Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Scoliosis

Scoliosis is common in girls and generally presents during the adolescence period. A scoliosis is a lateral bending or sideways curve in the spine that is apparent when viewing the spine from behind. In many occasions, there are asymmetry of the rib cage, shoulders and breasts. The pelvic ring usually tilts to one side. A mild degree of scoliosis is common, occurring in up to 50% of the population.

Scoliosis generally does not require any specific treatment. However, severe scoliosis does indeed need treatment. Scoliosis occurs mainly in the thoracic and thoraco-lumbar regions. There are two basic types of scoliosis, structural and functional. In the structural scoliosis the mechanics of the curve are such that rotation of the vertebrae occurs in combination with lateral curvature, and this usually produces a protruberance of one side of the rib cage, seen best when a person bends forward. This is the worst type of scoliosis, and it can be progressive. In the functional scoliosis, fixed rotation does not occur, and the curvature is usually non-progressive. This type of scoliosis is classified into postural, which disappears on forward bending, and compensatory, which is most commonly due to a short leg or tilting of the pelvic ring.

There are many causes of a structural scoliosis, but by far the most common (80 to 90 %) is the unknown, or idiopathic. This idiopathic scoliosis develops usually as the spine is growing rapidly. The earliest form, or infantile form, occurs in the first three years of life, and it usually resolves with time. The juvenile form occurs up to the age of nine, and has a high familial relationship. It can often be a progressive scoliosis. The adolescent form is the most common, and occurs from nine to fourteen years, and the most severe cases involve females. It is not known for sure why some children get scoliosis. It appears that genetic inheritance is a major contributor to a scoliosis.

It is often difficult for the untrained eye to detect a developing scoliosis when standing from behind, as although the bones may be twisted to a considerable degree the spine can appear straight because the spinous processes (the parts of the spine that project backwards and can be felt under the skin) can remain in a fairly straight line, while the front of the vertebrae rotate to a large extent. A better guide to the extent of a scoliosis can often be obtained by looking at a person from the front. In this view, the asymmetry of the body can be more readily detectable. This view may detect an abnormally shaped chest, or protruberance of some of the ribs on one side. The best way to look for a scoliosis is to look at the back from behind as the person bends forward. It is then easy to see the curve as one side of the rib cage will project more than the other. Plain x-rays of the spine can easily detect the extent of a scoliosis.

The most important part of the management of scoliosis is the early detection of its presence, as early management may prevent the need for surgery. Screening for scoliosis should be done on 13 and 16 years old schoolgirls.

The management of a scoliosis is determined by the extent of the scoliosis. A number of methods are used to decide upon the most appropriate treatment. In most instances a mild scoliosis or curve less than 400 requires no specific treatment. Advice in regard to posture and exercises may be offered. If the scoliosis is more severe it must be treated.

The options are:

1. Bracing: Although a definite inconvenience, bracing is sometimes necessary, and may prevent the need for surgery. A recent study has shown that bracing is effective in stopping the progression of the curve in about 80 per cent of patients, until the age of 16. A variable degree of relapse of the curve does occur after the cessation of bracing, usually at the age of 15 – 16. However, those children who have been braced generally still have curves within the acceptable range, which should not carry any particular disadvantage into adulthood.

2. Physiotherapy: Manipulation and physical therapies can help low back pain that occurs in association with a scoliosis. In the majority of functional scolioses, Physiotherapists can give advice regarding posture; strengthening of muscles and correction of muscle imbalance; strapping; ergonomics and exercise.

3. Surgery: In the rare cases where the scoliosis reaches the point of no return or curve is more than 400 or the curve is rapidly progressing, surgery may be required. In thoracic scoliosis it entails the insertion of metal rods along the spine. These rods act as braces to straighten the spine and prevent further deterioration of the scoliosis. These rods are usually left in the spine throughout life. It does not require the patient to wear a plaster jacket after the operation. The stay in hospital is about 7 to 9 days, and return to school is about 1 month. Life after surgery returns to near normal by about 9 months, except that body contact sports are not permitted.

Lumbar scoliosis is treated with other operations including fusion, and the underarm brace is required for up to 6 months after surgery.

If severe scoliosis is not treated the degree of scoliosis will usually become worse due to the continual loading on the spine during normal daily activities. The spine will buckle under the added load and the curve will become worse. During pregnancy the load on the spine increases dramatically, and the best way to prevent future problems associated with pregnancy is to deal with the scoliosis when it reaches a significant level during the earlier years. The quality and length of life are markedly affected by scoliosis. The prevalence of backache is twice that of the normal population and poor self-image is common. Respiratory and cardiac problems also become common, causing further severe disability and reduced life expectancy.

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