Spine problems

At Children’s Hospital Boston, our team pioneers innovative spine treatments. And because our research informs our treatment, we’re known for our science-driven approach. We’re home to the world’s most extensive pediatric hospital research enterprise, and we partner with elite health care and biotech organizations around the globe. But as specialists in family-centered care, our physicians never forget that your child is precious, and not just a patient.

In dealing with your child’s spine problems, you may want to know the basics about how the spine works.

What is the spine?

Made up of many individual bones called vertebrae, the spine is joined together by muscles and ligaments. Flat, soft discs separate and cushion each vertebra from the next. Because the vertebrae are separate, the spine is flexible and can bend. Together the vertebrae, discs, muscles and ligaments make up the vertebral column or spine.

Different regions of the spine are named differently. The cervical spine refers to the neck, the thoracic spine to the chest, and the lumbar and sacral spines to the lower back.

What are normal and abnormal spine curves?

The normal spine is strong and mobile. While it varies in size and shape from person to person, the healthy spine has natural front-to-back curves that enable us to walk, balance, sit, stand and twist—all of which are complex interactive movements. When these natural front-to-back curves become too large, they can present a potential problem:

• When the backward curve in the thoracic spine is too great, the condition is called kyphosis (thoracic hyper-kyphosis, “round back”).
• When there’s not enough backward curve in the thoracic spine, the condition is called hypo-kyphosis.
• When the natural outward curve in the thoracic spine is actually reversed, curving into the chest, the condition is called thoracic lordosis.
• When the inward curve in the lower back is too great, the condition is called hyper-lordosis (“swayback”).

Although the spine has natural curves from front to back, it shouldn’t curve sideways very much. A side-to-side curve is called scoliosis, and may take the shape of an “S” (double curve) or a long “C” (single curve). The spine is also rotated or twisted, pulling the ribs along with it to form a multidimensional curve.

When do normal spine curves develop?

• in utero: During fetal development, the primary curves develop (thoracic and sacral).
• as babies: All infants start life with a C-shaped spine. Their secondary curves (cervical and lumbar) develop as they become:
  • able to lift the head (cervical)
  • able to sit up (cervical)
  • able to crawl, stand and walk (lumbar)
• as children: As children grow, their natural spinal curves continue to develop into a normal spine.

What causes abnormal spine curves?

There are several causes of abnormal spinal curves:

• In many cases, as in idiopathic scoliosis, there’s no definite cause for (or way to prevent) the spine’s failure to grow as straight as it should.
   
• Some babies are born with spinal formation problems that cause the spine to grow unevenly—for example, congenital scoliosis, congenital kyphosis, spina bifida or Klippel-Feil anomaly.
   
• Some children have nerve or muscle (neuromuscular) diseases, injuries or other illnesses that cause spinal deformities—for example, cerebral palsy, spina bifida or muscular dystrophy. In these conditions muscle abnormalities, combined with the child’s growth, result in deformity.

Other causes may include:

• bone dysplasias: many generalized abnormalities of bone formation are associated with scoliosis
• connective tissue disorders: conditions with abnormal tissues and ligaments, such as Marfan syndrome and Ehlers-Danlos syndrome
• differences in leg lengths: mild leg length differences may cause a slight curvature, but rarely cause a serious curvature
• spinal cord injury with paralysis
• infection
• tumors

What are some of the spine problems that Children’s treats in infants and children?

• scoliosis: a condition in which the spine, in addition to the normal front to back curvature, has an abnormal side-to-side “S-” or “C”-shaped curvature. The spine is also rotated or twisted, pulling the ribs along with it. The condition isn’t rare. It mainly affects girls—many of whom have mild forms of scoliosis, are never even aware of it, and never need treatment.
  • idiopathic scoliosis: the most common form of scoliosis. “Idiopathic” simply means that there's no definite cause. Nothing you or your child did caused it, and there’s nothing you could have done to prevent it. Fortunately, most cases are self-limiting and require no intervention. Scoliosis does tend to run in families, and girls are eight times more likely to have it than boys.
  • Idiopathic scoliosis has three main types, corresponding to the age at onset:

• adolescent idiopathic scoliosis: the most common form, mainly affecting girls, often not needing intervention
   
• juvenile idiopathic scoliosis: about 10 percent of cases, affecting children aged 3 to 9 years, usually progressive
   
• infantile (early-onset) idiopathic scoliosis: rare (up to 5 percent of cases), more often affecting boys from birth to age 3 years

• neuromuscular scoliosis: scoliosis that's associated with disorders of the nerve or muscular systems like cerebral palsy, spina bifida, myopathy, muscular dystrophy or spinal cord injury
   
• congenital scoliosis: The spine forms and develops between three and six weeks after conception. Congenital scoliosis results from abnormal in utero spinal development, such as a partial or missing formation or a lack of separation of the vertebrae.

• kyphosis (thoracic hyper-kyphosis, adolescent hyper-kyphosis, Scheuermann’s kyphosis): a spine affected by kyphosis shows evidence of a curvature of the back bones (vertebrae) in the upper back area, giving the child an abnormally rounded or “humpback” appearance. Kyphosis is a type of spinal deformity and should not be confused with poor posture.
   
• spondylolisthesis: a progression of spondylolysis in which there’s a forward displacement of one vertebra on the other. This condition can be low-grade and treated like spondylolysis (see next). Or it can be high-grade—an uncommon but severe slippage.
   
• spondylolysis: a disruption of the normal bony ring within a vertebra; occurs in the area between the facet joints (pars interartilularis). This condition, which can include tiny stress fractures, is not present at birth and affects about 5 percent of the population. It can be spontaneous or can be associated with adolescent sports like football, gymnastics, wrestling and skating.
   
• spina bifida (myelodysplasia): a condition in which there’s abnormal development of the back bones, spinal cord, surrounding nerves and the fluid-filled sac that surrounds the spinal cord. This neurological condition can cause a portion of the spinal cord and the surrounding structures to develop outside, instead of inside, the body. The defect can occur anywhere along the spine.

How do you diagnose spinal problems?

Doctors will use medical and family histories, physical exams and diagnostic tests to determine the nature and extent of your child’s spinal condition. Testing can include:

• x-rays
• magnetic resonance imaging (MRI)
• computerized tomography scan (CT or CAT scan)
• blood tests
• ultrasound (sonogram)
• bone scans
• bone density scans (dual-energy x-ray absorptiometry, DEXA, DXA)

For details see diagnostics for:

• scoliosis
• idiopathic scoliosis
• neuromuscular scoliosis
• congenital scoliosis
• kyphosis
• spina bifida

How do you treat spine problems?

Treatment for a child’s spinal problem depends on the nature and severity of the condition—from complex to routine. Whether your child’s particular spinal condition is congenital-, idiopathic- or neuromuscular-related, the Children’s Spinal Program provides comprehensive treatment—including evaluation, diagnosis, consultation and follow-up care.

Treatments can include:

• simple observation and monitoring: In many cases, your child’s spinal condition may require only close monitoring during skeletal growth. Your physician will determine your child’s treatment plan and follow-up based on her x-rays and physical exams.
   
• physical therapy: Some spinal problems are helped by physical therapy. Our physical therapists work closely with specialists in our Spinal Program to also provide exercise programs and additional therapies to address the pain and muscular imbalance that can be associated with spinal abnormalities.
   
• bracing: Bracing can be an important part of treating spinal problems. For example:
  • In neuromuscular scoliosis, bracing helps positioning and function.
  • In idiopathic scoliosis, bracing can help control or correct curves. A bracing program may help avoid surgery.
     
• casting: Casting is commonly used for early-onset (infantile) idiopathic scoliosis.
   
• surgery: If surgery becomes necessary, our Spinal Program’s orthopedic surgeons use the most advanced surgical techniques for correcting spinal problems, some of which include:
  • spinal fusion: the most common surgical procedure for treating spinal problems
    • Usually, a fusion and instrumentation are combined to correct and solidify the curve.
       
  • for younger, growing children:
    • dual posterior growing rods (for early-onset scoliosis): control spinal deformity while allowing spinal growth with periodic lengthenings
       
    • expansion thoracostomy/VEPTR™ (titanium rib) procedure to control chest and spine deformity while permitting growth of both chest and spine
       
    • vertebral stapling (a minimally-invasive surgical alternative to bracing for scoliosis in some circumstances)

For details see Treatment & care for:

• scoliosis
• idiopathic scoliosis
• neuromuscular scoliosis
• congenital scoliosis
• kyphosis
• spina bifida

Will my child be OK?

The Children’s Spinal Program and Orthopedic Center take great pride in our basic science and clinical research leaders, who are recognized throughout the world for their achievements in the field.

Our research into spinal problems means that we can provide your child with the most innovative care available. As a result, the majority of children treated for spinal problems at Children’s have corrections that enable them to walk, play and live full lives.

FAQ

Q: What is a spinal abnormality?

A: A spinal abnormality is a condition in which the spine develops abnormally. Some abnormalities are congenital, such as congenital scoliosis or congenital kyphosis. Some are the result of nerve or muscle (neuromuscular) diseases, injuries or illnesses—for example, cerebral palsy, spina bifida or muscular dystrophy. In some cases, there's no definite cause (idiopathic) or means of prevention for the spine’s failure to develop normally.
 

Q: If my child has a spinal problem, will she be OK?

A: At Children’s Spinal Program and Orthopedic Center, we take great pride in our basic science and clinical research leaders, who are recognized around the world for their achievements in the field.

Our research into spinal problems means that we can provide your child with the most innovative care available. As a result, the majority of children treated for spinal problems at Children’s have corrections that enable them to walk, play and live full lives.

Q: How does Children’s treat spinal problems?

A: Treatment for spinal problems depends on the nature and severity of the condition—from complex to routine. Children’s Spinal Program provides comprehensive treatment—including evaluation, diagnosis, consultation and follow-up care. Treatments can include:

• simple observation and monitoring
• physical therapy
• bracing
• casting
• surgery

Q: What are the symptoms of spinal problems?

A: For details see symptoms for:

• scoliosis
• idiopathic scoliosis
• neuromuscular scoliosis
• congenital scoliosis
• kyphosis
• spina bifida

Q: If my child has a spinal problem, what should I ask our Children’s doctor?

A: If your child is diagnosed with a spinal problem, you may feel overwhelmed with information. It can be easy to lose track of the questions that occur to you. Lots of parents find it helpful to jot down questions as they arise—that way, when you talk to your child’s doctors, you can be sure that all of your concerns are addressed.

Some of the questions you may want to ask include:

• What is happening to my child, and why?
• Are other tests needed to diagnose my child?
• What actions might you take after you reach a diagnosis?
• What will happen with growth over time?
• Will there be restrictions on my child’s activities?
• Will there be long-term effects?
• What can we do at home?

Q: How is a spinal problem usually detected?

A: Most spinal problems are detected by a child’s parents or pediatrician, or by school screenings.

Q: How is a spinal problem usually diagnosed?

A: Once a problem is detected, doctors will use a medical and family history, physical exams and diagnostic tests to determine the nature and extent of your child’s spinal condition and options for treatment. Testing can include:

• x-rays
• magnetic resonance imaging (MRI)
• computerized tomography scan (CT or CAT scan)
• blood tests
• ultrasound (sonogram)
• bone scans
• bone density scans (dual-energy x-ray absorptiometry, DEXA, DXA)
• pulmonary function tests

For details see Diagnostics for:

• scoliosis
• idiopathic scoliosis
• neuromuscular scoliosis
• congenital scoliosis
• kyphosis
• spina bifida
   

Q: What’s the long-term outlook for children with spinal problems?

A: The long-term outlook depends greatly on the nature and severity of the spinal condition, as well as the nature and severity of any underlying (neuromuscular or other) conditions. Most spinal problems are compatible over time with full normal function, normal appearance and good general health.

Q: What causes abnormal spinal curves?

A: There are several causes of abnormal spinal curves:

• In many cases, as in idiopathic scoliosis, there’s no definite cause for (or way to prevent) the spine’s failure to grow as straight as it should.

• Some babies are born with spinal formation problems that cause the spine to grow unevenly—for example, congenital scoliosis, congenital kyphosis, spina bifida or Klippel-Feil anomaly.

• Some children have nerve or muscle (neuromuscular) diseases, injuries or other illnesses that cause spinal deformities—for example, cerebral palsy, spina bifida or muscular dystrophy. In these conditions, muscle abnormalities combined with the child’s growth result in deformity.

Other causes may include:

• bone dysplasias: many generalized abnormalities of bone formation are associated with scoliosis

• connective tissue disorders: conditions with abnormal tissues and ligaments, such as Marfan syndrome and Ehlers-Danlos syndrome

• differences in leg lengths: mild leg length differences may cause a slight curvature but rarely cause a serious curvature

• spinal cord injury with paralysis

• infection

• tumors

Q: What is Children’s experience treating spinal problems?

A: At Children’s Spinal Program, we’re known for our clinical innovations, research and leadership. We offer the most advanced diagnostics and treatments—several of which were pioneered and developed by Children’s researchers and clinicians.

Each year, our Spinal Program caregivers provide comprehensive treatment—including evaluation, diagnosis, consultation and follow-up care—in more than 6,000 outpatient visits. Our orthopedic surgeons perform more than 300 spine procedures per year on babies, children and teenagers.

Q: Do all spinal defects hurt?

A: Actually, most spinal defects aren’t painful in children. But there’s still the potential for significant risk of pain developing in adulthood.

Q: Will spinal defects like scoliosis affect my child’s lungs and/or other organs?

A: The lungs may be affected by severe deformities, particularly early-onset scoliosis. But even a severe spinal deformity doesn’t usually affect the function of other organs.

Q: Will my other children have spinal defects?

A: The possibility of a genetic component of spinal defects is still being studied. What’s known is that idiopathic scoliosis does tend to run in families. If you have a child with a spinal defect, it’s advisable to consult a geneticist, who can take a family history and discuss your particular situation.

Causes

Spinal problems can be:

• congenital (present at birth)
• neuromuscular (associated with a neuromuscular condition such as cerebral palsy or spina bifida)
• idiopathic (definite cause unknown)
• the result of bone dysplasias (genetically abnormal bone growth)
• related to metabolic conditions (internal body chemistry)
• related to connective tissue disorders
• related to differences in leg lengths
• related to spinal cord injury with paralysis
• related to infection
• related to tumors

Symptoms

For details see symptoms for:

• scoliosis
• idiopathic scoliosis
• neuromuscular scoliosis
• congenital scoliosis
• kyphosis
• spina bifida

When to seek medical advice

Several spinal problems can be seen at or shortly after birth—or sometimes even before birth using a prenatal ultrasound. Others, such as idiopathic scoliosis, will usually develop as the child grows, most often during the child’s adolescent growth spurt. Congenital scoliosis is present at birth, but may not be apparent until later. Consult your pediatrician if your family has a history of spinal problems, or if your child is:

• developing side-to-side curvatures (scoliosis)
• developing asymmetry of her shoulders or waist
• developing a round upper back (kyphosis)
• experiencing unusual back pain

Questions to ask your doctor

If your child is diagnosed with a spinal problem, you may feel overwhelmed with information. It can be easy to lose track of the questions that occur to you. Lots of parents find it helpful to jot down questions as they arise—that way, when you talk to your child’s doctors, you can be sure that all of your concerns are addressed.

Some of the questions you may want to ask include:

• What is happening to my child, and why?
• Are other tests needed to diagnose my child?
• What actions might you take after you reach a diagnosis?
• What will happen with growth over time?
• Will there be restrictions on my child’s activities?
• Will there be long-term effects?
• What can we do at home?

Who’s at risk

Risk factors for developing spinal problems vary from condition to condition. Common risk factors and predispositions for some spinal conditions can include:

• a family history of scoliosis
• other birth defects
• neuromuscular conditions
• metabolic conditions that affect bones
• syndromes that affect neurologic function
• other genetic syndromes

Complications

For details see complications for:

• scoliosis
• idiopathic scoliosis
• neuromuscular scoliosis
• congenital scoliosis
• kyphosis

Long-term outlook

The long-term outlook depends greatly on the nature and severity of the spinal condition, as well as the nature and severity of any underlying (neuromuscular or other) conditions. Most spinal problems are compatible over time with full normal function, normal appearance and good general health.

For details see the long-term outlook for:

• scoliosis
• idiopathic scoliosis
• neuromuscular scoliosis
• congenital scoliosis
• kyphosis
• spina bifida

For teens

If you’re a teen with a spinal problem, you have a lot to cope with. Besides the typical issues any teenager faces—from social acceptance to body changes and more—you’ll also have to deal with medical appointments and procedures, some delay of your natural wish for independence, feeling different and assuming a big personal responsibility for maintaining your own good health.

If you feel overwhelmed, depressed or anxious through this important time in your transition to adulthood, speak to your doctor or counselor to get help.

For adults

If you were treated for a spine problem as a child, you’re probably being followed by your orthopedist, since spine problems can:

• recur in adulthood
• cause serious or minor chronic complications, such as back pain
• be complicated by new spine issues such as osteoporosis, disc degeneration or compression fractures

Adults who’ve been treated at Children’s during childhood are often followed well into adulthood for their pediatric problem by their Children’s orthopedist. We also see young adults with spine problems that originated in childhood.

Prevention

Nearly all spine problems have no definite cause and/or no known method of prevention. Some are genetic in origin. Proper nutrition, prenatal care and vitamin consumption (especially folic acid) are always important if you’re pregnant, or if pregnancy is a possibility. If your family has a history of birth defects, it's advisable to consult a geneticist.

Spine problems glossary

• brace, bracing (spinal orthosis): If your growing child’s curve shows significant worsening or is already greater than 30 degrees, your physician may recommend a bracing program, in which a scoliosis brace is designed specifically for your child’s particular curve. The brace holds your child’s spine in a straighter position while she is growing in order to partly correct the curve or prevent it from increasing.
  
  There are many types of brace, including the Boston Brace developed at Children’s. A bracing program may help avoid surgery.
   
• The Center for Families at Children’s: dedicated to helping families find the information, services and resources they need to understand their child’s medical condition and take part in their care
   
• congenital scoliosis: The spine forms and develops between three and six weeks after conception. Congenital scoliosis results from abnormal in utero spinal development, such as a partial or missing formation or a lack of separation of the vertebrae.
   
• (dual posterior) growing rods: devices affixed to the spine (for early-onset scoliosis); these control spinal deformity while allowing spinal growth with periodic lengthenings.
   
• idiopathic scoliosis: the most common form of scoliosis. “Idiopathic” simply means that there is no definite cause. Nothing you or your child did caused it, and there’s nothing you could have done to prevent it. Fortunately, most cases are self-limiting and require no intervention. Idiopathic scoliosis tends to run in families, with girls eight times more likely to have it than boys.
   
• instrumentation: the metal rods, hooks, screws and wires implanted during spinal fusion surgery to correct the spinal curve and secure the spine in position while the fusion heals and becomes solid
   
• (hyper-) kyphosis: A spine affected by kyphosis shows evidence of excessive backward curvature of the back bones (vertebrae) in the upper back area, giving the child an abnormally rounded or “humpback” appearance. Abnormal (hyper-) kyphosis is a type of spinal deformity and should not be confused with poor posture.
   
• neuromuscular: affecting, or characteristic of, both neural (nerve) and muscular tissue
   
• neuromuscular scoliosis: scoliosis that is associated with disorders of the nerve or muscular systems like cerebral palsy, spina bifida, muscular dystrophy or spinal cord injury
   
• orthopedics: the medical specialty concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments
   
• orthopedic surgeon, orthopedist: a physician specializing in surgical and non-surgical treatment of the spine, skeletal system and associated muscles, joins and ligaments
   
• orthotics: the science of designing and fitting of devices such as braces to treat orthopedic conditions
   
• physical therapy: a rehabilitative health specialty that uses therapeutic exercises and equipment to help patients improve or regain muscle strength, mobility and other physical capabilities
   
• progression, curve progression: worsening of a scoliosis curve
   
• scoliosis: a spinal condition in which the spine, in addition to the normal front to back curvature, has an abnormal side-to-side “S-” or “C”-shaped curvature. The spine is also rotated or twisted, pulling the ribs along with it. Scoliosis occurs in three main types: idiopathic (no definite cause); congenital (present at birth); and neuromuscular (associated with neuromuscular diseases).
   
• spina bifida (myelodysplasia): a condition in which there's abnormal development of the back bones, spinal cord, surrounding nerves and the fluid-filled sac that surrounds the spinal cord. This neurological condition can cause a portion of the spinal cord and the surrounding structures to develop abnormally. The defect can occur anywhere along the spine.
   
• spinal cord: a nerve bundle within the vertebral column that extends down from the brain stem; it conducts signals in both directions between the brain and extremities, and allows for bodily motion and sensation
   
• spinal abnormality: a condition in which the spine develops abnormally. Some abnormalities are congenital, such as congenital scoliosis or congenital kyphosis. Some are the result of nerve or muscle (neuromuscular) diseases, injuries or illnesses—for example, cerebral palsy, spina bifida or muscular dystrophy. In some cases, there is no definite cause (idiopathic) or means of prevention for the spine’s failure to develop normally.
   
• spinal fusion: usually a solid fusion (solidification) of the curved part of the spine, achieved by operating on the spine, adding bone chips and allowing the vertebral bones and bone chips to slowly heal together to form a solid mass of bone called a fusion
   
• spine (spinal column, vertebral column): the series of vertebrae that move and form the axis of the skeleton and protecting the spinal cord
   
• spine curves, normal and abnormal: front-to-back and sideways curves of the spine
  • All spines have normal front-to-back curves. Abnormal front-to-back curves can indicate “round back” (hyper-kyphosis) or “swayback” (hyper-lordosis).
  • Normal spines do not have much sideways curvature. An abnormal sideways “S” or “C” curve can indicate scoliosis.
     
• spondylolisthesis: a progression of spondylolysis in which there’s a forward displacement of one vertebra on the other. This condition can be low-grade and treated like spondylolysis (see next). Or it can be high-grade—an uncommon but severe slippage.
   
• spondylolysis: a disruption of the normal bony ring within a vertebra; occurs in the area between the facet joints (pars interartilularis). This condition, which can include tiny stress fractures, is not present at birth and affects about 5 percent of the population. It can be spontaneous or can be associated with adolescent sports like football, gymnastics, wrestling and skating.
   
• VEPTR™ (titanium rib) procedure: operation that expands the chest and allows continued growth of the chest and spine. A curved metal rod fits the back of the chest and spine, helping the spine to become straighter and allowing the lungs to grow and fill with enough air to breathe. The device can be made longer as your child grows. The procedure is used for some early-onset scoliosis, with the device attaching to the ribs, spine or both.
   
• vertebra, vertebrae: the individual spine bones that form the spinal column
   
• vertebral stapling: a newer surgical technique that may prevent the curve progression in children and adolescents with moderate scoliosis. A minimally invasive procedure, stapling may be an alternative to bracing for some children at risk for progression of their scoliosis and the prospect of spinal fusion in their future.