What is scoliosis?

Scoliosis is a three-dimensional curvature of the spine, involving the sagittal, frontal, and transverse planes. In the sagittal plane, there is a decrease in thoracic kyphosis or lumbar lordosis. In the frontal plane, there is a lateral curvature of the spine. Rotation and torsion of the vertebrae are observed in the transverse plane. Scoliosis is typically diagnosed when the frontal plane curvature exceeds 10°. For smaller angular values of curvature, the term “postural scoliosis” is used.

Epidemiology of scoliosis, who is most at risk?

Scoliosis is the most common orthopedic condition among children and adolescents, with an estimated prevalence of up to 15.3%. Literature reports similar occurrence rates of frontal plane spinal deformities ranging from 6° to 10° in both boys and girls. However, when the curvature exceeds 21°, the ratio of girls to boys is 5.4 to 1. According to Głowacki et al., for every boy with a Cobb angle in the range of 20°-30°, there are up to 10 girls. The prevalence of scoliosis is dependent on age and gender.

Etiology of scoliosis, where does it come from?

In some cases, the cause of scoliosis can be determined, but in many cases, the etiology remains unclear. It can be related to factors such as limb length discrepancy, pain, muscle weakness, or congenital abnormalities. The development of lateral spinal curvature may also be associated with an oblique pelvic tilt, which changes the distribution of forces in the hip joints and the lumbar spine. When the vertebrae are misaligned in the frontal plane, it disrupts the axis of rotation, which is in the transverse plane. The gravitational force acting on this abnormal axis generates rotational forces on the vertebrae. This rotation can lead to the development of lateral spinal curvature and its associated consequences.

Importantly, the largest group of scoliosis cases, accounting for up to 90%, is idiopathic (of unknown cause). There are only hypotheses regarding the factors that may contribute to their development. Genetic factors, early exposure to toxins, and hormonal imbalances are believed to play a role. Biomechanics, lifestyle factors, and environmental conditions are also considered as potential causes [6,7]. Researchers in this field have developed various theories to explain the etiology of scoliosis based on clinical observations and studies. However, none of these theories have been fully confirmed.

Classification of scoliosis

Scoliosis can be classified based on various criteria, including chronology, location of the curvature, angular magnitude, and etiology. Wejsflog proposed a classification of scoliotic symptoms into three groups based on the degree of deformity in the musculoskeletal system. In first-order scoliotic symptoms, there is torsion and wedging of the vertebrae, as well as three-dimensional spinal curvature. Second-order symptoms involve skeletal elements directly associated with the spine. These include posterior rib hump on the convex side and rib depression on the concave side. On the anterior surface of the chest, the situation is reversed, with depression on the convex side and a rib hump on the concave side. Second-order symptoms also include lateral displacement of the hip, inclination of the chest, and its displacement, typically towards the convex side. Third-order changes involve further regions of the musculoskeletal system. These include deepening of the waist triangle on the concave side. Asymmetrical positioning of the shoulders and scapulae is observed, with the scapula on the convex side protruding and rotating outward.

Taking into account the chronology of scoliosis development, James proposed a classification. According to him, there are early-onset scoliosis, which occur around the age of 3, during the first growth spurt. These scoliosis types are more common in boys, and the deformity affects the thoracic spine. This type of scoliosis can be progressive or non-progressive. In the progressive cases, the curvature can exceed 100° according to Cobb. In non-progressives cases, the scoliosis spontaneously resolves and disappears by the age of 4. The second group, according to James, is juvenile scoliosis. They usually appear between the ages of 5 and 8 and can have significant angular values. They are always accompanied by body asymmetry, such as rib hump, shoulder or waist asymmetry. The third group, which is the most common among age-related scoliosis, is adolescent scoliosis. They appear between the ages of 10 and 14 and do not reach high angular values.

There is also a classification based on the location of the curvature. It includes primary thoracic scoliosis, which typically curves to the right, primary lumbar scoliosis, which is usually left-sided. This group also includes primary thoracolumbar scoliosis and double curvature, which has both thoracic and lumbar curvatures.

Taking into account the etiology, the most widely used classification is the one introduced by Cobb, which distinguishes between functional and structural scoliosis. Functional scoliosis is characterized by a small angular value of the curvature and easy correction in the lying position. There are no structural changes within the vertebrae [10]. These types of scoliosis can occur due to factors such as limb length discrepancy, pain, or weakness in the musculoskeletal system. A slight scoliosis can occur due to different leg lengths and should be compensated for with orthopedic aids such as shoe inserts. This is particularly important during the growth period and ensures the proper conditions for the spine to grow. In structural scoliosis, clinical and radiological changes in the vertebral bodies can be observed.

Cobb proposed a classification of scoliosis based on the Cobb angle measurement, which divides it into four degrees:

• Degree I curvature – up to 30°
• Degree II curvature – 30-60°
• Degree III curvature – 60-90°
• Degree IV curvature – above 90°

Symptoms of scoliosis, what to look for in a child?

Scoliosis often goes unnoticed as it can be asymptomatic, leading to delayed diagnosis. The condition is often discovered incidentally through chest X-rays. Additionally, the symptoms of scoliosis are nonspecific. It is a progressive condition that worsens as the child grows, and the progression stops when spinal growth ceases. The most noticeable sign is a change in the appearance of the back. Scoliosis can cause asymmetrical positioning of the shoulders and shoulder blades, and a noticeable hump may appear on one side of the chest, particularly when bending forward. There may also be a noticeable protrusion, especially when bending forward, in the lower back. Asymmetry of the shoulders, lateral displacement of the upper body relative to the pelvis, and uneven waist indentations are also signs to look for. Pain symptoms typically occur only in untreated scoliosis cases. Pain is often caused by nerve compression and, in severe cases, can even lead to compression of the spinal cord. Large scoliosis curvatures can progress even after skeletal growth has stopped due to degenerative changes in the intervertebral disc, with the disc nucleus shifting towards the convexity of the curve.

It is crucial to observe the child without a shirt, and any asymmetries should catch our attention.

I suspect my child has scoliosis, what should I do next?

The first step is to seek proper diagnosis, which involves multiple aspects in the case of scoliosis. It is advised to visit an orthopedic doctor who will assess the presence of 1st, 2nd, and 3rd degree symptoms related to the spine and surrounding musculoskeletal areas. To make a precise diagnosis and prognosis, an X-ray examination is necessary to evaluate the length and angle of the scoliotic curve according to Cobb’s method. The rotation of the vertebrae and the degree of wedging are also assessed. The evaluation of bone maturity is essential for predicting the progression of the curvature, and this can be done using the Risser test. Assessing the flexibility of the spine, the corrective potential of the curvature, and the mobility of the hip joints are also important aspects of diagnosis. The next part of the diagnostic process involves baropodography, which evaluates the distribution of body weight on the feet and the position of the center of gravity. Based on a comprehensive diagnosis, an appropriate treatment plan can be established [14].

Diagnosis and treatment monitoring of scoliosis at MIRAI

Regular monitoring of the curve angle, torso deformity, and pelvic asymmetry is crucial in the treatment of scoliosis. Objective assessment of these parameters has traditionally required regular X-ray examinations, which involve exposure to potentially harmful radiation. Fortunately, there is an alternative!

Our clinic has a device for comprehensive functional analysis of the spine and posture during movement, which allows for three-dimensional evaluation of body posture without the need for X-ray radiation. The examination is completely non-invasive, and its results highly correlate with conventional X-ray examinations. This examination is dedicated to monitoring treatment progress without the need for regular exposure to X-ray radiation. Furthermore, the examination enables not only the assessment of the pelvis and spine but also the evaluation of weight distribution on the feet using 4,000 pressure sensors integrated into the treadmill, which is part of the measurement system. Importantly, our system also allows for the assessment of pelvic and spinal alignment and measurement of foot loading during walking or running. Thus, we are not limited to static examination. We can perform measurements during functional activities such as walking and running, which can help to plan rehabilitation interventions more accurately.

The device for comprehensive functional analysis of the spine and posture during movement is available at MIRAI in Warsaw Wola, at ul. Wolska in Warsaw.

Jakub Olewiński, MSc., is responsible for scoliosis examinations at our clinic.

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