the nervous system and the whole organism.

In addition to exercise, a rational diet is important, which should prevent overweight and obesity. Too much body weight contributes to spinal problems and other secondary problems or diseases in adulthood.

Read the following articles:
Overweight and obesity in children and young people
Mediterranean diet

The presence of symptoms is influenced by the form of scoliosis, its severity and extent. In idiopathic scoliosis of the first degree, we may not notice any deformity of the spine. On the contrary, at II and higher degree it is already detected even by a layman.

Thus, the manifestations of scoliosis may or may not be visible at first sight. Therefore, regular childhood examinations are necessary to detect this problem early.

The situation changes in the case of secondary scoliosis. In this case, the symptoms depend on the underlying or associated disease and on the involvement of one or more organs. Thus, it largely depends on whether it is a congenital or acquired form.

With severe misalignment, the functions of the thoracic organs, and therefore the respiratory or cardiovascular system, may be impaired. 

Spinal pain may not be present at all. Therefore, the child does not warn that he has a problem. Alternatively, it is present only with mild intensity or occurs after physical exertion and with fatigue. Similarly, it occurs with prolonged sitting or standing.

And because of the absence of pain, it is necessary to pay attention to the child's posture, movement pattern, spine and overall posture.

We can recognize a difference in shoulder height when one shoulder is in a lower posture than the other. Because of this, one arm may appear to be longer than the other. The head is tilted.

When looking at the back, the shoulder blades are visible, with one more prominent than the other. Similarly, the trunk can be shortened, rotated on one side. 

A hump, or gibbus, is formed. 

Furthermore, there is an unevenness in the hips, in the pelvis - the hip bone is unilaterally higher. The body tilts to one side.

Summary of main features:

• head tilt
• one shoulder higher
• one arm seems longer
• one shoulder blade protruding
• tilt/inclination of the torso
• the hump, or gibbus, and its accentuation when bent forward
• deformity of ribs, the rib cage
• unequal hips - asymmetry in the cervical region
• resulting in shortening of one limb (elevation of the side of the pelvis, not shortening of the limb)
• tilt/inclination of the body
• in prone position accentuation of the spinal curvature

Scoliosis is most often detected in childhood between the ages of 10 and 18. It mostly affects fast-growing and slender girls. Fewer cases are diagnosed later in life.

For this reason, regular preventive examination of the spine by a paediatrician is necessary.

Important: 
Of course, parents also play an important role.
They should have an overview of the state of the child's musculoskeletal system.
It is necessary to notice:
posture, gait, movement habits,
from all sides:
from the front, from behind, from the side, and bending forward.

The spine can be affected by several forms of deformity and disease.

Spinal deformities by frequency:

1. adolescent idiopathic scoliosis
2. congenital scoliosis
3. congenital kyphosis
4. infantile idiopathic scoliosis
5. juvenile idiopathic scoliosis
6. kyphosis in adolescents and young adults
7. spondylolysis and spondylolisthesis
8. neuromuscular scoliosis
9. deformities in syndromes

Diagnosis requires history taking and clinical examinations. A familial occurrence in girls, among other things, is menarche, that is, the first menstrual bleeding.

The doctor examines the spine, its curvature, symmetry of the shoulders, hips, assesses the pre-curvature, the possible appearance of a hump and elevation of the shoulder blades, a functional test of the spine.

The main curve, compensatory curve, end vertebra, vertebral apex, orientation of the curve, its localization are evaluated.

A ruler, a spirit level (measuring the rib prominence - the hump, or gibbous) or a plumb line, a scoliometer are used. Screening methods, such as Adam's forward bend test, assessment of the degree of bone maturity, measurement of vertebral rotation, determination of bone age according to the Risser zone and others.

If necessary, a neurological examination will be added as needed. This also includes EMG, EEG. In some cases, cardiological examination (ultrasound) and examination of the vital capacity of the lungs, as well as endocrinological examination are necessary.

Among imaging methods, X-ray is preferred. Images are taken from different sides and in different positions. Angles are then assessed - the Cobb angle, and the severity of spinal curvature is measured.

This may be supplemented by CT or MRI, which can be used to assess the spinal canal and spinal cord or spinal nerves.

The course of scoliosis also depends on its form, the associated disease. For example, in neuromuscular scoliosis, progression, that is, the progression of spinal deformity, is assumed. 

As mentioned above, 80% of scoliosis cases develop without a known cause.

In adolescent girls, when the adolescent form is said to occur, there is an increased likelihood of spinal bulging.

Predpokladá sa multifaktoriálny vplyv, ako je príliš rýchly rast a účinok hormonálnych zmien.

Conversely, in the case of infantile scoliosis, which is reported to be more common in young boys, the deformity disappears with growth.

It is important to think about the risk factors that will promote the progression of spinal deformity and to eliminate them. For this reason, it is necessary to guide children from an early age to physical activities.

The child won't complain...

Of course, we need to think about the appropriate type of sport so as not to overload the child's organism unnecessarily. Children can mentally cope with the onslaught of sport and will not complain of fatigue.

Surely also to please the parents.

However, in the later period, excessive load can manifest itself in problems with the musculoskeletal system, joints.

Parents and the pediatrician take note of posture, movement patterns, and the spine as a whole, from each side. As scoliosis progresses, spinal pain may not occur.

The greatest progression of spinal misalignment is thought to occur during adolescence and growth. Scoliosis in adulthood will already have minimal progression.