UNM COC:  Your Healthcare Primer for Long Term Care

 
Scoliosis

Javier Aceves MD

Definition

Scoliosis refers to the abnormal deviation of the spine. Deviations can occur in different directions. Sometimes it may be due to exaggerations of normal curvatures.

Introduction

The spine serves as the main trunk support. It is a collection of 28-29 small bones (vertebral bodies) located on our back that help us support the body erect and also allow the trunk to rotate and bend in different directions. The spine has some normal or physiologic curvatures that help us assume certain positions when we stand sit or move around; it also distributes the body’s weight in accordance to our height and body shape to help us keep our balance. The spine is divided into four sections: the neck or cervical spine; the upper back or thoracic spine; the lower back or lumbar area and the tailbone or sacrum. The upper and lower backs are the one most commonly deviated.

When the spine curves in a way it is not supposed to then there is scoliosis. Sometimes this can happen because the vertebral bodies did not develop normally (congenital reasons) or because the muscles that attach to them are pulling (tight) in an unbalanced way. There are multiple conditions (syndromes) that babies can be born with that result in having scoliosis; an example is spina bifida. It is important to keep in mind that the brain helps to control muscle strength, action and tone. Abnormal muscle tone is frequently due to brain injuries as it happens in cerebral palsy.

Other times one leg may be shorter from birth or because the hipbone came out of its socket resulting in a functional shortening of the leg. This happens when the hips become dislocated. When the spine compensates for this shorter leg in an attempt to keep the trunk straight it creates an abnormal curvature. Most of the times the spine deviates to the sides (it bends) but it also can rotate (twist).

Common Symptoms: The indication that some one has scoliosis relates mostly to the changes in orientation of the spine/trunk. In other words the spine does not look straight down the midline. It becomes "crooked and/or twisted". One of the shoulders may be lower when standing or sitting up. Sometimes you can tell from the way the person is sitting or how the arms swing when they walk. At times, the first indication is back pain. Pain can be localized to any portion of the spine.

Complications: The range of complications can be wide. Complications are related to the section of the spine that is crooked, the degree to which it is deviated and how long the scoliosis has been in place. Some complications are related to the original cause of the spinal deviation.

Pain: Usually as a result of unbalanced muscle use and abnormal position or posture. Sometimes soft tissue like muscles can be pinched or stretched or bony parts that are normally apart may be touching against each other causing some pain.

Posture problems: it may be difficult to keep the head looking forward or sit straight depending on the section of the spine that is involved. When one person is unable to face another during a conversation it interferes with effective communication. If the deviation is significant then it may even be difficult to fit in a chair, which also interferes with being able to sit by a table for meals or ride in a car with appropriate seat belt holds.

Eating & swallowing: when the twisting and exaggerated curvatures are significant, the person with scoliosis may have a difficult time placing food in the mouth and then swallow with an increased risk for aspiration and or choking.

Breathing/pulmonary: sometimes the deviation of the spine is such that it interferes with pulmonary ventilation because part of a lung may be compressed and not able to function properly.

Diagnosis

Diagnosis can be made during physical exam and with spine x-rays. During a physical exam scoliosis can be determined by having the individual bend forward without flexing their knees and observing the spine for abnormal lateral deviations and unevenness of the shoulder blades. Other indirect ways include observation of how the shoulders or hips line up and general body posture. Individuals with developmental disabilities frequently have physical limitations where some of these maneuvers are not possible or reliable and therefore x-rays are more frequently ordered.

Since scoliosis is a condition that you can be born with or develop later on in life screening for scoliosis during annual physical exams is important. Going through growth spurts may exacerbate already abnormal curvatures. It is important to monitor with x-rays progression of scoliosis through puberty.

Prevention and Treatment

Whenever possible it should be prevented! When there is known muscle unbalance likely to result in scoliosis, physical therapy can be beneficial. Other times medication can be useful to decrease the abnormal muscle tone. Some spine supports have been used to delay or ameliorate spine deviation although not always successfully. When the scoliosis is severe then surgery is recommended. There are different techniques to straighten the spine or to de-rotate it. Some procedures involve placing metal rods along the spine and or fuse (glue together) several of the vertebral bodies. The surgery is usually done through the back but in occasions it is also done through the front of the chest. When surgery is elected then the person with scoliosis stay in the hospital for several days. Patients undergoing surgery are encouraged to walk soon after surgery to minimize complications and expedite recovery. A back brace may be recommended for before and after surgery for some time. Sometimes scoliosis surgery needs to be repeated or enhanced.

Emergency Situations - What Can Go Wrong

Scoliosis can be mild or severe; when severe it can limit our ability to breathe properly and therefore makes us prone to lung infections like bronchitis and pneumonias. As stated above it can interfere with communication and quality of life issues. Depending on the type of deviation and severity it can also lead to many postural problems. There are some emergencies that relate to the risk of the operation to correct the scoliosis. There can be significant bleeding that results in blood transfusions. Sometimes blood is drawn from the patient several weeks prior to the surgery and kept in the blood bank to be transfused later at the time of surgery. When the surgical technique includes opening of the chest cavity then drainage tubes are placed. Then there is pain to be considered as well as respiratory concerns if the person had limited ability to breathe to begin with. With the operation there is the risk for infection and for the metal bars to protrude out through the skin.

Conclusion

Scoliosis is not an uncommon problem. It is related to the rotation and exaggerated bents of the spine. Some persons can be born with it and some develop it after some neuromuscular conditions progress. At times it can be prevented. Physical therapy can be useful and surgery is only occasionally recommended. Scoliosis can greatly interfere with quality of life issues such as personal verbal and non verbal communication. Persons with developmental disabilities are more prone to having scoliosis due to common brain injuries.