Scoliosis

About scoliosis

Scoliosis is the abnormal twisting and curvature of the spine.

It is usually first noticed by a change in appearance of the back.

Typical signs include:

• a visibly curved spine
• one shoulder being higher than the other
• one shoulder or hip being more prominent than the other
• clothes not hanging properly
• a prominent ribcage
• a difference in leg lengths

Back pain is common in adults with scoliosis. Young people with scoliosis may also experience some discomfort but it’s less likely to be severe.

When to get professional help

If you or your child have signs of scoliosis, make an appointment to see your GP. They can examine your back and can refer you for an X-ray for confirmation.

If you or your child are diagnosed with scoliosis, it’s important to see a scoliosis specialist to talk about treatment options.

Read more about diagnosing scoliosis.

Rarely scoliosis can cause a condition called cauda equina syndrome to develop. Cauda equina syndrome is a rare but serious back condition which can lead to permanent damage or disability. If you develop this condition you’ll need to be seen by an emergency specialist spinal team.

What causes scoliosis?

In around eight out of every 10 cases, a cause for scoliosis is not found. This is known as idiopathic scoliosis.

A small number of cases are caused by other medical conditions, including:

• cerebral palsy – a condition  associated with brain damage
• muscular dystrophy – a genetic condition that causes muscle weakness 
• Marfan syndrome – a disorder of the connective tissues

Rarely, babies can be born with scoliosis, as a result of a problem with the development of the spine in the womb.

In adults, age related changes in the discs and joints of the spine and a reduction in bone density may cause scoliosis. Adults can also experience worsening over time of previously undiagnosed or untreated scoliosis.

Read more about the causes of scoliosis.

Who is affected

It used to be thought that scoliosis was only a childhood condition, but it’s now increasingly recognised as a condition that affects older adults as well.

It can develop at any age, but is most common in children aged 10-15. In the UK, around three or four in every 1,000 children need treatment for scoliosis.

It’s more common in females than males.

How scoliosis is treated

Treatment for scoliosis depends on your age, how severe it is, and whether it’s thought it will worsen with time.

In very young children, treatment is not always necessary because the curvature of the spine may improve naturally as they get older. If treatment is necessary, bracing or casting may be used to attempt to halt the curve’s progression.

If the infant or younger child’s curve continues to progress despite bracing or casting, an operation may be necessary. This will usually involve inserting metal rods into the back to stabilise the spine, which are lengthened at regular intervals as your child grows.

In older children and adults, it is unlikely that scoliosis will improve with time, and in some it may progressively worsen.

The main treatments for older children are:

• a back brace worn until they stop growing, to prevent the spine from curving further
• surgery to correct the curvature – where the spine is straightened using rods attached to the spine by screws, hooks and/or wires

In adults, treatment primarily aims to relieve any pain. Non-surgical options, such as painkillers and exercises are often tried first, with correctional surgery seen as a last resort.

Read more about treating scoliosis in children and treating scoliosis in adults.

Further problems

Scoliosis can sometimes lead to further emotional and physical problems.

Having a visibly curved spine or wearing a back brace can cause problems related to body image, self-esteem and overall quality of life. This is particularly the case for children and teenagers with scoliosis.

If this is a problem for you or your child, you may find it useful to contact a scoliosis support group, such as Scoliosis Association UK. These groups are a good source of information and support for people with scoliosis.

In rare cases, scoliosis can lead to physical problems if it’s severe. For example, significant curvature of the spine can sometimes put increased pressure on the heart and lungs.

Read more about the possible complications of scoliosis.

Causes of scoliosis

In most cases, the cause of scoliosis is unknown and it cannot usually be prevented.

It is not thought to be linked with things such as bad posture, exercise or diet.

If the cause of scoliosis is unknown, it is called idiopathic scoliosis. About eight out of every 10 cases of scoliosis are idiopathic.

However, researchers have found there is a family history of the condition in some idiopathic cases, which suggests a possible genetic link.

Idiopathic scoliosis can affect adults and children. Some cases may only become noticable in later life.

Known causes

In a small number of cases, a cause is identified.

Other health conditions

Some cases of scoliosis are caused by conditions that affect the nerves and muscles (neuromuscular conditions), such as:

• cerebral palsy – a condition that affects the brain and nerves and occurs during or shortly after birth
• muscular dystrophy – a genetic condition that causes muscle weakness
• neurofibromatosis – a genetic condition that causes benign tumours to grow along your nerves

Scoliosis can also develop as part of a pattern of symptoms called a syndrome. This is known as syndromic scoliosis. Conditions that can cause syndromic scoliosis include:

• Marfan syndrome – a disorder of the connective tissues inherited by a child from their parents
• Rett syndrome – a genetic disorder, usually affecting females, which causes severe physical and mental disability

These conditions are usually diagnosed at a young age and children with them are often monitored for problems such as scoliosis.

Birth defects

In rare cases, babies can be born with scoliosis. This is known as congenital scoliosis. Congenital scoliosis is caused by the bones in the spine developing abnormally in the womb.

Long-term damage

In adults, scoliosis can sometimes be caused by gradual deterioration to the parts of the spine. This is known as degenerative scoliosis.

This can occur because some parts of the spine become narrower and weaker (osteoporosis) with age.

Diagnosing scoliosis

Scoliosis can usually be diagnosed after a physical examination of the spine, ribs, hips and shoulders.

You may be asked to bend forward to see if any areas are particularly prominent. For example, one of your shoulders may be higher than the other or there may be a bulge in your back.

Initial examinations are usually carried out by a GP. If scoliosis is suspected, you should be referred to an orthopaedic specialist (a specialist in conditions that affect the skeleton) for further tests and to discuss treatment.

Scans

The orthopaedic specialist will take an X-ray to confirm the diagnosis of scoliosis.

The X-ray images will also help determine the shape, direction, location and angle of the curve. The medical name for the angle the spine curves is known as the Cobb angle.

In some cases, scans such as a magnetic resonance imaging (MRI) scan or a computerised tomography (CT) scan may also be recommended. 

Treating scoliosis in children

If your child has scoliosis, their treatment will depend on their age and how severe it is.

The main treatment options are:

• observation
• casting
• bracing
• surgery

These are described below.

There is a separate page about treating scoliosis in adults.

Observation

Treatment is not always necessary for very young children because their condition often corrects itself as they grow.

However, if the curve does not correct itself, it can reduce the space for the internal organs to develop in, so careful monitoring by a specialist is important.

Your specialist will usually recommend having regular X-rays to monitor the curvature to see if it improves, stays the same, or gets worse.

Casting

In some cases affecting young children, the spine may need to be guided during growth in an attempt to correct the curve. In a child aged under two years of age, this can sometimes be achieved by using a cast.

A cast is an external brace to the trunk made out of a lightweight combination of plaster and modern casting materials. The cast is worn constantly and cannot be removed, but is changed regularly to allow for growth and remodelling.

The cast will be changed under anaesthetic every two to three months with the aim of gradually straightening the spine. However, your child may still need to use a removable brace (see below) after treatment.

Bracing

If the curve of your child’s spine is getting worse, your specialist may recommend they wear a back brace while they are growing. A brace cannot cure scoliosis or correct the curve, but it may stop the curve from getting worse.

However, while there is some evidence bracing may be of benefit in certain cases, it’s not recommended by all scoliosis specialists.

If a brace is used, it will need to be carefully fitted to your child’s spine. To do this, a cast of your child’s back may need to be taken. This can be done as an outpatient which means that your child will not have to stay overnight in hospital.

Braces are often made of rigid plastic, although flexible braces are sometimes available. In general, modern back braces are designed so they are difficult to see under loose-fitting clothing.

It’s usually recommended that the brace is worn for 23 hours a day, and is only removed for baths and showers. The brace should not interfere with normal everyday activity and can be worn during most non-contact sports. However, it should be removed during contact sports and swimming.

Regular exercise is important for children wearing a brace. This helps improve muscle tone and body strength, and will help make wearing the brace more comfortable.

The brace will usually have to be worn for as long as your child’s body is still growing. For most children, this will mean they can stop wearing it when they are around 16 or 17 years old.

Surgery

If your child has stopped growing and their scoliosis is severe, or other treatments have been unsuccessful, corrective surgery may be recommended. They type of surgery will depend on your child’s age.

Surgery in children

For younger children, generally those under the age of ten, an operation may be carried out to insert growing rods. These rods aim to allow for continued controlled growth of the spine while partially correcting the scoliosis.

After surgery to insert the rods, your child will need to return to their specialist every 4-6 months to have the rods lengthened to keep up with the child’s growth. This procedure will be done through a small incision, and takes place often as a day case or an overnight stay.

In some cases, rods that can be lengthened using external magnets during an outpatient appointment may be used. Many children will also have to wear a brace to protect the growth rods.

When your child stops growing, the adjustable rods can be removed and a spinal fusion (see below) will be carried out.

Surgery in teenagers and young adults

In teenagers and young adults whose spine has stopped growing, an operation called a spinal fusion may be carried out.

This is a major operation where the spine is straightened using metal rods attached with screws, hooks, and/or wires, and bone grafts are used to fuse the spine in place. This metalwork will usually be left in place permanently, unless they cause any problems.

The surgery will take several hours. After surgery, your child will be transferred to an intensive care unit (ICU) or high dependency unit (HDU), where they will be given fluids through a vein (intravenously) and pain relief. Most children are well enough to leave intensive care after a day or two, although they will often need to spend another five to 10 days in hospital.

After the operation, most children can return to school after a few weeks and can play sports after a few months. Contact sports should be avoided for 9-12 months. Occasionally a back brace may need to be worn to protect the metal rods after surgery.

Risks of surgery

Spinal fusion surgery is a major operation which, like any surgical procedure carries a risk of complications. It will not be recommended unless the surgeon feels the benefits outweigh these risks.

Some of the main risks the spinal fusion procedure include:

• bleeding – if this is severe your child may need a blood transfusion
• wound infection – this can usually be treated with antibiotics
• the implants moving or the grafts failing to fuse properly – additional surgery may be required to correct this
• in rare cases, damage to the nerves in the spine – this can lead to permanent numbness in the legs, and can sometimes cause paralysis of the legs and loss of control of the bowels and bladder

It’s important that parents and children understand the risks of spinal fusion surgery so that they can make an informed decision about treatment. Make sure you discuss the potential complications with your child’s surgeon.

Additional therapies

There is no reliable evidence to suggest that other therapies such as osteopathy and chiropractic can be used to correct the curvature of the spine or stop it progressing.

The role of scoliosis specific exercises is currently under investigation.

Physiotherapy  may be beneficial when used in combination with a back brace. Exercise can help significantly with any muscular pain experienced with scoliosis, and back health in general. 

Treating scoliosis in adults

Back pain is one of the main problems caused by scoliosis in adults, so treatment is mainly aimed at pain relief.

In some cases, surgery may be carried out to improve the shape of the spine as a way of helping with back and leg pains.

Medication

Painkilling medication is usually recommended to help relieve the pain that can be associated with scoliosis.

Over-the-counter painkillers, such as paracetamol and ibuprofen, are often recommended initially. See your GP if these don’t work. They may prescribe stronger painkillers or refer you to a specialist pain management clinic.

In some cases, corticosteroids or local anaesthetic may be injected into your back to relieve pain caused by the bones in your spine compressing or irritating nearby nerves. However, these injections only work in the short-term and are mostly useful in helping work out where your pain is coming from.

If it’s thought that osteoporosis of your spine is contributing to your symptoms, you may be given medication and supplements to strengthen your bones. Read more about treating osteoporosis. 

Exercise

General strengthening and stretching exercises can improve your general posture and flexibility, and may help control any back pain.

Exercises can also help you maintain a healthy weight, which can reduce the strain on your back.

Some people may benefit from physiotherapy, where they are taught specific exercises to carry out.

Bracing

Braces are not often used to treat scoliosis in adults, although they can provide pain relief in some cases.

A brace may be considered as an alternative to surgery if you are not well enough to undergo an operation.

Surgery

Surgery for adults with scoliosis is usually only recommended if the curve in the spine is severe, if it’s getting significantly worse, for back pain related to standing in an abnormal posture, or if the nerves in the spine are being compressed.

There are two types of surgery:

• decompression surgery – if a disc or bone is pressing down on a nerve, it can be removed to reduce the pressure on the nerve
• spinal fusion surgery – where the position of the spine is improved using metal rods, plates and screws before being fused into place using bone grafts

These are major operations and it can take up to a year or more to fully recover from them. They also carry a risk of potentially serious complications, including:

• failure to reduce pain – surgery is generally better at relieving pain that radiates to the legs, rather than back pain
• the implants becoming displaced, broken or loose
• infection
• blood clots
• rarely, damage to the nerves in the spine – in severe cases this can result in permanent leg numbness and the loss of bladder or bowel control

Read more about lumbar decompression surgery.

Possible complications of scoliosis

Physical complications of scoliosis are rare, although serious problems can develop if it’s left untreated.

Emotional issues

Having a visibly curved spine or wearing a back brace may cause problems related to body image, self-esteem and overall quality of life. This is particularly the case for children and teenagers with scoliosis.

Modern back braces are designed to be difficult to see under loose-fitting clothing, but your child may still worry that they look different or unusual.

Encouraging your child to talk with other teenagers who have scoliosis can help improve their confidence and lessen any feelings they are alone with their condition.

There are several support groups, such as the Scoliosis Association UK, that provide information and support for people with scoliosis. Some also host message boards so teenagers from across the world can compare experiences, share tips and exchange messages of encouragement.

Lung and heart problems

In particularly severe cases of scoliosis the ribcage can be pushed against the heart and lungs, causing breathing problems and making it difficult for the heart to pump blood around the body.

This can also increase the chances of lung infections, such as pneumonia, and lead to problems such as heart failure.

Nerve compression

In some cases of scoliosis, particularly those affecting adults, the bones in the spine compress nearby nerves. In severe cases, this can cause problems such as:

• back and leg pain
• numbness or weakness in the legs

When to get professional help

Rarely scoliosis can cause a condition called cauda equina syndrome to develop. Cauda equina syndrome is a rare but serious back condition which can lead to permanent damage or disability. If you develop this condition you’ll need to be seen by an emergency specialist spinal team.