The backbone to good health is good spinal health – and it starts in childhood. 

We’ve all heard it: “Stand up straight. Shoulders back, head up.” But for kids with scoliosis, following those simple commands may not be simple at all. 

A sideways curvature of the spine, scoliosis is most often diagnosed in adolescents between the ages of 10 and 12 years old. Most cases of scoliosis are mild, but some curves worsen as the child grows and severe cases can be disabling. According to Johns Hopkins Medicine, roughly 3 million U.S. children are diagnosed with scoliosis each year.  

Locally, some of those children receive care from Dr. Scott Luhmann, head of surgery in pediatric orthopaedics at Shriners Hospital for Children-St. Louis and pediatric surgeon at Washington University Orthopedics. Luhmann specializes in pediatric and adolescent orthopedic surgery, with special expertise in reconstructive spine surgery of the cervical, thoracic and lumbar spine; and congenital, neuromuscular and early-onset scoliosis.  

While he said scoliosis diagnoses have stayed constant over the years, the majority of cases (idiopathic) have no known cause. 

In children, scoliosis diagnoses fall into four broad-based buckets: idiopathic, congenital, neuromuscular and syndromic. Cases that present during adolescent growth spurts are idiopathic in nature. 

“Most individuals with idiopathic scoliosis are involved, to some degree, in athletic endeavors whether it be recreational or high-level competition, at the time they are diagnosed with scoliosis,” Luhmann said. “Often sports are interwoven into their day-to-day activities, so a new diagnosis of scoliosis raises questions about what sporting activities and level of participation, a person with scoliosis may participate.”

Congenital scoliosis is defined as asymmetric growth at birth, or as a young infant, while neuromuscular scoliosis can occur in children who have existing spinal medical conditions, such as muscular dystrophy, cerebral palsy, Marfan syndrome and spina bifida. Syndromic scoliosis occurs as part of genetic and non-genetic syndromes, such as Ehlers-Danlos, Prader Willi and Down syndrome.

Doctor checking patient for scoliosis

Dr. Scott Luhmann examining a patient with scoliosis. (Photo courtesy of physician)

A scoliosis diagnosis is made when the spine curves more than 10 degrees off center. “A huge amount of population has up to a 10-degree curvature and doesn’t know it,” Luhmann said. 

With low magnitude scoliosis, up to 20 degrees of curvature, the ratio is 1:1 male to female. However, Luhmann said gender bias comes into play in surgical cases of 50-degrees or higher – and the medical community does not know why. 

“Females are much more likely to need surgical intervention, with a ratio of 8:2 female to male cases,” Luhmann said.

In general, with lower magnitude deformity (less than 20 degrees), observation is warranted over treatment. When deformities are less than 20 degrees, physicians will consider the patient’s age, diagnosis, medical history, previous treatment, medical condition and other aspects of the spine when constructing possible treatment options.

The two most critical periods for spinal growth are up to age 5 and around puberty.

“The time between these two periods, specifically around 5 years (of age) to the start of puberty, the child and spine do grow but not as rapidly as those earlier and later time periods. Hence, a slower progression of a spinal deformity is typically expected during this time period,” Luhmann explained.

In early-onset scoliosis (under age 10), compromised lung capacity is the main concern. The two main issues impacting a child’s lungs are the shortening of the spine (neck to pelvis) and the twisting of the spine. Other organ systems (heart, gastrointestinal) are impacted to a lesser degree and, unlike the impact on lungs, can be more easily reversed. 

According to the Mayo Clinic, signs and symptoms of scoliosis can include uneven shoulders with one shoulder blade appearing more prominent than the other; having an uneven waist with one hip higher than the other; having one side of the child’s rib cage jutting forward; or prominence on one side of the back when bending forward. In most scoliosis cases, the spine will rotate or twist in addition to curving side to side. This causes the ribs or muscles on one side of the body to stick out farther than those on the other side.

Since scoliosis can develop gradually and without pain, parents and children may not realize that changes are taking place. Having a child’s physician do a scoliosis check as part of their annual physical can help detect scoliosis when it is easiest to treat. 

In response to questions he has received over the years, Luhmann began addressing different aspects of scoliosis in a blog (growingspineblog.wustl.edu). The blog addresses treatment options, post-operative care and the impact of scoliosis on the patient. 

One treatment option involves wearing a brace and regularly performing specific exercises to help stop the curvature’s progression. The combination is extremely effective to maximize correction and function while minimizing pain and discomfort, Luhmann writes in his blog. 

“Compliance with the brace is very individually specific as it can have a negative psyche-social impact,” Luhmann said. “It is mainly the girls who don’t want to look different.”

Surgical correction options for severe cases of scoliosis can include:

• Fusing two or more vertebrae together and inserting bone or a bone-like material to create a straight plane. According to the Mayo Clinic, metal rods, hooks, screws or wires typically hold that part of the spine straight and still while the old and new bone material fuses together.

If the scoliosis is progressing rapidly at a young age, surgeons can attach one or two expandable rods along the spine that can adjust in length as the child grows. According to the Mayo Clinic, the rods are lengthened every 3 to 6 months either with surgery or in the clinic using a remote control.

• Vertebral body tethering, which involves surgically placing screws along the outside edge of the abnormal spinal curve through which a strong, flexible cord is threaded. When the cord is tightened, the spine straightens. According to the Mayo Clinic, as the child grows, the spine may straighten even more.

Surgery is not the answer for every patient with scoliosis.

In his blog, Luhmann also offers advice for mitigating back pain while living with scoliosis. His three top recommendations include: staying away from nicotine, which can burn out discs in the neck and lower back and accelerate arthritis; maintaining an ideal body weight; and engaging in aerobic, or fitness, activities that cause perspiration and raise the heart rate while simultaneously improving core and abdominal muscles.

“The first instinct with back pain is to lay down. That is wrong,” Lohmann said. “Exercise is much healthier and there should be an improvement of back pain. We encourage all patients with scoliosis to be as athletically active as they desire, as the benefits of an active lifestyle are well-known.”