Scoliosis: Do parents need to worry?

The Pediatric Insider

© 2013 Roy Benaroch, MD

“My daughter was sent home from school with a note—they say she has scoliosis. I’m worried, is she going to need surgery? Will she ever be normal?”

Chances are, she’ll be absolutely fine—and chances are, she’s already normal. Let’s back up (Ha! Get it?) and take this step by step.

Scoliosis is a curvature of the spine from left to right. It’s normal for human spines to curve if you look at someone from the side. But from the front, the spine should be more-or-less straight, at least to a quick glance. It turns out that many people, when x-rayed, have at least a little bit of curvature. Anything less than 7 degrees is just considered “normal.” So a small amount of scoliosis observed at a school screening may  turn out to be absolutely nothing. In fact, the US Health Preventative Services Task Force specifically recommends against school screening, because casual exams by volunteers are not accurate. They end up calling normal backs “scoliosis”, and miss a significant proportion of true cases of scoliosis. Your child’s doctor is the best person to screen for scoliosis, and this ought to be done at every yearly physical.

Let’s say that the doctor really does notice some asymmetry on the back exam that suggests scoliosis. What next? Our eyeballs can fool us. Often an observed curve is related to a difference in the length of the legs, or a pelvic tilt—and really has nothing at all to do with the back. Our eyes are also very poor at judging the degree of curvature. So a suspicion on scoliosis on a screening physical exam is only a warning flag. The next step is to confirm what’s going on with a spinal x-ray.

From the x-ray, we can determine if there really is scoliosis, what degree it is (the larger the number, the worse the curve), and if there is anything physically going on that’s causing the curve, like a malformed vertebrae. Usually, scoliosis is “idiopathic,” meaning it isn’t caused by a specific physical issue. This is the kind of scoliosis that develops during the rapid growth spurt, at about 11-12 years for girls or 12-13 years for boys. Idiopathic scoliosis can run in families, and it’s far more common in girls.

If there truly is scoliosis, what happens next depends on three questions: How big is the curve? How mature is the child (that is, how much growth is still left)? And are there any symptoms?

Symptoms of back pain from scoliosis aren’t common, especially if the curve is less than 20-30 degrees. But scoliosis accompanied by back pain may benefit from more-aggressive therapy.

Regarding growth maturity: once scoliosis is there, it can get worse as a child grows. In other words, the closer your child is to the end of their growth, the less opportunity there is for the scoliosis to worsen. Most girls stop growing within a few months of when their periods get regular. Scoliosis always needs to be monitored and treated more aggressively in younger children, or children early in puberty.

The exact criteria for different interventions may vary with other factors, but as a general rule a curve of ten degrees or less needs little follow-up; 20-30 degrees will be watched closely with x-rays every 3-6 months; curves of 30 degrees or more may require bracing, and curves of over 40-50 degrees may need surgery. All of these are rules of thumb, and also depend on skeletal maturity and other factors. The vast majority of ordinary idiopathic scoliosis does not require any therapy at all.

If a curve is large or progressing in a child who is still growing, first line therapy is usually a brace. This device can delay or slow the progression of the curve, but can’t fix a curve that’s already there. If the brace fails to halt progression of the curve, or if the curve is to such a degree that it’s causing symptoms, surgical fixation may be needed.

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