Scoliosis

Scoliosis is a condition where the spine curves sideways, often forming a C or S shape, instead of being straight. While most cases are mild and don’t cause symptoms, it can sometimes lead to back pain and uneven posture. This condition affects millions of people worldwide and is most commonly diagnosed during adolescence.

Table of contents

• What is scoliosis?
• Types of scoliosis
• How common is scoliosis?
• Symptoms and signs
• Causes of scoliosis
• Parts of the spine affected
• How is scoliosis diagnosed?
• Treatment options
• Living with scoliosis

What is scoliosis?

Scoliosis is an abnormal sideways curvature of the spine.^[1] Your spine naturally has slight curves when viewed from the side – the upper back bows outward and the lower back curves slightly inward. However, when viewed from behind, a healthy spine should appear as a straight line from the base of the neck to the tailbone.^[2]

With scoliosis, the spine curves to the left or right, creating a C or S shape when viewed from behind.^[1] This is different from the normal front-to-back curves your body naturally has. Scoliosis is usually defined as a spinal curvature that measures greater than 10 degrees on an X-ray.^[7]

Scoliosis is more complex than just a simple sideways curve. It’s actually a three-dimensional problem that affects the spine in multiple ways. Most often, the spine rotates or twists as well as curving side to side.^[2] This rotation causes the ribs or muscles on one side of the back to stick out more than the other side.^[2]

• Spine (vertebral column)
• Cervical spine (neck)
• Thoracic spine (upper and middle back)
• Lumbar spine (lower back)

Types of scoliosis

Healthcare providers classify scoliosis into several types based on its cause and when it develops. Understanding these different types helps doctors determine the best treatment approach for each patient.

Idiopathic scoliosis is by far the most common type, accounting for about 80 percent of all cases.^[4] The word “idiopathic” means the cause is unknown, although research suggests it may run in families and have a genetic link.^[1] Healthcare providers further divide idiopathic scoliosis based on the age when it’s diagnosed:^[1]

• Infantile scoliosis: Diagnosed in children younger than age 3
• Juvenile scoliosis: Diagnosed in children age 4 through 10
• Adolescent scoliosis: Diagnosed in children age 11 through 18 (this is the most common form)
• Adult idiopathic scoliosis: Diagnosed any time after age 18 when skeletal growth is complete

Congenital scoliosis is a rare spine abnormality present at birth that a healthcare provider may detect when a baby is born.^[1] It occurs when the bones that make up the spine (vertebrae) don’t form properly during development before birth. Because these abnormalities are present from birth, congenital scoliosis is usually detected at a younger age than idiopathic scoliosis.^[4] Patients with congenital scoliosis must be evaluated for cardiac and renal abnormalities.^[5]

Neuromuscular scoliosis develops when abnormalities in the muscles and nerves that support the spine cause the curvature.^[1] This type usually happens alongside other conditions that affect the nervous system or muscles, such as spinal cord injury, cerebral palsy, spina bifida, or muscular dystrophy.^[1] Neuromuscular scoliosis generally progresses more rapidly than idiopathic scoliosis and often requires surgical treatment.^[4]

Degenerative scoliosis (also called adult-onset scoliosis) affects older adults and is caused by wear and tear on the spinal joints or discs.^[1] Some people may have had mild, undiagnosed scoliosis throughout their life, but symptoms increase or appear as the body ages. This type specifically develops when disks and joints weaken or when people lose bone density (osteoporosis).^[1]

How common is scoliosis?

Scoliosis is one of the most common spinal conditions. It affects an estimated 2 to 3 percent of the population worldwide.^[4] In the United States alone, this equals over 6 to 9 million people.^[1]

Scoliosis can develop in infancy or early childhood, but the primary age when it appears is between 10 and 15 years old, occurring equally among both boys and girls.^[4] However, girls are eight times more likely to develop a curve severe enough to require treatment.^[4] Adolescent idiopathic scoliosis is 10 times more common in girls than boys.^[7]

Every year in the United States, scoliosis patients make more than 600,000 visits to private physician offices. An estimated 30,000 children are fitted with a brace, and 38,000 patients undergo spinal fusion surgery annually.^[4]

Symptoms and signs

Most people with scoliosis don’t experience symptoms, especially in mild cases. However, some symptoms can occur, particularly as the condition progresses or in adults with the condition.^[1]

Symptoms that may occur include:^[1]

• Back pain
• Difficulty standing upright
• Core muscle weakness
• Leg pain, numbness or weakness

Back pain is common in people who develop scoliosis as an adult, but it’s rare among children and adolescents. When a child or teenager with scoliosis experiences back pain, this may be a sign that they have some additional condition.^[14] In one study, about 23 percent of patients with idiopathic scoliosis presented with back pain at the time of initial diagnosis. Ten percent of these patients were found to have an underlying associated condition.^[4]

Because scoliosis doesn’t usually cause symptoms that you can feel, many people have it and don’t even know. This is why recognizing the visible signs is so important. Signs of scoliosis that can be seen include:^[1][2]

• A visibly curved spine
• Uneven shoulders – one or both shoulder blades may stick out
• Head that doesn’t center directly above the pelvis
• Uneven waist
• One hip higher than the other or elevated hips
• Constant leaning to one side
• Uneven leg length
• One side of the rib cage pushing forward or sticking out on one side
• Changes in skin appearance or texture (dimples, hair patches, skin discoloration) on the back along the spine^[1]

Over time, people with scoliosis may also notice height loss and uneven alignment of the pelvis and hips.^[1] Due to changes in the shape and size of the chest, scoliosis may affect lung function, and severe curves can push on the lungs and make it hard to breathe.^[2]

If you notice any of these signs in yourself or your child, contact a healthcare provider for a screening.^[1] It’s unlikely that there’s anything seriously wrong, but it’s best to get it checked out.^[3]

Causes of scoliosis

The cause of scoliosis varies depending on the type. In more than 80 percent of cases, a specific cause is not found, and these cases are termed “idiopathic,” meaning “of undetermined cause.”^[7] Idiopathic scoliosis cannot be prevented and is not thought to be linked to things such as bad posture, exercise, or diet.^[3]

Despite being called “idiopathic,” research does indicate that this type may run in families and has a genetic (hereditary) link.^[1] Your genes may make you more likely to get it, as it sometimes runs in families.^[3]

When the cause can be identified, it may include:^[1]

• Vertebrae (the bones that make up the spine) that don’t form properly during development before birth
• A genetic change
• A spine injury
• A tumor on the spine
• Conditions that affect the nerves or muscles

Less commonly, scoliosis may be caused by:^[3]

• The bones in the spine not forming properly in the womb (congenital scoliosis, present from birth)
• An underlying nerve or muscle condition, such as cerebral palsy or muscular dystrophy (neuromuscular scoliosis)
• Wear and tear of the spine with age (degenerative scoliosis, which affects older adults)

The main cause of scoliosis is not well understood. However, some factors that may influence the development of this condition include genetics, growth patterns, hormonal changes, bone mineral density changes, abnormalities in body tissue, abnormal platelet calmodulin levels, biomechanical factors, and central nervous system abnormalities.^[16]

Parts of the spine affected

Scoliosis can affect any part of the spine. The spine has three major sections: the cervical spine (neck), thoracic spine (chest and upper back region), and lumbar spine (lower back).^[4]

The location where scoliosis develops can differ depending on age:^[1]

• In adolescents: Most cases occur in the thoracic spine (rib cage) area
• In adults: The main concern is in the lumbar or lower spine. The lumbar spine is most susceptible to the changes seen with aging or degeneration, which increases symptoms like pain

How is scoliosis diagnosed?

To diagnose scoliosis, a healthcare professional typically begins with a medical history and asks about recent growth. During the physical examination, the provider may have the patient stand in a relaxed position with arms at the sides and will view them from behind, looking for curvature of the spine, shoulder blade asymmetry, waistline asymmetry, and any shift in the trunk.^[7]

A key part of the examination is having the patient bend forward at the waist with arms hanging loosely. This position allows the healthcare provider to observe the rotation of the spine. Scoliosis can create a rib prominence in the upper back or a flank or waist prominence in the lower back.^[7] This is because the spine rotates as well as curves side to side, causing one side of the rib cage to stand out more than the other.^[2]

If scoliosis is suspected following the physical examination, the healthcare provider will usually order X-rays of the entire spine from the neck to the pelvis, including both back and side views.^[7] X-rays can confirm the diagnosis of scoliosis and measure the spinal curve. If scoliosis is present, the doctor will measure the spine’s curves and provide a number in degrees to help describe the severity.^[7]

Children who are growing most often get X-rays every six months to see if the curve is getting worse.^[9] To reduce radiation exposure from repeated X-rays, some medical centers offer special types of X-ray imaging that use much lower doses of radiation.^[9] Some children may also get an X-ray of the hand to show how much more they’ll grow, as the hand X-ray shows whether the growth plates are open and still growing.^[9]

A healthcare provider may also perform a neurological exam to check for muscle weakness, numbness, and reflexes.^[9] An MRI scan might be ordered if the healthcare professional suspects that an underlying condition, such as a spinal cord issue, is causing the scoliosis. MRI scans don’t use radiation.^[9]

A patient should be referred to a specialist if the curve is greater than 10 degrees in a patient younger than 10 years of age, is greater than 20 degrees in a patient 10 years of age or older, has atypical features, or is associated with back pain or neurological abnormalities.^[5]

Treatment options

Most cases of scoliosis are mild, don’t cause symptoms, and don’t need treatment.^[1] Many people with scoliosis will not need any treatment, and only a small number will need surgery on their spine.^[3] The treatment for scoliosis depends on several factors, including age, the severity of the curve, and the risk of progression.^[5]

Observation

Observation is recommended for curves less than 25 to 30 degrees or for people who have stopped growing and have curves that aren’t changing or causing problems.^[13] Many children have curves that will never progress past 25 or 30 degrees and will never need to wear a brace. X-ray evaluations occur every 4 to 6 months so doctors can determine whether bracing is necessary.^[13]

Children who have mild curves (less than 20 degrees) and are still growing will usually be monitored to make sure the curve is not getting worse. The doctor will check the growing child’s spine about every 6 to 12 months. If the child is fully grown, they may not ever need more X-rays.^[11] Observations may continue for years, with doctor visits reduced to every year or every few years, to ensure the scoliosis doesn’t progress into adulthood.^[13]

Bracing

Wearing a brace is recommended for curves larger than 25 degrees but smaller than 45 to 50 degrees in someone who is still growing.^[13] The goal of wearing a brace is to stop the curves from getting bigger, not to cure scoliosis or make the curve smaller.^[17] A brace can help prevent a curve from getting worse.^[3]

For babies and toddlers, a plaster cast or plastic brace may be fitted to their back to stop the curve from getting worse as they grow.^[3] Older children may wear a back brace to stop the curve from getting worse until they stop growing.^[3]

Back braces are not often used in adults with scoliosis, but they can provide pain relief by supporting the spine. A brace may be considered as an alternative to surgery if a person is not well enough to undergo an operation.^[12]

Physical therapy and exercise

Physical activity is generally beneficial for people with scoliosis. Unless there is pain or a doctor gives specific instructions, patients should continue to participate in the activities and sports they love, even if they wear a brace.^[17] Keeping the core trunk strong is good for the back.^[17]

Activities that strengthen and stretch the back may help reduce pain. Exercise can also help maintain a healthy weight, which can reduce the strain on the back.^[12] Some people may benefit from doing back exercises taught by a physiotherapist. These are unlikely to improve the curvature of the spine but may help with pain.^[12]

Best exercises for people with scoliosis include core strengthening exercises like planks and gentle Pilates movements, yoga and stretching (such as cat-cow stretch or child’s pose), aquatic therapy, and walking.^[20] It does not matter what type of exercise is chosen; the important thing is to keep the back moving.^[12]

It’s not clear whether back exercises help improve scoliosis, but general exercise is good for overall health and should not be avoided unless advised by a doctor.^[3] Some professionals believe scoliosis-specific exercises can prevent curvature from getting worse, although evidence is limited.^[11]

Pain management

For adults, treatment is mainly aimed at pain relief.^[12] Painkilling tablets may help relieve the pain that can be associated with scoliosis. NSAIDs (nonsteroidal anti-inflammatory drugs), such as ibuprofen, are usually the first treatment recommended. These are available to buy from pharmacies and supermarkets without a prescription.^[12]

If over-the-counter painkillers do not work, a healthcare provider may prescribe stronger painkillers or refer the patient to a specialist pain management clinic.^[12] Scoliosis can sometimes irritate or put pressure on the nerves in and around the spine. In these cases, injections of steroids and local anesthetic given into the back may help, though the benefits normally only last a few weeks or months.^[12]

Other pain management strategies include heat therapy (applying a heating pad to sore muscles), massage therapy to relieve muscle stiffness, and mindfulness techniques like meditation, deep breathing, and progressive muscle relaxation.^[20]

Surgery

Surgery is recommended for people with curves usually greater than 45 or 50 degrees and who are at high risk of continued worsening even after they are finished growing.^[13] Curves that grow very large may cause pain, limit certain body functions, and cause difficulty or discomfort in breathing.^[13]

Most adults with scoliosis will not need surgery. However, it may be considered if the curve in the spine is severe or getting significantly worse, if there is severe back pain and other treatments have not helped, or if the nerves in the spine are being irritated or squeezed.^[12]

Surgery may involve lumbar decompression surgery to relieve pressure on nerves in the spine, or spinal fusion to join two or more vertebrae together to stabilize, strengthen, and straighten the spine.^[12] Sometimes surgery may be needed to control the growth of the spine until an operation to straighten it can be done when growth stops.^[3]

Spinal surgery is a major operation, and it can take up to a year or more to fully recover. It also carries a risk of potentially serious complications, including failure to reduce pain, wound infection, blood clot, and rarely, damage to the nerves in the spine.^[12] Surgery is almost always a family decision, one that patients and their families or guardians will make based on how they feel.^[13]

Living with scoliosis

Most people with scoliosis are able to live normal lives and can do most activities, including exercise and sports.^[3] With the right strategies, people with scoliosis can improve their quality of life and maintain an active, healthy lifestyle.^[20]

The condition does not usually cause significant pain or any other health problems and tends to stay the same after growth stops.^[3] However, it’s important to see a healthcare provider if the condition gets any worse.^[3]

Daily life adjustments

Maintaining proper posture is especially important for people with scoliosis, as it can help alleviate strain on the spine and reduce discomfort. This includes distributing weight evenly when standing, using chairs with good lumbar support, and keeping shoulders open by rolling them back.^[20]

Setting up home and workspace to support physical comfort is crucial. This can include using adjustable chairs, raising computer monitors to eye level, sleeping on a supportive mattress (medium-firm mattresses are often recommended), and wearing shoes with adequate arch support.^[20]

Lying on the back is typically the best sleeping position for scoliosis because it helps the entire spine remain elongated, preventing twisting and bending. Using a thin pillow under the neck can put it in a more natural position.^[22]

Activities and restrictions

Physical activity is generally beneficial, and unless there is pain or specific instructions from a doctor, people with scoliosis should continue to participate in the activities and sports they love.^[17] In fact, keeping the core trunk strong is good for the back.^[17]

While carrying a heavy backpack is not good for the back or posture in general, it will not worsen scoliosis.^[6] People with scoliosis should avoid certain activities only if they are in pain or if their doctor gives them certain instructions.^[17]

Emotional support

Having scoliosis or wearing a back brace can be tough and may cause problems with body image and self-esteem, particularly for children and teenagers.^[3] If wearing a brace, it’s important to remember that the person wearing it is much more aware of its presence than others. In many instances, others don’t notice the brace unless attention is brought to it.^[17]

Finding a support group can be very helpful. Starting with friends and explaining how the scoliosis diagnosis affects daily life can help build a support system. It can also be useful to contact a support group, such as Scoliosis Support & Research. These groups are a good source of information and support, and they may be able to connect people with others in similar situations.^[3]

Long-term outlook

Predicting curve progression in individuals remains difficult, even with research and evidence from the general population. However, some trends have been observed: thoracic (upper and middle back) curves typically progress more rapidly than lumbar curves, larger curves are more likely to progress, and the further away a patient is from reaching full growth, the greater the likelihood for curve progression.^[17]

Once someone is fully grown, scoliosis curves less than 30 degrees are unlikely to worsen significantly.^[11] Generally, the curves in a spine with scoliosis can’t be reversed without surgery.^[17] The goal of wearing a brace is to stop the curves from getting bigger, not to cure scoliosis.^[17]