Scoliosis. Diagnostics & Therapy
Scoliosis is often undiscovered in its early stages.
An asymmetrical back, breathing problems or pain during certain movements are just some of the signs that may occur in advanced skoliosis. In the early stages of the disease, however, only a few of those who are affected have physical discomfort. This is why it often is undetected until the age of puberty.
By medical examination, the curvature's changes of the back and the degree of scoliosis can be diagnosed. The necessary treatment steps against the misalignment of the spine can then be initiated.
What types of treatment are available for scoliosis?
There are various conservative and surgical options when it comes to treating scoliosis. The overall aim is to prevent progression of scoliosis to a more severe form and as experience tells us, the subsequent effects associated with this such as pulmonary impairment, back pain etc. Scoliosis therapy is determined definitively by the cause, the patient's age and the degree of non-alignment and the likely course and outcome of the condition.
Diagnostics, therapy & treatment of scoliosis.
Diagnostics. How a scoliosis of the spine is is detected
Can scoliosis be detected in the early stages?
Scoliosis in its early stages is difficult to detect especially as it also asymptomatic. There is a risk of idiopathic types of scoliosis developing to a greater or lesser degree of progression particularly in the times of the greatest growth phases of the spine, i.e. during puberty. Because of the deformation of the spine with its associated asymmetry of the body, scoliosis usually becomes most noticeable over the duration of the illness when viewed from behind.
How is scoliosis identified?
In the first instance the focus is on a detailed physical examination carried out by the doctor. Sometimes scoliosis can be diagnosed just from looking at the spine. The picture is one of rotational non-alignment of the body, which because of the lateral curvature and asymmetry, can fundamentally alter the body's physical proportions The doctor checks whether the shoulders and the pelvis are level and whether the spine is perpendicular i.e. that the cervical spine is straight and centred above the sacrum in the frontal plane. In addition an evaluation is made as to whether there is any deviation from the normal profile. A marked rib hump or eminentia in the lumbar region are often visibly noticeable with more severe forms of scoliosis even when standing.
The forward bend test in the case of mild scoliosis.
In less severe forms it is often better to use Adam's forward bend test to make a diagnosis. From the standing position, the patient bends his upper body, which is unclothed, forwards. From this aspect the doctor is better able to determine from behind, whether the ribs bulge backwards (rib hump). In this case thoracic scoliosis is present. If there is eminentia in the lumbar region, then this indicates lumbar scoliosis. In addition the waist triangle (= the triangle formed by the waist and the lowered arms) will be unequal.
After diagnosis: Research into causes.
Once the doctor has diagnosed scoliosis, possible causes must be found and the extent and type of scoliosis determined. Besides a thorough physical examination, both the patient's medical history and if need be further examinations are useful here.
Other examinations for scoliosis.
- X-ray image: If scoliosis has been diagnosed, then the preparation of relevant X-rays is obligatory. It is best if X-rays on two planes of the whole spine are carried out with the patient in a standing position (from behind = frontal and from the side = sagittal). These images provide further information about the potential cause, type and degree of the scoliosis.
- Bending- X-ray images = X- rays taken while the patient is bending: Necessary if treatment with a corset or surgery is planned. At the same time the patient actively tries to correct the curvature by leaning to one side. This allows for the degree of existing fixation (stiffness) of a curvature to be evaluated and flexible compensatory curvatures differentiated from "real" i.e. actual and fixed curvatures of structural scoliosis.
- raster stereography: is used to evaluate the progression of scoliosis. This photo optical X-ray-free system provides 3D measurements of the body's surface allowing judgements to be made as to the exact extent of the scoliosis.
- Magnetic-Resonance Tomography (MRT/MRI): is necessary prior to any surgery that might be required for certain types of scoliosis, especially congenital malformations of the spine. Any noticeable areas must be supplemented by a CT scan directly before a planned operation.
- Computed tomography (CT)
- lung function examination: To evaluate lung function directly prior to surgery and for more severe types of scoliosis.
How is the severity of scoliosis identified?
The severity of the spinal curvature is measured using a special angle measuring procedure (Cobb's angle). The level of severity of the curvature is measured from a frontal X-ray image using the most tilted vertebra in the curvature (called the end vertebra). A line is drawn along the end plates of these vertebra, so that at the point of intersection of these lines the angular degree can be determined using a goniometer (Cobb's method). Because of the importance of these measurements among other things to evaluate the likelihood of progression of the scoliosis and the treatment options, scoliosis is often arbitrarily classified into different degrees of severity. Accordingly, an angle of up to 30 means slight scoliosis, moderately severe scoliosis lies between 30 - 60 and if it is more than 90 then this means very severe scoliosis.
Conservative therapy measures of the scoliosis
Physiotherapy for scoliosis under 20°.
Scoliosis in childhood or in adolescence with an angle of curvature of less than 20-25 degrees generally has only a slight chance (<=20%) of progressing during the rest of adolescence and causing the relevant symptoms later on. Therefore only physiotherapy is recommended. By means of physiotherapy exercises (e.g. with the three-dimensional scoliosis therapy according to Katharina Schroth) it is possible to strengthen all of the back musculature as well as the individual muscle groups and thereby counteract any further curvature. Overstretched muscles are strengthened so that they can oppose the twisted vertebra with more pull. This specially developed treatment concept stretches and corrects the curved spine while stabilising its musculature. Another component of the treatment is Katharina Schroth's rotational angle breathing method. This aims to correct disturbed breathing patterns. There are however no highly-rated scientific studies which document any one particular effect of physiotherapy on the course and outcome of scoliosis.
Corset therapy for children with scoliosis of more than 25°.
If the the malalignment of the spine is more than 25° by the time of diagnosis during adolescence, or if mild scoliosis increases over time to more than 25°, then a corset to correct the truncal spine, i.e a remedial corset, should also be worn. The background to this procedure is the knowledge that scoliosis of more than 25 degrees has a high risk of progressing further. Such a corset, usually made from plastic and tailor made from a plaster impression, should only be made by an experienced orthopaedic technician and be fitted in cooperation with the orthopaedist specialising in scoliosis. Then it should be worn if possible for 23 hours a day, i.e. day and night. It should only be removed for personal hygiene reasons or for sporting activities which are expressly recommended. The corset corrects the spinal malalignment as best possible and keeps it in the correct position. The growth of the spine should be directed along "the right path".
The aim is to prevent progression of the scoliosis.
The ultimate aim of such a corset is to avoid any further progression of the scoliosis in adolescence and any possible consequential damage or even surgery. Children must therefore wear the corset until the end of adolescence. In addition regular check ups are necessary for early recognition of any progression of scoliosis in spite of corset therapy. Because of the changing proportions of the body as it grows it is also necessary to adjust or occasionally make a new corset. We therefore recommend check ups at least every six months.
Corset therapy is no longer an option for adults.
With idiopathic scoliosis in adults, corset therapy is no longer normally used. During childhood and adolescence growth can still be directed, in adults this is no longer possible because growth has finished. An exception is painful idiopathic scoliosis in patients who decline surgical therapy. In this case however the corset has the stabilising function of alleviating pain.
Treatment of the scoliosis by surgical intervention.
Beyond which level of curvature should surgery be undertaken in children and young people?
- Thoracic scoliosis of 50° and more (curvatures of the thoracic spine )
- Double S scoliosis from 40-50°
- (Thoracolumbar scoliosis from 35-40° (curvatures of the lumbar spine)
In adults a differentiation must be made between idiopathic and de novo scoliosis.
The above-mentioned indications for surgery are not so easily applicable to scoliosis in adulthood. For instance it is important to differentiate between the presence of idiopathic scoliosis, or if it is scoliosis caused by wear and tear, i.e. degenerative scoliosis, which is typically localised in the lumbar spine. Since this type of scoliosis occurs as a new phenomenon in adults because of asymmetric intervertebral wear and tear, it is called "de novo scoliosis" and must be differentiated from adult idiopathic scoliosis. In terms of definition, idiopathic adult scoliosis is the type of scoliosis which is not treated or has not been treated adequately in childhood and the teenage years and therefore continues through into subsequent years.
When should adults have surgery?
The main reason for therapy of scoliosis in adults is however because of the occurrence of pain, caused by progressive wear and tear on the sections of the spine where there is a load imbalance, which cannot usually be treated adequately by conservative methods. This is mostly linked with an increase in the scoliosis. As already mentioned, scoliosis of more than 35 to 40° in the region of the lumbar spine and more than 50° in the region of the thoracic spine, has a high risk of progressing in adulthood. Also the cosmetic distortion of the body can also be a reason for surgery.
What is the operative procedure?
Metal screw/rod systems are used in corrective scoliosis surgery. Access to the spine varies. This is either a posterior or anterior approach. Following correction the sections of the spine treated surgically have to be stiffened to guarantee long-term corrective stability throughout the duration of life.
Aims of operative therapy in scoliosis:
- 3-dimensional correction of shape with
- the best possible correction of curvatures, perpendicular alignment of the spine and equal shoulder heights
- Optimisation of the profile
- Correction of the malrotation and therefore the rib hump, and/or lumbar prominence
- Short section of stiffening
- surgery must only be carried out on a "genuine" structural curvature of the spine. Typically this involves the respective end vertebra of the curvature to be operated on and takes place following careful analysis of the existing curvatures.
- Primary stability
- This means that the implant system used is anchored so firmly in the vertebrae that it allows the necessary stability for mobilisation after surgery even without the additional use of a corset. In addition it also allows long-term bone stiffening without loss of correction. Today this is almost always possible using modern implant systems.
- Good cosmetic result
- Greatest possible safety
- Preoperative autologous blood donation and recycling of blood lost during surgery together with intraoperative nerve measurement during surgery (known as neuromonitoring) are also used to minimise possible complications. As an alternative to neuromonitoring, an intraoperative consciousness test can be carried out once correction has taken place. The patient is woken up during the operation having been given painkillers and has to move his legs and feet when spoken to so that the surgeon can check to his satisfaction for intactness of the spinal cord and nerves.
Are there major risks associated with scoliosis surgery?
Scoliosis operations counts among the major interventions on the spine. The greater and more inflexible the curvature of the spine, the more difficult, complex and risky the operation. In rare cases complications can occur, which may make further interventions necessary. An example would be a loosening or fracture in the implant with subsequent loss of the correction achieved. Such complications are rare with the modern, screw fixation type of implants used today. Even possible neurological complications are rare in experienced hands and to minimise these nerve function tests are carried out during surgery (e.g. neuromonitoring).
What happens after the operation?
What happens after surgery?
With the exception of a few cases, the patient is mobilised as early as the day after the operation. So that patients feels as little wound pain as possible after the operation and can be mobilised quickly, a pain catheter is inserted into the spinal canal towards the end of surgery, which is filled continuously during the first days after the operation with anaesthetic and morphine-like substances. A plaster or corset is only necessary in exceptional cases (e.g. if there is very poor bone quality). Firstly exercises are started under the supervision and instruction of physiotherapists with a gradual increase in mobilisation. If the patient is safe to stand and walk i.e. is sufficiently mobilised, he can be discharged from the hospital.
What happens after discharge from hospital?
From experience, wound pain continues for a few weeks after the operation with an enormous breadth of variation depending on the individual. The administration of painkillers is gradually reduced on an outpatient basis depending on symptoms. In most cases this is after 12 - 14 days. Thereafter for 3 - 6 months prophylactic avoidance of strenuous physical activity is necessary. Types of sport where there is a danger of falling should not be undertaken for about a year.