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Scoliosis is not a disease, but rather it is a term used to describe any abnormal, sideways curvature of the spine. Viewed
from the back, a typical spine is straight. When scoliosis occurs, the spine can curve in one of three ways:

The spine curves to the side as a single curve to the left (shaped like the letter C), called levoscoliosis

The spine curves to the side as a single curve to the right (shaped like a backwards letter C), called

The spine has two curves (shaped like the letter S).

Idiopathic Scoliosis

This article focuses on the most common form of scoliosis, idiopathic scoliosis, which occurs in approximately 2% the
population. The term idiopathic means a condition or disease with no known cause.
Idiopathic scoliosis is by far the most common cause of scoliosis in children. (Degenerative scoliosis is the most common
form of scoliosis in adults.)
Idiopathic scoliosis rarely causes pain, and in most cases the curve is minor enough to be considered an asymmetry and
does not require any treatment. However, once scoliosis is detected it should be closely monitored by a medical
professional in the event that the curve progresses and needs treatment.
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Because the skeletons of children and young adults grow quickly, there is a reasonable chance that if a curve is detected,
the degree of the spinal curve may worsen as the spine continues to grow. In those cases, scoliosis treatment may become
advisable. Rarely (in 0.2 to 0.5% of all cases), untreated scoliosis can progress to where it restricts space in the ribcage
needed for optimal heart and lung function.1,2
It is important to note that idiopathic scoliosis is not caused by activity such as exercise, sports, or carrying heavy object;
nor does it come from sleeping position, posture, or minor differences in leg length.

Detection, Diagnosis, and Monitoring

Scoliosis most typically occurs in individuals 10 to 18 years old and is often detected by school screenings or regular
physician visits. A medical professional will look for:

Curvature of the spine

Uneven shoulders, or protrusion of one shoulder blade

Asymmetry of the waistline

One hip higher than the other.

Once scoliosis is detected, a physician will continue to monitor the curvature (read more aboutscoliosis observation). The
progression of spinal curvature is very well understood and is measured in degrees.

Mild curvature that remains at 20 degrees or less will most likely require monitoring and observation, but further
treatment is rarely needed.

Curvature greater than 20 degrees may require non-surgical or surgical intervention, including treatments such as
a back brace for scoliosis or scoliosis surgery, both of which prevent further progression of the curve.

Preventing severe curvature is important for the physical appearance and health of the patient. Curves greater than 50
degrees are more likely to progress in adulthood. If a curve is allowed to progress to 70 to 90 degrees, it will produce a
disfiguring deformity.
A high degree of curvature may also put the patient at risk for cardiopulmonary compromise as the curve in the spine
rotates the chest and closes down the space available for the lungs and heart.

Scoliosis Rarely Causes Back Pain

It is important to note that idiopathic scoliosis results in spinal deformity, but is not typically a cause of back pain. Of
course, people with scoliosis can develop back pain, just as most of the adult population can develop back pain. However,
it has never been found that people with idiopathic scoliosis are any more likely to develop back pain than the rest of the

Other Types of Scoliosis

While adolescent scoliosis is the most common, other common types of scoliosis include:

Congenital scoliosis, which is present in infants

Neuromuscular scoliosis, which is the results of neuromuscular conditions

Degenerative scoliosis, which occurs later in life

Types of idiopathic scoliosis are categorized by both age at which the curve is detected and by the type and location of the
When grouped by age, scoliosis usually is categorized into three age groups:

Infantile scoliosis: from birth to 3 years old

Juvenile scoliosis: from 3 to 9 years old

Adolescent scoliosis: from 10 to 18 years old

This last category of scoliosis, adolescent scoliosis, occurs in children age 10 to 18 years old, and comprises approximately
80% of all cases of idiopathic scoliosis. This age range is when rapid growth typically occurs, which is why the detection
of a curve at this stage should be monitored closely for progression as the childs skeleton develops.

Terms Used to Describe Spinal Curvature

Scoliosis curves are often described based on the direction and location of the curve. Physicians have several detailed
systems to classify specific curves, but here are some common terms used to describe scoliosis:
Terms that describe the direction of the curve:

Dextroscoliosis describes a spinal curve to the right ("dextro" = right). Usually occurring in the thoracic spine,
this is the most common type of curve. It can occur on its own (forming a "C" shape) or with another curve
bending the opposite way in the lower spine (forming an "S").

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Levoscoliosis describes a spinal curve to the left ("levo" = left). While common in thelumbar spine, the rare
occurrence of levoscoliosis in the thoracic spine indicates a higher probability that the scoliosis may be
secondary to a spinal cord tumor. A physician will order an MRI for a thorough diagnosis.

Terms that describes the location of the curve:

Thoracic scoliosis is curvature in the middle (thoracic) part of the spine. This is the most common location for
spinal curvature.

Lumbar scoliosis is curvature in the lower (lumbar) portion of the spine.

Thoracolumbar scoliosis is curvature that includes vertebrae in both the lower thoracic portion and the upper
lumbar portion of the spine.

Using directional and locational terms together, physicians can accurately describe specific curves. Two typical examples

A C-shaped curve described as thorocolumbar dextroscoliosis refers to a single curve that spans the lower
thoracic and upper lumbar vertebrae.

An S-shaped curve described as thoracic dextroscoliosis and lumbar levoscoliosisindicates that there are two
curves of which the upper curve is located in the thoracic spine and leans to the right, and the bottom curve is in
the lumbar spine and leans to the left.

Other Types of Scoliosis

The most commonly known type of scoliosis is idiopathic scoliosis.Other types of scoliosis include:

Congenital scoliosis, which develops in utero and is present in infancy. A rare condition, affecting one in
10,000, there is no known cause, but in most cases the spinal curve must be corrected surgically.

Neuromuscular scoliosis, which sometimes develops in individuals who cannot walk due to a neuromuscular
condition such as muscular dystrophy or cerebral palsy. This may also be called myopathic scoliosis.

Degenerative scoliosis (adult scoliosis), which is a common condition that occurs later in life as the joints in the
spine degenerate. Read more about adult scoliosis.

Rarely, scoliosis is caused by spinal lesion or tumor. Patients who are usually younger (age 8 to 11) than typical scoliosis
patients will experience symptoms such as pain, numbness and a left-curving thoracic spine (levoscoliosis). A physician
who sees any or a combination of these symptoms will order additional diagnostic tests, such as an MRI, to rule out the
possibility ofspinal tumor or other lesions as a cause of scoliosis.

In children and teenagers, scoliosis often does not have any noticeable symptoms. The curvature of the spine does not
cause pain, and if it is mild, it can go unnoticed.
While a healthy spine, when viewed from the side, has natural curvature, when viewed from the back the spine appears as
a straight line. A person with scoliosis, however, will appear to have a lateral (side-to-side) curve in their spine when
viewed from the back.

Signs of Scoliosis
Without an X-ray of the spine, there are several common physical symptoms that may indicate scoliosis. One of the most
common tests for detecting scoliosis is called the Adam's Forward Bend Test, in which the individual bends from the waist
as if touching the toes. The medical professional then observes for one or more of the following signs of scoliosis:

One shoulder is higher than the other

One shoulder blade sticks out more than the other

One side of the rib cage appears higher than the other

One hip appears higher or more prominent than the other

The waist appears uneven

The body tilts to one side

One leg may appear shorter than the other

Any type of back pain is not usually considered a scoliosis symptom.

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Pain Needs Further Investigation

Pain is not a typical symptom of scoliosis. Back pain in a child or teen who has scoliosis may indicate another problem
and the child should be evaluated by a pediatrician and/or spine specialist. If a child or teen has back pain and also has
scoliosis, it is very important that he or she see a doctor to find out the cause of the pain, as it is probably something other
than the scoliosis causing the back pain and may require treatment.

See Back Pain in Kids and Teens

Girls at Higher Risk

The risk of curvature progression increases during puberty when the growth rate of the body is the fastest. Scoliosis with
significant curvature of the spine is much more prevalent in girls than in boys, and girls are eight times more likely to need
treatment for scoliosis because they tend to have curves that have a greater probability of progression. Still, the majority of
all cases of scoliosis are mild and do not require treatment.

Neurologic Pain and Numbness

Pain and/or leg numbness that signals a neurologic injury is also a very rare presenting symptom of scoliosis. In this
case, spinal curvature is caused by a spinal lesion or tumor. Signs that scoliosis is caused by an injury to the spine are:

Patient is slightly younger (8-11) than a typical scoliosis patient

Patient is experiencing pain and numbness that indicates a neural impingement

Thoracic or thorocolumbar curve that leans to the left (levoscoliosis)

A patient with any or a combination of the above symptoms should receive diagnostic tests, such as an MRI, to discover
whether there is a neurologic injury present; if so, immediate treatment is typically recommended.

Scoliosis treatment decisions are primarily based on two factors:

1. The skeletal maturity of the patient (or rather, how much more growth can be expected)
2. The degree of spinal curvature.

Although the cause of idiopathic scoliosis is unknown, the way scoliosis curves behave is well understood. In essence:

A small degree of curvature in a patient nearing skeletal maturity is not likely to need treatment;

Conversely, a younger patient with a bigger curve is likely to have a curve will continue to advance and will need

There are three main scoliosis treatment options for adolescents:


Back braces

Scoliosis surgery

No exercises for scoliosis have proved to reduce or prevent curvature. However, exercise is highly recommended for both
scoliosis and non-scoliosis patients alike to keep back muscles strong and flexible.
This page will discuss non-surgical options for scoliosis treatment.

Once scoliosis is detected, observation by a physician is the next step. The physician will measure the curve on a regular
schedule and base treatment decisions on the rate of curvature progression.

Measuring and Tracking Scoliosis Curves

The orthopedic surgeon may order an X-ray of the spine and use the "Cobb method" - an extremely accurate measuring
technique - to calculate the curvature of the spine and its progression.

Curves that are less than 10 degrees are not considered to represent scoliosis but are considered to be spinal
asymmetry. These types of curves are extremely unlikely to progress and generally do not need any treatment,
but the child's physician should continue to monitor the curve during regular checkups.

Curves beyond 20 to 30 degrees in a growing child should be observed at 4 to 6 month intervals by an

orthopedic surgeon with expertise in scoliosis

In a patient that is still growing, treatment will be needed if the following factors are present:

The spinal curve progresses more than 5 degrees during a typical period of observation, or;

The spinal curve has already reached 30 degrees or more.

If the curve progresses less than 5 degrees during a specified period of observation, the physician may determine that the
curve is not worsening rapidly enough to cause deformity, and treatment may not be necessary.

Scoliosis surgery is extensive surgery and is only recommended when scoliosis curves are progressing rapidly enough to
potentially cause severe deformity. It is important for patients to understand the risks of surgery and the post-surgery

Surgery Risks
1. Paraplegia
The most concerning risk with scoliosis surgery is paraplegia. It is very rare (about 1 in 1,000 to 1 in 10,000 chance) but is
a devastating complication. To help manage this risk, the spinal cord can be monitored during surgery through one of two

Somatosensory Evoked Potentials (SSEPs). This test involves small electrical impulses that are given in the legs
and then read in the brain. If there is the development of slowing of the signals during surgery this can indicate
compromise to the spinal cord or its blood supply. Another way to monitor the cord is with Motor Evoked
Potentials (MEPs), and often both are used throughout a surgery.

Read more with Somatosensory Evoked Potentials (SSEP).

Stagnara wake up test. This test involves waking the patient during the surgery and asking them to move their
feet. The patient does not feel any pain during this procedure and will not remember it afterwards.

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If either of these tests indicates spinal cord compromise, the rods can be cut out and the surgery abandoned. Fortunately,
this situation is extremely uncommon, and many procedures can be rescheduled if the patient is found to be neurologically
intact after the surgery.
2. Excessive Blood Loss
Another risk with scoliosis surgery is excessive blood loss. There is a lot of muscle stripping and exposed area during the
surgery. With proper technique the blood loss can usually be kept to a reasonable amount and blood transfusions are rarely
needed. As a precaution, many surgeons will ask the patient to donate his or her own blood prior to surgery (autologous
blood donation), which can then be given back to the patient after the surgery. Also, during scoliosis surgery the patient's
blood can be collected and transfused back to the patient.
3. Other Potential Risks and Complications

The rods breaking or the hooks or screws dislodging (although with modern instrumentation systems, this type
of hardware failure is quite uncommon)

Infection (less than 1%)

Cerebrospinal fluid leak (rare)

Failure of the spine to fuse (about 1%-5%)

Continued progression of the curve after surgery

See Spine Fusion Risks and Complications

Postoperative Care
Following scoliosis surgery, patients usually can start to move around about 2 to 3 days after the procedure. The total
hospital stay is usually about 4 to 7 days. Patients can return to school about 2 to 4 weeks after surgery, but activity needs
to be limited while the bone is fusing.
It is important to note that the more immobile the spine is kept the better it will fuse. Bending, lifting, and twisting are all
discouraged for the first three months after surgery. For this reason, some surgeons will prescribe wearing a back brace for
a period following the surgery which helps to restrict movement. Any physical contact or jarring type activities are
restricted for about 6 to 12 months after surgery.
Generally the patient will be monitored with intermittent examinations and X-rays for 1 to 2 years after the surgery. Once
the bone is solidly fused no further treatment is required.
For the most part, patients can resume normal activity levels after a thoracic fusion since fusing the thoracic and upper
lumbar spine does not change the biomechanics of the spine all that much. Female patients who have had a scoliosis
fusion can still become pregnant and deliver babies vaginally.


A lateral curvature of the spine, may be found in thoracic, lumbar, or

thoracolumbar spinal segment.

The curve may be convex to the right (more common in lumbar curves) or to
the left (more common in lumbar curves).

Rotation of the vertebral column around its axis occurs and may cause rib cage

It is often associated with kyposis (humpback) and lordocis (swayback).

Etiology And Pathophysiology

Idiopathic scoliosis exact etiology is unknown. Accounts for 65% of cases.

Possible causes include genetic factors, vertebral growth abnormality. Classified
into three groups based on age at time of diagnosis.
Infantile birth to age 3.
Juvenile presentation between age 11 and 17.

Congenital scoliosis exact etiology unknown; represented as

malformation of one or more vertebral bodies that results in asymmetric growth.
Type I failure of vertebral body formation e.g. isolated hemivertebra,
wedged vertebra, multiple wedged vertebrae, and multiple hemivertebrae.
Type II failure of segmentation e.g. unilateral unsegmented bar,

bilateral block vertebra.

Commonly associated with other congenital anomalies.
Paralytic or musculoskeletal scoliosis develops several months after

symmetrical paralysis of the trunk muscles from polio, cerebral palsy, or muscular

Neuromascular scoliosis child has a definite neuromascular condition

that directly contributes to the deformity.

Additional but less common causes of scoliosis are osteopathic

conditions, such as fractures, bone disease, arthritic conditions, and infections.

Miscellaneous factors that can cause scoliosis include spinal irradiation,

endocrine disoders, postthoracotomy, and nerve root irritation.

As the deformity progresses, changes in the thoracic cage increase.

Respiratory and cardiovascular compromise can occur in cases of severe


Poor posture, uneven shoulder height.

One hip more prominent than the other.
Scapular prominence.
Uneven waist line or hemline
Spinal curve observable or palpable on both upright and bent forward.
Back pain may be present but is not a routine finding in idiopathic scoliosis.
Leg length discrepancy.

Nursing Diagnosis

Disturbed body image related to negative feelings about spinal deformity and

appearance in brace.

Risk for impaired skin integrity related to mechanical irritation to brace.

Risk for injury related to postoperative complications.

Diagnostic Evaluation

X-ray of the spine in the upright position, preferably on one long 36-inch
cassette, show characteristic curvature.
MRI, myelograms, or CT scan with three dimensional reconstruction may be
indicated for children with severe curvatures who have a known or suspected
spinal column anomaly, before management decisions are made.
Pulmonary function tests for compromised respiratory status.
Evaluate for renal abnormalities in children with congenital scoliosis.
Nursing Interventions

Prepare the child for casting or immobilization procedure by showing materials

to be used and describing procedure in age-appropriate terms.


Promote comfort with proper fit of brace or cast.

Provide opportunity for the child to express fears and ask questions about
deformity and brace wear.
Assess skin integrity under and around the brace or cast frequently.
Provide good skin care to prevent breakdown around any pressure areas.
Instruct the patient to examine brace daily for signs of loosening or breakage.
Instruct patient to wear cotton shirt under brace to avoid rubbing.
Instruct about which previous activities can be continued in the brace.
Provide a peer support person when possible so the child can associate positive
outcomes and experiences from others.