What Is Scoliosis? Symptoms, Causes And Treatments

Scoliosis is a three-dimensional progressive condition that causes lateral curvature and rotation of the spine in a “C” or “S” shape. Curvature and rotation can occur anywhere in the spine, and a person with scoliosis can have one, two or even three curves.

Types and Causes of Scoliosis

The main types of scoliosis include:

• Adolescent idiopathic scoliosis (AIS), which comprises about 80% of scoliosis cases. AIS usually presents when a person enters puberty around 10 to 12 years of age. It’s seven to 10 times more prominent in females than males. Idiopathic means “having no known cause,” and there’s no way to prevent it. There’s evidence to suggest AIS can be related to genetic factors.
• Early onset scoliosis (EOS), which is a category of diseases used for children less than 3 years old, and it is the most difficult to treat. EOS includes:
  • Congenital scoliosis, which is present at birth and is the result of developmental factors.
  • Neuromuscular scoliosis, which occurs when spinal development is affected by the surrounding musculature. Spinal development, strength and tone can be affected by conditions like cerebral palsy and muscular dystrophy and diseases like spina bifida.

Common early symptoms of scoliosis may include:

• Skeletal asymmetry, which can manifest in leaning to one side, one shoulder or hip appearing higher than the other, one shoulder blade appearing more prominent or visible than the other or a prominence of one side of the rib cage.
• Uneven posture, which is visible when standing or sitting up straight.

In moderate or severe cases, scoliosis symptoms may include:

• Pain, which may be chronic or acute, present in the back or shoulder(s) and related to muscle spasms, local inflammation or degeneration of intervertebral discs or joints.
• Changes with walking. The spinal rotation may cause the hips to be out of alignment, which can affect a person’s gait.
• Reduced range of motion. Spinal twisting can increase its rigidity and reduce its flexibility.
• Fatigue. Compensation to maintain balance for uneven posture can cause muscles to tire sooner.
• Lower self-esteem. Commonly overlooked or minimized by outside observers, reduced self-esteem can be a significant factor for people who have a noticeable spinal deformity, especially adolescents who are particularly concerned about fitting in.

Most people with scoliosis are able to live normal, healthy lives without restriction of activities. Although rare, severe cases of scoliosis with curvatures between 60 and 100 degrees can restrict pulmonary and cardiovascular output and affect a person’s quality of life. For these patients, surgery is typically recommended to provide appropriate spinal correction and prevent worsening conditions.

Featured Sponsor Offer

Partner Offers feature brands who paid Forbes Health to appear at the top of our list. While this may influence where their products or services appear on our site, it in no way affects our ratings, which are based on thorough research, solid methodologies and expert advice. Our partners cannot pay us to guarantee favorable reviews of their products or services

Professional Therapy, Done Online

• Prices vary and start at $65/week
• Users can be matched with one of over 35,000 licensed therapists in as little as 24 hours
• Over 4 million people have received support through BetterHelp
• Subscription includes a weekly one-on-one session and optional group session, journaling, worksheets, goal setting, and more
• Ability to switch therapists or cancel at any time

Get Started

On BetterHelp's Website

Scoliosis is usually diagnosed through a physical examination, X-rays and spinal radiographs. It can also be diagnosed via CT scan and MRI.

Early detection is important to monitor the potential progression of spinal curvature during a period of rapid growth. For this reason, many adolescents undergo school screening for scoliosis, which may be conducted by a school nurse or as part of an annual physical by a health care provider. School screenings for scoliosis involve a trained professional assessing rotation of the spine using the Adams Forward Bend Test. This simple, non-invasive procedure requires a person to bend forward toward their toes while a trained professional examines their back for structural or functional indicators of scoliosis.

If indicators are present, a person might be referred to a pediatric orthopedic specialist for a spinal radiograph (X-ray) to create detailed pictures of the spine. Newer technology, such as EOS imaging, uses significantly less radiation than traditional X-rays. EOS can produce two-dimensional (2D) or three-dimensional (3D) orthopedic images of the body, including frontal and lateral views, while a person is standing or sitting.

“If your child is referred for further evaluation after a school screening, there is no great cause for alarm,” says Karl Rathjen, M.D., orthopedic surgeon and assistant chief of staff at Scottish Rite for Children, a premier pediatric orthopedic hospital specializing in spine conditions and research in Dallas, Texas. “There is a high likelihood they will never require any treatment.”

More than half of patients referred after a school screening are determined not to have scoliosis. Of those, Dr. Rathjen says 45% of patients will be observed, and most of them will never develop scoliosis.

How Scoliosis Curves Are Measured

The Cobb angle is the most widely used measurement to determine the magnitude of spinal curvature. It’s measured in degrees of lateral deviation from a straight spine by adding the tilt angle measurements from the upper and lower vertebrae in a curvature.

The degree of spinal curvature is only part of the story when it comes to diagnosing and treating scoliosis, however. The Sanders Maturity Scale, based on a left hand radiograph, is the best predictor of a patient’s phase of skeletal maturity and potential for curve progression. It’s a scale scored from one to eight, with number seven divided into 7a and 7b.

“The most rapid phase of growth is three, four and five,” says Dr. Rathjen. “Patients start to slow down around six and are not growing much by eight.”

The Sanders score is widely regarded by orthopedic surgeons to be a better indicator of bone age than the Risser sign, which is also determined from an X-ray. The Risser sign is evaluated by the level of bone formation and hardening of the iliac apophysis, which is the top of the curve of the pelvic bone.

Scoliosis treatment goals fall under two primary categories: morphological, relating to aesthetics, and functional. Both aspects relate to the patients’ quality of life, psychological well-being and disability.

Scoliosis treatments can include observation, bracing, casting, physical therapy and/or surgery. Treatments are specific to each individual and vary depending on their skeletal maturity and their type of spine deformity.

A physician may decide a patient needs treatment for scoliosis based on their skeletal maturity, the degree and location of the curve(s), and their potential for progression.

Physical therapies, such as the Schroth Method, include specific exercises for a patient’s spine curvature to improve its rotation, elongation and stability. These treatments are still being researched for their effectiveness and may be recommended in tandem with other methods. Bracing and surgery are the most commonly prescribed scoliosis treatments that are proven to be most effective.

Scoliosis Braces

About 2% to 3% of people with scoliosis may require a brace while their bones are still growing. This need is determined by the degree of curvature in the spine, as well as clinical characteristics like appearance in the back. To meet the criteria for bracing, a candidate should be skeletally immature and have at least one scoliotic curvature measuring between 25 and 45 degrees at risk for progression. The goal of bracing is to prevent spinal curvature from worsening and to avoid surgery.

Braces for scoliosis are designed to “tease the spine into growing straighter,” says Dr. Rathjen. They work by applying external forces via the shape and padding inside the brace. He notes that bracing usually doesn’t improve spinal curvature for AIS patients when they aren’t in their brace, and permanent correction is very rare.

Scoliosis braces fall into two categories: full-time, which are worn day and night, and nighttime, which are only worn while the person is lying down. Each brace, made by an orthotist, is custom designed to fit the wearer’s body and place pressure strategically on areas that support curvature correction and spinal stability while they wear it. As a patient grows, they may need more than one brace over the course of their treatment.

The amount of time a person needs to wear their brace varies from case to case, but full-time bracewear is usually recommended to span 16 to 22 hours a day. “The faster you’re growing, the more you need the brace,” says Dr. Rathjen. A person who’s maturing quickly might have to wear their brace for 23 hours a day, but only for one year, whereas someone who has a slower growth pattern may be able to wear a nighttime brace but for a longer period of time until their growth is complete, as indicated by their Sanders score.

Boston Braces

The thoraco-lumbar-sacral-orthosis (TLSO) Boston brace model is the most commonly prescribed full-time scoliosis brace. It’s a rigid brace that’s fitted to a plaster mold of the person’s body. Padding applies corrective pressure to the convex (outer) side of the curve, with corresponding cutouts or areas of relief on the concave (inner) side of the curve, so the spine can move toward that direction and be corrected while the person wears the brace. It goes under one arm, has a cutout for the rib cage on the concave side and extends to the sacrum. People with this type of brace are advised to wear a T-shirt or tank top underneath it to protect skin from irritation. The plastic brace is fitted tightly and opens in the back, so someone may need assistance getting in and out of their brace. Regular clothing may be worn on top of the brace, though waistbands may need to be a size or two larger. Other full-time scoliosis braces  include the Wilmington brace and the Rigo Ch​​êneau.

Nighttime Braces

Nighttime braces are meant to be worn while a person is lying down or sleeping and can therefore apply more force than full-time braces, providing a 50% to 80% spinal correction as the person wears the brace. The Charleston Bending Brace and the Providence Brace apply strong pressure to bend and hold the spine in an overcorrected position. The Charleston brace bends the spine’s curve in the opposite direction while a Providence brace elevates one shoulder and applies lateral and rotational forces on the curve(s).

Body Casting

For infants and very young children, developing a large scoliosis curve may become a source of morbidity if left untreated. Body casting, or Mehta casting, may be an option to straighten the spine as it grows. This fairly aggressive form of treatment is regarded as highly effective and may help mitigate the need for future scoliosis treatment. As patients get older, their doctor may recommend growing rods, which are special rods attached to the spine that require a surgical lengthening approximately every six months to allow continued growth of the spine, chest cavity and lungs.

Halo-Gravity Traction

With this method, surgeons attach a ring to the person’s skull and then suspend them by their own body weight with the use of traction. This process stretches and strengthens the spine prior to surgery. This method is frequently used for children with large or rigid curvatures, such as some patients with neuromuscular scoliosis and AIS patients with curvatures approaching 100 degrees.

Scoliosis Surgery

For adolescent idiopathic scoliosis (AIS), the range for surgical candidacy depends on the individual, but it’s typically reserved for curvatures approaching 50 to 60 degrees or more. For early onset scoliosis, the threshold may be curvatures greater than 10 degrees in children younger than 10 years old.

While the relationship between scoliosis and pain is complex, Dr. Rathjen says some patients with preoperative pain may find some relief from that pain with surgery, though it’s not guaranteed. Alternatively, patients who have high levels of anxiety about surgery and fear of the unknown may experience worsened pain symptoms. Straightening the spine, however, may also help bolster a patient’s self-image.

“Your emotional state totally turns on your perception,” says Dr. Rathjen. “If you feel better about your back, does your back feel better?”

Spinal Fusion

Today, the most common surgical option for AIS is a posterior spinal fusion and instrumentation. This procedure involves the correction of spinal curvature and permanently freezing it in that position with a fusion. In this invasive procedure, an incision is made through the back to reveal the vertebrae, where the surgeon attaches anchor points (screws) the spine, to which they then attach two rods. The screws and rods are used to pull the spine into a straight correction. Meanwhile, a bone graft is placed in between the vertebrae, which, as the spine heals, fuses the vertebrae into a single column of solid bone.

The location of each fusion and the number of vertebrae fused depends on the location and extent of the spinal curvature(s). It takes approximately six months to a year to complete the final fusion of bone.

The surgery has a very good success rate with low risk for complications, according to pediatric orthopedic surgeon Dan Sucato, M.D., chief of staff and director of the Scottish Rite Center for Excellence in Spine Research. However, surgery inhibits motion of the spine in the fused segments.

“Children and adolescents don’t notice that much, especially if it’s in the thoracic spine,” says Dr. Sucato. “If it’s in the lumbar spine, that’s more noticeable in terms of their lack of motion and being able to bend forward to the extremes that they were doing before. [But] from a functional standpoint, they’re able to get back to doing all activities.”

Vertebral Body Tethering (VBT)

VBT is a surgery used to treat AIS. The concept is to correct—but not fuse—the spine. It works like an internal brace that maintains full motion of the individual vertebrae in the spine. The surgery involves tethering the convex side of the spine, which theoretically allows the concave side to continue to grow and correct the curve.

Though people may think harnessing curve correction in VBT surgery sounds more appealing than spinal fusion, Dr. Rathjen says the procedure’s outcomes are far less predictable.

“The data [for this surgery is] somewhat promising, but also somewhat concerning,” says Dr. Sucato. “The mechanical aspect to it is fairly straightforward. I think the problem is we just don’t understand growth as much as we would like in each child and how the spine grows, and therefore, there have been some challenges along the way.”

Dr. Rathjen agrees, noting that “most families overestimate the value of motion in the spine and underestimate the difficulty of surgery from tethering.”

MAGEC Growing Rods

MAGnetic Expansion Control (MAGEC) growing rods are used to treat early onset scoliosis. Following initial surgical implantation, the rods are lengthened as the child grows via a magnetic remote control. MAGEC rods support spinal correction for moderate and severe EOS as the child grows. They also prevent complications that could arise from repeated invasive surgery and anesthesia exposure, which is required to adjust traditional growing rods.

Recovery from Scoliosis Surgery

Advancements in scoliosis surgery have been tremendous in recent years, facilitating a much faster surgical recovery for patients.

Spinal fusion surgery previously used a hybrid of screws and hooks to hold the spine in place, but surgeons have transitioned to the exclusive use of pedicle screws (a type of screw that provides extra support and strength to the fusion while it heals), leading to improved correction (including derotation), shorter fusions and lower risks of complications.

Real-time monitoring of the spinal cord has also improved, making surgery safer than ever before. Enhanced Recovery after Surgery (ERAS) programs, including but not limited to advancements in the types of drugs and pain management patients receive, allows patients to have shorter postoperative hospital stays and heal more quickly.

More than a decade ago, it was not uncommon for spinal fusion surgery to require a three-month period of strictly limited activity and a period of six to 12 months before a patient could resume normal activities. Now, Dr. Rathjen says patients who receive the same surgery can return to half days at school after about two weeks and return to normal daily activities within five weeks. As far as a return to full athletic activities goes, “I tell patients that they are only limited by pain,” he says. “Your body will allow you to do what you will do, which is more than you think.”

Wearing a scoliosis brace can be an incredibly difficult experience, both physically and mentally, which can negatively affect bracewear compliance. Still, bracing for scoliosis is the most effective non-invasive treatment available that physicians can recommend to their patients whose spinal curvatures do not meet the threshold for surgery.

Only 30% to 50% of patients wear their brace as recommended, according to Dr. Rathjen. Though patients are counseled on its importance, compliance wanes after the first six months of wear, especially if a patient is early in skeletal maturity and looking at potentially wearing their brace for a minimum of two years. Even still, one in four AIS patients’ curvatures will progress to levels requiring surgery within the first 10 years after they stop wearing the brace.

Conversely, fear of surgery makes some patients hypercompliant with their bracewear, adds Dr. Rathjen.

Research in a variety of health domains shows emotional health can directly affect both physical health and treatment outcomes.

Dr. Rathjen sees this connection manifest in his practice, which has led to his strong interest in the emotional health of his patients with scoliosis. “I think [emotional health] drives a tremendous amount of scientific evidence across medical fields,” he says. “Socioeconomic and emotional health probably have a bigger impact on [overall] health than anything else.”

Patients in scoliosis treatment who are supported and validated throughout their experiences are most likely to have successful treatment outcomes, observes Dr. Rathjen. He says those who are ashamed of their brace, lack sufficient emotional support and/or engage in power struggles with family members over wearing their brace are less likely to wear it. However, patients who accept scoliosis and bracewear as part of their identity and who share it with their families and friends have much better outcomes.

For parents of AIS patients in braces specifically, he recommends being an advocate for your child’s independence. Rather than fighting them to do something that may be difficult, gamify the experience by providing incentives for doing the job well. Such incentives should be age-appropriate and based on the motivation(s) of that particular child.

Additionally, surveys provided to patients and their family members during clinic visits can help a patient’s medical team evaluate how all parties feel about the way treatment is going. For those who could benefit from additional support, a referral to a psychologist, behavioral therapist for families and/or peer support groups are recommended.

“We are aware of the emotional toll and resilience [it takes] to wear a brace, and we are doing things for it as far as measuring it and [learning] how to make it better,” says Dr. Rathjen.

Despite all that’s known about scoliosis, there’s still much to learn and understand about this condition.

Dr. Rathjen hopes for a new scoliosis brace concept in the near future that’s easier to wear so more than 80% of patients are brace compliant, therefore decreasing the number of patients in surgery. “The back is designed to move,” he adds, and 100 years from now, he expects us to laugh at the concept of a spinal fusion. Ultimately, he hopes there will be more studies delving into the emotional cost of scoliosis—particularly when wearing a brace—as well as factors that allow a patient to continue to move throughout—and after—treatment.

Current research challenges include the ever-present need for more funding, as well as the need for more detailed phenotyping (clinical evaluation) of patients with scoliosis to help identify specific subtypes of scoliosis that respond to different treatments. “This is where the intersection of basic and clinical research may have the greatest impact: understanding why some patient curves progress despite current bracing treatment and developing new strategies for those patients,” says Carol Wise, Ph.D., director of molecular genetics and the director of basic research at the Scottish Rite Center for Excellence in Spine Research, and Jonathan Rios, Ph.D., assistant director of molecular genetics at Scottish Rite.

“The end result we’re hoping for is to cure this disorder,” adds Dr. Wise, who was the first to identify a gene for adolescent idiopathic scoliosis (AIS). “Certainly, [we hope] to treat [scoliosis] noninvasively so that we’re not taking children to surgery to correct a deformity of their spine,” she says.

“The most important thing that we do is ask: What are the important clinical questions we have for our patients?” shares Dr. Sucato. “And what are the answers we don’t have today that we can research today so we have a better answer for tomorrow?”