Causes, Symptoms, Pathogenesis, Treatment, Ayurveda understanding

Article by Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S

Scoliosis is a condition marked by a ‘sideways curve’ in the spine (backbone).

The spine will have its natural curves so as to enable us to move our body and back flexibly while doing many day-to-day activities but it is ‘not naturally curved sideways’. So, a curve in the spine which is sideways is abnormal and is termed as scoliosis. This condition often shows up in childhood or teenage years.

Most scoliosis cases are mild in nature. On the other hand, some curves become worse as the child grows. Severe scoliosis can cause disability. Larger spinal curves can reduce the space within the chest, causing difficulty in lung function

X-rays are needed to monitor mild scoliosis in children closely so as to observe if the curve is getting worse.

Many cases of scoliosis might not need any treatment. To stop the curve from worsening, children might need to wear braces. More serious curves would need surgical intervention.

When do we consider a sideways curve in the spine as scoliosis?

The angle of the curve of the spine may be small or large. Sometimes it is somewhere in between these measurements. But any angle measuring ‘more than 10 degrees’ on an X-ray is considered as scoliosis. Letters ‘C’ and ‘S’ are used by the doctors to describe the curve.

Causes for Scoliosis

Doctors many times do not know the causes for most common types of scoliosis. Hereditary factors are said to be involved since this condition runs in families. Less common types of the disease may be caused by one of the below-mentioned factors –

–         some kinds of neuromuscular conditions like cerebral palsy, muscular dystrophy etc.

–         birth defects which affect the development of vertebrae

–         spinal cord irregularities

–         injuries to the spine

–         infections of the spine

–         previous chest wall surgery in babies

The curves of scoliosis are categorized into two types –

Non structural scoliosis – In this condition the spine looks curved but the functions of the spine are normal. This happens in people who have one leg longer than the other, muscle spasms and inflammations. The scoliosis goes away when these related problems are treated.

Structural scoliosis – Here the curve of the spine is rigid and it cannot be reversed.

The causes include – cerebral palsy, muscular dystrophy, birth defects, genetic conditions (Down syndrome, Marfan syndrome), tumors, infections etc.

Idiopathic scoliosis – The risk factors in this type of scoliosis are genetics and family history. If a parent or one of their children has scoliosis there would be a possibility that the other child / children too might have this condition. Therefore, the other kids need to be medically checked regularly. When all other causes are excluded, Idiopathic scoliosis is diagnosed. It comprises about 80% of all cases of scoliosis. The most common type of scoliosis is adolescent idiopathic scoliosis. It is usually diagnosed during puberty.

Congenital scoliosis – These results from embryonic malformation of one or more vertebrae.

Neuromuscular scoliosis is secondary to neurological or muscular diseases.

Risk Factors for scoliosis (most common type of scoliosis) –

–         adolescence (age wherein signs and symptoms first appear)

–         being girl – girls have higher risk of the curve worsening and require treatment

–         family history – scoliosis runs in families, on the other hand many children having scoliosis do not have a family history of scoliosis

When does scoliosis show up?

Most often, scoliosis shows up when the children are between 10 and 15 years of age. It equally affects both sexes, but in girls, the curves are 10 times more likely to worsen and might also need treatment.

The scoliosis diagnosed during teen years of an individual can continue into their adulthood. If the spine curve is more there is more possibility that the curve gets worse over time. People who had scoliosis in the past should get their back checked regularly by the doctor.

Symptoms of Scoliosis

Below mentioned are the symptoms of scoliosis –

1. Visible symptoms

–         Leaning while standing
–         Curve in the back which is visible / prominence on one side of the back when bending forward
–         Uneven shoulders, waist or hips
–         One shoulder blade appears more prominent (visibly bigger) than the other
–         Ribs stick out farther on one side in comparison to the other
–         Head is not centered directly above the pelvis
–         There are changes in the appearance or texture of the skin overlying the spine (dimples, color abnormalities, hairy patches)

2. Other symptoms

–         Low back pain
–         Stiffness in the back
–         Pain and numbness in the legs
–         Fatigue (caused due to strain in the muscles)
–         Breathing difficulty (since the upper spine is curved)

In addition to curving side to side there is rotation or twisting of the spine in most cases of scoliosis. This will cause the muscles or ribs on one side to stick out farther than those of the other side of the body.

In one study it was found that, at the time of initial diagnosis, about 23% of patients with idiopathic scoliosis presented with back pain. About 10% of these patients were found to have an underlying condition like spinal tumor, herniated disc, spondylolisthesis or syringomyelia. A thorough evaluation of other causes of pain is recommended if idiopathic scoliosis patients have more than mild back discomfort.

When is the right time to see the doctor?

See the doctor immediately if –

–         you notice scoliosis signs in your child,
–         mild curves can develop without our knowledge, appear gradually and also without pain – so keep a check

Complications of Scoliosis

In most people scoliosis would manifest in a mild form. Sometimes it can cause complications which include –

–         Breathing problems – difficulty in breathing may result due to the rib cage pressing against the lungs in severe scoliosis.
–         Back problems – if people have had scoliosis in childhood, it is more likely that they develop chronic back pain as adults. This happens mainly in cases or large and untreated curves.
–         Appearance – noticeable changes like uneven hips and shoulders, prominent ribs, shift of waist and trunk to one side occurs as scoliosis worsens.
–         Stress – people with scoliosis can get stressed because they can get self-conscious about how they look.

Diagnosis of Scoliosis

Detailed medical history, physical examination and interrogation about recent growth will help the doctors to diagnose scoliosis. Neurological exams to elicit muscle weakness, numbness and reflexes may be done.

Inspection – The doctor can diagnose that you have scoliosis just by looking at your spine. You may be asked to bend at the waist to elicit the curve in your spine.

X-ray – Plain X-rays – helps in confirming the diagnosis of scoliosis. If there is a curve in your spine an X-ray may be recommended to confirm if it is scoliosis. They may also reveal the seriousness of the spinal curvature.

MRI – is preferred if there is a suspicion of an underlying condition that might be causing scoliosis, ex – spinal cord irregularity or to rule out things like a tumor which might be causing the curve in the spine.

Ultrasound – is an option but it can be less precise in determining the seriousness of the curve of scoliosis.

Adam’s Forward Bend Test – is a standard exam used by pediatricians sometimes. Here, the patient leans forward with his or her feet together bending 90 degrees at the waist. Any asymmetry of the trunk or abnormal spinal curve can be detected easily from this angle. This initial screening test cannot determine the exact type of severity of the deformity accurately.

Types of Scoliosis

Idiopathic Scoliosis – This kind of scoliosis exists without a known cause. We also need to know that the doctors do not find the exact reason for a curved spine in as many as 80% of cases.

Congenital Scoliosis – This results from embryonic malformation of one or more vertebrae. It may occur in any part of the spine. This condition begins as ‘the back’ of a baby develops before birth. The curvature and other deformities are caused by vertebral abnormalities. This is because one area of the spine lengthens at a slower rate than the rest. The vertebrae may fail to divide properly or the vertebrae may itself be incomplete. This condition is often identified at birth or may not be diagnosed until the child grows into teen age.

Note – Congenital scoliosis is usually diagnosed at a younger age in comparison to idiopathic scoliosis since the abnormalities are present at birth.

Neuromuscular Scoliosis – Neuromuscular scoliosis is secondary to neurological or muscular diseases. This condition usually progresses more rapidly than idiopathic scoliosis and often needs surgical treatment. Conditions / disorders like cerebral palsy, spinal cord injury, muscular dystrophy, spinal muscular atrophy or spina bifida may cause neuromuscular scoliosis. Since these conditions might damage the muscles, they will not be able to support the spine correctly. This can cause your back to curve.

Degenerative Scoliosis – This condition usually develops in the lower back and majorly affects the adults. This is because the disks and joints of the spine in the lower back region begin to wear out with ageing.

Classification of scoliosis

In children, scoliosis is classified by age –

0 – 3 years of age – infantile scoliosis
3 – 10 years of age – juvenile scoliosis
11 years or older or from onset of puberty until skeletal maturity – adolescent scoliosis

There is a known increased incidence of other congenital abnormalities in children with congenital scoliosis. These are commonly associated with –

–         Spinal cord (20%)
–         Genitor-urinary system (20-33%)
–         Heart (10-15%)

When congenital scoliosis is diagnosed it is important to evaluate these systems.

In adults

Most adults with scoliosis are divided into the below mentioned categories –

a.   Adult scoliosis patients who were treated surgically as adolescents
b.   Adult scoliosis patients who have not received treatment during their young age
c.    Adult scoliosis patients with degenerative scoliosis

Progression of scoliosis in adults

A 20 year study showed that –

–         About 40% of adult scoliosis patients experienced progression
–         10% among these showed very significant progression
–         The other 30% experienced a very mild progression

Degenerative scoliosis – This occurs mostly in the lumbar spine commonly affecting people of 65 years or older. It may be accompanied by spinal stenosis. Back pain begins gradually and is linked with activity. In this condition the curve is relatively minor. Surgery is advised only when conservative methods fail to alleviate the associated pain.

Prevention of Scoliosis

There are no known ways of preventing scoliosis. So, childhood sports injuries and weight of the textbooks the child carries during schooling do not cause scoliosis. Coming to the postures, the way in which a person sits or stands does not affect their chances for scoliosis. On the other hand, a curved spine may cause a visible lean (lean which is noticeable). So the parents should be concerned if their child is not able to stand upright. They should meet a doctor or spine specialist or pediatrician for an opinion.

Scoliosis Treatment

Treatment of scoliosis depends on the size of the curve. Therefore the treatments vary. Treatment is not needed at all in children having mild curves / mild scoliosis. They may need regular checkups to monitor if the curve worsens as the children grow up. In moderate or large curves, bracing or surgery may be needed.

In cases (children) requiring treatment for scoliosis, the doctor may suggest –

Braces – Wearing braces, usually made up of plastic around the torso might stop the curve of the spine in scoliosis from getting worse.

Braces are effective in children who have moderate scoliosis and whose bones are still growing. Braces are not a cure for scoliosis. They also will not reverse the curve. But they will usually prevent the curve from getting worse. Braces are more effective when they are worn for more hours in a day, between 13-16 hours a day. Wearing braces, children can usually participate in most activities with few restrictions. When there are no further changes in height they are discontinued.

Surgery – Surgery – Surgery may be suggested to straighten the curve and prevent it from getting worse in case of severe scoliosis.

Spinal fusion surgery – This surgery wherein pieces of bone or a material similar to bone are put in between the vertebrae until they fuse can lessen the spine curve and will also keep the curve from getting worse.

Spine and rib-based growing operation – This operation is done in ‘scoliosis’ children who are growing in order to correct more serious spine curves. Here, rods are attached to your spine and hardware with ribs. The length of the rods is adjusted as the child grows older. The rods are lengthened once every 3-6 months. This method is also preferred in case of rapidly progressing scoliosis (of the young people).

Decompressive Laminectomy – The roof of the vertebrae (laminae) are removed to create more space for the nerves.

Minimally Invasive Surgery (MIS) – Making small incisions through MIS, fusion can sometimes be performed.

Vertebral body tethering – In this, screws are placed along the outside edge of the spinal curve after making small incisions. A strong flexible cord is threaded through the screws. The spine tightens when the cord is tightened. The spine may straighten even more as the child grows.

Bleeding, infection or nerve damage are some of the complications of spinal surgery.

Alternative medicine

Studies show that chiropractic manipulation, soft braces, dietary supplements and electric stimulation of muscles do not help in correcting the curve of scoliosis.

Coping and Support

Anger, fear and insecurity are some of the problems that the teens experience when scoliosis is diagnosed. The child (or teen) needs to accept scoliosis and also bracing or surgery at some point. For this, a strong and supportive peer group can have a significant impact on their life. The child should be encouraged to talk to his or her friends and ask for support.

One shall consider joining a support group for parents and kids with scoliosis.

Other types of Spine curvature disorders

Lordosis (swayback) – In this condition the spine curves significantly inward at the lower back.

Kyphosis – In this condition the person would have abnormally rounded upper back i.e. more than 50 degrees of curvature.

Scoliosis – In this condition, the person will have a sideways curve to their spine which is often S or C shaped.

Incidence and Prevalence

Scoliosis affects 2-3 percent of the population.

It can develop in infancy or early childhood. Primary age of onset is 10-15 years of age and scoliosis occurs equally in both genders. Females are eight times more likely to make a progress to a curve magnitude that often requires treatment.

It is estimated that about 6 lakhs patients of scoliosis visit doctors every year. About 30,000 children are fitted with a brace. About 38,000 patients undergo spinal fusion surgery.

Scoliosis Research & Care

Many research works are constantly in progress and many have been done with an objective of understanding different perspectives of the disease, genetic link, possibilities in providing better interventions and finding new modules of treatment protocol.

In this perspective the works of groups like “Scoliosis Research Society (SRS)” and “Scoliosis Research and Education Foundation (SREF)” is highly appreciable.

“Mayo Clinic Children’s Center” is providing a comprehensive spine deformity treatment program with state-of-the-art spinal care for children from birth to adulthood. This clinical care is supported by an extensive research program aimed at improving treatment and quality of life for children with scoliosis.

Scoliosis – Ayurveda Understanding

There is no one condition explained in Ayurveda which can be exactly correlated with scoliosis. ‘Kubja’ or ‘Kubjatva’ – one among the eighty Vata disorders fits into the closest comparison with scoliosis. Kubjatva also defines a condition known as kyphosis and a condition wherein these two coexist i.e. kypho-scoliosis.

To understand scoliosis in Ayurveda language, the disease needs to be studied with an Ayurveda lens taking many factors into consideration. Only after understanding scoliosis properly its prognosis and treatment protocol can be decided.

Related Reading – “Scoliosis – Ayurveda Understanding”