paediatric scoliosis

Scoliosis is a Greek term meaning bent. The spine is meant to be straight when looking at it front on and have gentle curves from the side. The spinal column are the vertebral segments that function to suspend the axial skeleton and torso, in addition to being intercalated and variably mobile at each level. It also houses the spinal cord and each exiting nerve root from the brain down to the bum, so to speak. Scoliosis is present when there are curves present in the coronal plane. This can however be posturing or a list, as our spine is meant to be mobile. Children and adolescents may sometimes stand or list away from painful disc disease or bony lesions, present with spinal rigidity in the setting of osteomyelitis/discitis, or posture to compensate for a leg length discrepancy. The real clue about the presence of a true scoliosis, is the presence of axial rotation. This is manifest clinically as truncal asymmetry, either a rib or flank prominence on forward bend. On plain X-rays, the eyes of the pedicles can be seen ‘winking’ or moving across the square of the vertebral body with rotation. Scoliosis can have many causes, and it is important to see a specialist to diagnose the likely cause as it will determine the prognosis.

In brief:

1. Congenital is associated with malformations of the vertebral segements and potentially there are spinal cord anomalies or other midline organ abnormalities.

2. Syndromic is associated with an identifiable genetic abnormality, that will help prognosticate other neurological, developmental and even cardiac issues. A number of the bone dysplasias including the collagen disorders such as Marfan’s, Neurofibromatosis and Ehler’s Danlos are collected under this heading.

3. Neuromuscular is associated with Cerebral Palsy, muscular dystrophy and myopathies. There are a number of causes with variable manifestations of severity and disability. Care is tailored to each patient individually and their family.

4. Idiopathic is a medical term used where medicine hasn’t identified the exact cause. It is likely to be genetic but no consistent genetic trait has been identified, even when there is clustering in families. Sometimes a neurological association is identified on MRI: which can include a syrinx, Chiari or tether.

Other prognostic factors include the age at presentation, and the rate of progression. Scoliosis is not from an unstable spine. It is known to change more rapidly or even present during rapid phases of growth. The common type of Adolescent Idiopathic Scoliosis often seems to appear during the early phase of the adolescent growth spurt, consistent with this.

Treatment aims depend on the curve severity (as measured by the Cobb angle), the rate of progression, and the amount of growth remaining. As a general principle, under 10yo will have growth friendly casting/ bracing or surgery to maximise their spinal height and lung function. Over 10yo will be able to be braced if the curve is amenable and the patient is compliant; or surgery will be offered when bracing is not efficacious, or the curves are too stiff or severe.