Keeping an eye on the curve
Regular scoliosis exams are important
Shopping for bathing suits, Erin Williams saw that her 6-year-old
daughter Megan's back and shoulders were visibly uneven. A trip
to the pediatrician and a standard Adam's forward bend test showed
that Megan had scoliosis. Instead of resting flat, her back had
a small hump on one side. X-rays showed a total of three spinal
curves, one at 40 degrees and two in the high 30s. Because of
the multiple curves and their degree of severity, Megan was referred
to Children's Hospital Boston.
Healthy spines naturally curve toward the front and back, but
scoliosis is an unnatural side-to-side curve of the spineóeither
in a C or S shapeóthat measures at least 10 degrees on x-ray.
Scoliosis, which can be classified as structural or nonstructural,
affects 2 percent of women and 0.5 percent of men. Structural
scoliosis appears in an abnormal spine with a fixed lateral curvature
and can have a range of causes, including disease, congenital
and post-traumatic. Nonstructural scoliosis, also called functional
scoliosis, occurs in a normal spine and is caused by a secondary
condition such as an inflammation, spasm or variation in leg length.
It often goes away once the secondary condition is treated. Additional
forms of scoliosis include neuromuscular, associated with muscular
dystrophies or cerebral palsy; and syndromic scoliosis, associated
with neurofibromatosis, Marfan's disease and other connective
tissue disorders.
The large majority of scoliosis cases (over 80 percent), however,
are idiopathic and according to the National Institute of Arthritis
and Musculoskeletal and Skin Diseases, three to five out of every
1,000 children develop spinal curves that are considered large
enough to require treatment. Idiopathic scoliosis can run in families
and usually occurs in children after age 10. Girls are much more
likely to have scoliosis and to require surgery to correct it.
Other forms of idiopathic scoliosis can occur in children younger
than 10 years of age, but are very rare.
Standard school screenings for scoliosis occur in kindergarten,
fourth, seventh and 10th grades. Between the ages of 10 and 14,
regular screening is especially important, as children often experience
an accelerated growth rate. "Idiopathic scoliosis usually pops
up around early adolescence," says
Daniel Hedequist, MD, assistant in Orthopaedic Surgery
at Children's. "As they develop, their spines are growing rapidly,
and if they have a curve, it can also grow rapidly."
The Adam's forward bend test that Megan underwent is the standard
method for identifying scoliosis. "During the test, we look for
specific asymmetries of the body when it is in certain positions,"
says Dr. Hedequist. "Are the shoulders level? Is one shoulder
higher than the other? Is there symmetry of scapula in the back?
Is there symmetry of the waist? Does one side look straight where
the other side has more curves? Do the levels of the pelvis look
equal?"
"We also look for signs of problems with the spinal cord in the
middle of the back," he adds. "Do they have a hairy patch, do
they have skin dimpling or a discoloration over the spinal column
itself, all of which might mean something is wrong inside the
spinal cord?"
It is important for pediatricians and general practitioners to
check for scoliosis at routine physical check-ups, as only about
half the states in the United States require public schools to
test for the disorder. In New England, Connecticut, Maine, Massachusetts,
and Rhode Island require school testing, but New Hampshire and
Vermont do not.
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When an Adam's forward bend test reveals signs of scoliosis,
patients should be referred to an orthopaedic specialist for diagnosis
and possible treatment. X-rays are usually required and, to minimize
a child's exposure to radiation, it is best that only the orthopaedic
specialist orders x-rays, based on knowledge of what will provide
the most appropriate and valuable information for treating and
diagnosing spinal deformities. "A lot of patients referred to
Children's don't end up having scoliosis, but are appropriate
referrals as they have some signs of scoliosis," says Dr. Hedequist.
"Among children with straight spines, 30 to 40 percent will have
some signs of scoliosis that merit closer examination through
a referral, whether it is asymmetry of the shoulder blades, inequality
of the shoulders or inequality of the waist," he adds.
Once a diagnosis of scoliosis is confirmed, the next step is
treating it. And fortunately for Megan, scoliosis treatment has
come a long way. Like most children with curves between 30 and
50 degrees, she was fitted with a Boston back brace. Unlike the
old-style Milwaukee braces, with metal rods connecting the shoulders
to a neck ring, the Boston back brace is made of lightweight plastic
and is barely visible under clothes. Many patients, who otherwise
would have spent months in the hospital after surgery, can now
benefit from wearing a close-fitting brace like the Boston back
brace or the Wilmington brace, both of which are custom made to
fit a child or teen. "The goal of the brace is to stop the curve
from progressing," says Dr. Hedequist. "If a curve can be treated
with a brace instead of surgery, that's the best option."
It's important for kids who wear braces because of scoliosis
to be active and fit. "Regular activities help children maintain
their self-confidence, increase the strength and flexibility in
their back and of course, exercise is an important part of staying
healthy," says Dr. Hedequist.
Unfortunately, in Megan's case, her curves continued to progress.
Just two years after being fitted for the brace, she required
corrective surgery. "Once a curve is greater than 50 degrees,
a corrective procedure can be done to straighten the spine by
permanently implanting metal rods parallel to the spinal column,"
says Dr. Hedequist. Megan spent just six days in the hospital,
went back to school in three and a half weeks and began regular
activities in less than three months. Today Megan is doing well,
playing softball, lacrosse and riding her bike. Children's Hospital
Boston is one of a select group of hospitals involved in a prospective
national study to determine the surgical outcomes of patients
with idiopathic scoliosis.
