What is a Spine?
The Spine is an integral part of the human body that protects our spinal cord and supports our body weight. A healthy spine is made up of multiple small bones called vertebrae that are stacked on top of each other with fibrous discs placed in between them. These small bones are interlocked together by facet joints and are supported by ligament and back muscles to form a flexible and stable spine to support body weight.
Anatomy of the Spine
- The anatomy of the spine can be described by subdividing it into three major regions: Cervical, Thoracic and Lumbar Spine.
- Cervical Spine: (C-Spine) is the upper portion of the Spine that supports the head and neck; it comprises if seven vertebrae.
- Thoracic Spine: (T-Spine) comprises of 12 vertebrae and the supports the torso region.
- Lumbar Spine: It is made up of 5 large vertebrae and is responsible for supporting the body’s mass and weight.
The Spine runs from the lower part of our skull to the pelvis with three gentle curves which give it an ‘S’ shape. These three natural curves absorb the stress from our body movements and make sure that our weight is evenly distributed. As a part of a healthy spine, they work in tandem to keep everything balanced and stable giving an upright position.
Abnormal Spinal Curve and Spinal Deformities
An abnormal curvature of the spine creates an imbalance and puts uneven stress on the body creating a domino effect on other body movements and functions as well. This abnormality in the curvature that is seen from the side includes Kyphosis, Flatback syndrome, chin-on-chest syndrome. The abnormality of the spine that manifests when seen from the back is called Scoliosis, which is considered the most critical deformity of the lot, if left untreated.
Scoliosis is a neuro-muscular condition in which a patient’s spine in the back is curved sideways at an abnormal angle and may also undergo rotation as the condition progresses. The angle of the curve varies based on the severity of the condition but if the angle is more than 10 degree, it is considered as Scoliosis. Read more
Structural Scoliosis is when the patient suffers from abnormal lateral curve and rotation of the spine and Non-structural Scoliosis is when the spine is affected by the sideways curve only. The cases of Scoliosis can be further classified based on their etiology (causes):
Idiopathic Scoliosis is the most common type of Scoliosis that generally affects children. The curves in Idiopathic Scoliosis are mostly mild but as the condition develops during the growth phase, the curves can worsen affecting lungs, joints and causing other deadly problems.
Though it can also develop in toddlers in most cases it hits right after puberty. As the curves are mild, the condition may fly under the radar until it gets noticed and treated. The treatment of Idiopathic Scoliosis depends on its onset and it can be classified further into three types based on the age of onset
Infantile Idiopathic Scoliosis
Scoliosis that is diagnosed in children between their birth and age 3 is defined as Infantile Idiopathic Scoliosis. It accounts for 1% of total Scoliosis cases of which 60% of them are males. In addition to the age of onset, the diagnosis of the condition is based on the location of the curve, physical examination, other spinal cord problems, X-rays and MRI.
While some children have their mild curve unchanged and stable, some of them have a curve that progresses gradually. The child with this type of deformity is kept under observation of the paediatric spine surgeon to determine if the spinal curve is progressing. The observation is done until there is a sudden increase in the curve. Fortunately, in most of the cases, the curve improves and the cases are resolved. However, in cases of the curve showing the progression, other treatment options like casting, bracing, spinal fusion or surgery are used to correct the deformity in development.
Juvenile Idiopathic Scoliosis
Diagnosed in children aged between 4 and 10, Juvenile Idiopathic Scoliosis accounts for around 10 to 15% cases of Idiopathic Scoliosis. At the early end of the age spectrum, this spinal deformity is more predominant among boys and the curve is left sided. The Later end of the spectrum the curve is found to be mostly right sided with girls making the majority of the cases. Both Infantile and Juvenile Scoliosis are together called as early onset scoliosis.
Unlike Infantile Idiopathic Scoliosis, the curves, in this case, do not always resolve spontaneously. Children with Juvenile Idiopathic Scoliosis suffer a higher risk of the curve progression calling for early diagnosis and immediate medical attention. Physiotherapy, Bracing, Casting and Surgery techniques are used to treat Juvenile Idiopathic Scoliosis based on the severity, age, and progression of the spinal curve.
These methods are proven to be very efficient and children treated are expected to live a healthy and active life without any limitations.
Adolescent Idiopathic Scoliosis
By far the most common form of Scoliosis is Adolescent Idiopathic Scoliosis which is diagnosed is children between 10 and 18 years of age that is late childhood or adolescence. It accounts for almost 80% of the Idiopathic cases and most common Scoliosis condition seen by Paediatricians and Spinal Surgeons.
Mild curves of the spine during this age does not cause pain, difficulty in movement or breathing. They often go unnoticed and are first detected by parent or paediatrician during a regular check-up. In most cases the curve is stable but in some cases, they do progress over time and worsen the condition. These progressive curves are more frequent in girls when compared to boys. Read more
Causes of Idiopathic Scoliosis
Infantile, Juvenile or adolescent; etiology of Idiopathic Scoliosis is still unknown, hence the name Idiopathic (without a known cause). Carrying a heavy backpack, heavy sports or bad posture are never the causes of the Idiopathic Scoliosis. In fact, infants or kids do not have any control over the onset, it probably results from the genetic factors. Though this means that it could run in the family, it is often the rest of a ‘spontaneous mutation’. That doesn’t mean it cannot be treated.
Mild or severe, the onset of Scoliosis below 10 years of age is called as Early Onset Scoliosis (Infantile + Juvenile Idiopathic Scoliosis). But there are other types of Scoliosis that affect children other than the Idiopathic cases.
Unlike the above types of Scoliosis where a curve begins to develop at a certain age of the child, Congenital Scoliosis is when the child is born with a birth defects due to failure of formation of some parts of the spine or a failure of differentiation of the spinal segments. This happens because of the underdevelopment of the vertebrae as the child grows inside the womb. These vertebrae which are like the building blocks of a healthy spine. If a part of the spine has not formed or not differentiated as is a predictable norm, it can lead to asymmetric growth. This asymmetry can lead to curvature of spine with the abnormal growth. Read more
What happens after Congenital Scoliosis is discovered?
Though Congenital Scoliosis can be discovered right in the womb, in most cases it is not identified until the baby is more and some it may not appear until teenage years. The patient with Congenital Scoliosis also has more chance of developing breathing, kidney, liver or bladder problems if the curve worsens as the child grows. A series of scans are required early to identify the nature and extent of these problems. The specialists then need to be consulted. These scans include Ultrasound of the abdomen, Echocardiogram of the heart, MRI and CT scans of the entire spinal column.
Neurological or muscular disorders leading to the abnormal curvature of the spine is called Neuromuscular Scoliosis. Abnormalities in the central nervous system of the child and the subsequent alteration in the muscle control subjects the gentle vertebrae of the baby to abnormal forces causing the spinal curves. These curves are more likely to worsen their curvature. As the child grows, the nerve and muscular disorders worsen, weakening the muscles which further creates a more severe and collapsing c-shaped spinal curve.
Tilted, un-even shoulders and waistline, prominent ribs; the symptoms of Neuromuscular Scoliosis is similar to that of Idiopathic Scoliosis. But the progression of the curve is faster and thus the complication is severe and quicker. As the condition continues into the adulthood of the child, it not only deforms the appearance but also hinders the ability to perform daily activities like sitting, eating and dressing.
It is the second most common form of scoliosis after Idiopathic Scoliosis and also is the most dangerous one at that, with progressive complications. However, surgical correction is documented to have a positive impact on the deformity and excellent improvement in the quality of life has been reported post the corrective surgery. Read more
Treatment Options for Neuromuscular Scoliosis
Given the complexity of the condition and its rapid progression, a team of neurologists, Orthopaedists, urologists, and nutritionist work with the child’s paediatrician to help the child’s treatment plan. Treatment depends on the age of the patient, severity, progression of the curve and also the underlying neurological and muscular disorders present at the time of treatment. While non-surgical treatments like bracing can be used to delay the progression of the curve and improve the condition, surgical treatment is deemed mandatory at some point along the line.
Adult Spinal Deformity
Deformities suffered by patients of age 21 and older are called as Adult Spinal Deformities which can include Kyphosis, Scoliosis, Spondylolisthesis or Flatback. These conditions might cause pain and severely impact the daily activities of the patients. Though most of the cases are congenital, it is not uncommon for adult men and women to be affected by spinal deformities. In most cases, these Spinal Deformities happen to develop in adolescence and progressively worsen with age. Sometimes, Spondylolisthesis and Osteoporosis also cause these Spinal Deformities.
Two main types of Adult Spinal Deformities
Anatomy of the Spine
- Adult Idiopathic Scoliosis: Develops in adolescents and progresses into adulthood.
- Adult Degenerative Scoliosis: Develops in adults who have had a history in Scoliosis. The wear and tear of the Spine due to aging and arthritis can cause the disk breakdown and spine collapse resulting in an abnormal spinal curve.
Patients with this condition can experience lower back pain, numbness, stiffness, pain radiating into the legs affecting their quality of life. Physical therapy, exercise, injections are some of the non-surgical alternatives that are temporarily effective in treating the condition. As for surgery, it is performed based on the severity of the condition. Often younger patients are offered surgery to prevent the progression of the deformity. But the recent medical advancements have made the procedure less invasive and efficient for everyone. Read more
Spondylolisthesis is a spinal condition that occurs when one vertebra in your spine rides or slips forward onto another vertebra causing significant pain. As the vertebrae are stacked upon one another with cushions (discs) in between them, this slippage may squish the nerves which run through the spine causing excruciating pain or numbness wherever those nerves go. Age, lifestyle, birth defects, heredity are some of the likely causes of this condition. Sporting activities like football gymnastics, weight lifting may also cause the condition when the lower back pain is subjected to overstress or strain. Read more
Symptoms and Treatment for Spondylolisthesis
Not all the cases report pain but severe cases can hinder your daily activities and require immediate attention. Persistent pain in the back, stiffness, thigh pain, leg pain, hamstring, and glute pain are some of the symptoms suffered by patients with Spondylolisthesis. Physiotherapy sessions, back braces, surgical correction are some of the treatment options available to treat the condition.
Treatment of Scoliosis depends on the severity of the potential progression of the curve. Predominantly, there are two types of treatments
- Non-invasive Treatments: Observation, Bracing, and Casting.
- Invasive Treatments: Surgery – Spinal Fusion, Growing Rods, Anterior, and Posteriors Corrections.
Non-invasive Treatment Options for Scoliosis
Young children are not the ideal candidates for surgery and in fact, they may not even need one in the first place. There are non-invasive treatment options available, that can help in correcting the budding abnormal spinal curve.
Observation: Masterly Inactivity
Not all patients need active treatment for Scoliosis. In most of the cases, Infantile Idiopathic Scoliosis will not progress and the condition of the patient improves without any treatment. The doctor carefully monitors the patient with X-rays to determine the condition of the spine to see if treatment options are necessary. This method is opted if the curves are less than 25 º or patients being treated are past their growth phase and their curves longer pose the problems. These observations continue for years until the patient is ensured by the doctor that the condition doesn’t progress any further. Read more
Bracing is recommended for the patients in their growth phase with a curve greater than 25º but less than 45 º or more. The goal of bracing is to slow the progression of the curve and allow the child to grow until a definitive corrective measure is taken if needed be.
A brace is a stiff plastic jacket that is made to fit around the torso of the child from arms to the hips in order to straighten the spine and keep it in the alignment. Resorting to this rigid brace during this important phase helps in lowering the further progression of the curve. The recommendation of the brace depends on the age of the child and as the child grows, new braces have to be fabricated, say after every 12 or 15 months. Children with a flexible curve between 20 ˚ to 40 ˚ are more likely to benefit from the Bracing procedure. Read more
Given that the ripe time for the progression of Idiopathic Scoliosis is during the growth spurt, Casting is often the first treatment option that is chosen to treat early onset Scoliosis. A serial casting procedure can be used to correct the deformity of the child even before opting for bracing.
The cast can be seen as a non-removable full-time brace that is done under general anaesthesia by a skilled team of surgeons. These casts are changed for every 4-5 months to ensure that the spine comes under proper alignment. This treatment can be followed by bracing to maintain the alignment that is corrected by the Casting. The Casting procedure can be used to correct the curve as well as slow the progression, i.e. restricting the magnitude of the curvature. It is the preferred treatment option of the parents as Casting helps solve the compliance problems that they face with non-cooperating children.
Invasive Treatment Options
Despite treating with the Bracing technique, sometimes the spinal curves continue to grow into adulthood. If the curve progresses more than 45 degrees, the condition is expected to worsen affecting the function of lungs making surgery an inevitable option.
Surgery for Scoliosis
Surgery is the most effective procedure to stop the progressing curve which can become detrimental to the normal function of the patient if left untreated. The surgery can correct the deformity of the spine helping the patient to stand straight and maintain the right body balance.
So, the main goals of opting for surgery are: Stopping the progression of the curve, reducing the body deformity and maintaining the balance of the upper body. To achieve these goals, a spinal fusion procedure is performed where the rods, screws and bone grafts are used to realign the vertebrae and straighten the curve by fusing them together as one bone. The surgeon attaches metal rods to either side of the spine using screws and hooks, with a bone graft placed between the vertebral spaces. The bone graft placed in the vertebrae grows and fuses the vertebrae together and the metal rods ensure that the spine stays straight while the fusion takes place. This process is called spinal fusion, a front line procedure opted to permanently straighten the spinal curve in the back.
This procedure is approached via either front side (anterior) or back (posterior) of the patient depending upon the ease of access and location of the curve.
Posterior Scoliosis Surgery: The surgery is performed by making an incision along the midline of the posterior (back). This is the most often used approach surgery to correct the abnormal curve of the spine and is found effective for all type of curves. Read more
Anterior Scoliosis Surgery: In the case of the ASS, this incision is made on the side over the wall of the chest or abdomen based on the curve s location. This approach opts while treating the curves at the lower back and renders a more favourable outcome. Read more
Growing Rods Systems
Insertion of metal rods can help young children with progressive scoliosis where bracing was not successful enough to stabilize the curve. These metal rods are inserted to support the back and align the spine without opting for the complicated fusion procedure. As the children grow these rods have to be replaced for every 6 months to ensure the alignment of the spine. With the advanced surgical option of magnetic rods, this replacement surgery can be avoided by using an external remote which controls the expansion of the rod that is implanted inside the patient. Read more
Minimal Invasive Surgery for Scoliosis: Anterior Scoliosis Corrective Surgery
Anterior Scoliosis Corrective Surgery is a new approach to the surgery that uses a flexible cord instead of metal rods to correct the deformity. This approach uses the growth spurt of the patient to modulate the bone growth by implanting the screws on the deformed vertebrae, running a flexible cord through them and tightening it to straighten the spinal curvature. This minimally invasive surgical approach to scoliosis not only preserves the flexibility of the spine but also helps in optimal growth correcting the spine over time without stiffening it.
While there are many surgical procedures to accomplish these goals, the choice of the surgical approach depends upon a variety of factors that include the location of the curve, ease of access to the region and your surgeon. Latest advances in scoliosis surgery procedures have made sure that abnormal curve is straightened over time without any further complications. So, if you notice any change in your kid’s condition we advise you to consult your nearest Spinal Surgeon as soon as possible.