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SCOLIOSIS

What is Scoliosis (Spine Curvature) and How is it Treated?

Spinal curvature, called “scoliosis”, is a disorder that is mostly diagnosed during adolescence. Scoliosis, which develops when the vertebrae curve to the right, left or rotate around themselves due to different reasons, can start at a young age and seriously affect a person’s life if left untreated.

What is Scoliosis?

Scoliosis is the oldest known spinal deformity, with a prevalence ranging from 0.2 to 6%. While it can develop due to a variety of reasons such as trauma and congenital developmental disorders, the cause of 80% of scoliosis cases is unknown. It is usually noticed by the mother and father at the beginning of the developmental period, with findings such as shoulder asymmetry in the child, a bulge in part of the back, and hips not being at the same level.
Scoliosis is a lateral bending of the spine greater than 10 degrees. In a normal and healthy spine, the vertebrae extend in a straight line from top to bottom when viewed from the back, that is, in the neck, back and waist areas. In scoliosis, the vertebrae are displaced to the right or left and also rotate around their own axis. Therefore, it is defined as a three-dimensional deformity.
Due to scoliosis, in addition to the spine, shifts occur in the hips, rib cage and shoulder blades, resulting in posture and appearance disorders. In developing children, this condition causes abnormal load on the developing and growing spine and, as a result, deformities in the vertebrae.
The incidence of scoliosis varies between 0.2 – 6%. It is more common and progresses more in girls. It is seen in 1.5% of school children, and it is estimated that at least 150,000 children in Turkey have scoliosis.
This disorder, which is frequently seen in boys during the preschool period, is 3-5 times more common in girls during puberty, depending on their growth rate. Scoliosis, which does not cause any strong complaints in the patient in the early stages, is mostly detected incidentally as a result of school screenings or in x-rays taken for any reason. On the other hand, the disorder in the child’s trunk appearance is one of the most important reasons for families to consult a doctor. The first noticeable findings are symmetry disorders seen in the shoulders, shoulder blades, breast level and waist folds. This condition may also be accompanied by waist and back pain. As the degree of curvature increases, respiratory distress may also occur.

What are the Symptoms of Scoliosis?

Scoliosis may not show symptoms in the early stages. Even if the symptoms of scoliosis appear, action is often not taken because they do not cause many complaints in the person. If there are any complaints, they are very minimal. For this reason, it is detected either as a result of school screenings or by chance in x-rays taken for any reason. The first symptom that brings the family to the doctor is usually visual disturbance. The first noticeable finding in scoliosis of unknown cause is that one shoulder is higher than the other. Asymmetry in the shoulder blades, breast level, waist folds or trunk are the first visible visual disorders. Back and waist pain is present in 40% of cases. Curvatures over 50 degrees may cause respiratory distress.

Scoliosis Degrees

The natural course of scoliosis may not always remain the same. Spinal curvature may progress, remain the same, or rarely improve. An increase of 5 degrees or more in the spine for curvatures over 20 degrees in two or more consecutive examinations, and an increase of 10 degrees for curvatures below 20 degrees is considered progression. Double curvatures, curvatures in the back area, female gender, and a greater degree of curvature at the time of diagnosis. Curves diagnosed under the age of 10 tend to progress. The progression rate is quite low for curvatures below 30 degrees. Scoliosis degrees are listed as follows;
Chronological Classification
  • Infancy: 0-2 years old
  • Juvenile period: 3-9 years old
  • Adolescence: Between 10-17 years of age
  • Adulthood: 18 years and above
Classification According to Placement
When the anatomical structure of scoliosis is examined, it can be classified as cervical vertebrae, neck and upper back, regional back vertebrae, lower back and lumbar vertebrae, and regional lumbar vertebrae.
Angular Classification
Imaging methods are used to grade angular scoliosis. After the imaging method, the curvature in the spine is diagnosed in terms of angle. This method is especially useful when determining the need for surgical intervention in scoliosis.
Angles below 10 degrees: This degree, which is called “spinal asymmetry” in medical language, does not have any effect on the health of the person. In order for the curvature to be treated, the curvature must be above 10 degrees. The patient must be examined at regular intervals to prevent low-degree curvatures from posing a risk of scoliosis in the future. The important thing here is to determine whether scoliosis is progressing or not.
Angles between 20 and 40 degrees: Curvatures of 20 to 40 degrees are more common in adolescence. In this degree, which is considered as moderate scoliosis, exercise, physical therapy and corset are mostly effective.
Angles at 40 degrees: 40 degree scoliosis curves have largely completed their growth and progression. In order for surgical intervention to be performed, the back curvature must be over 45-50 degrees; The curvature in the waist area should be 40 degrees.

Causes of Scoliosis

The cause of the curvature cannot be determined in 80% of scoliosis patients. However, when looking at the structural disorders that cause scoliosis; It can be said that it can be caused by congenital structural disorders, nerve and muscle diseases (cerebral palsy, syringomyelia, polio, muscle diseases, etc.), spinal tumors, trauma, spinal infections and metabolic diseases. In addition, posture disorders and difference in length of the legs are also causes of scoliosis. The causes of scoliosis can be briefly explained as follows;
  • – Congenital scoliosis caused by congenital spine bone structure disorders
  • – Infantile and juvenile scoliosis starting in early childhood
  • – Due to neuromuscular causes, muscular dystrophy etc. Scoliosis caused by muscle diseases
  • – Scoliosis due to connective tissue diseases such as Marfan Syndrome, Ehler Danlos Syndrome
  • – Scoliosis due to polio, inflammatory diseases and trauma
  • – Scoliosis caused by leg inequality and hip and knee joint problems

How is Scoliosis Diagnosed?

The diagnosis of scoliosis can be determined by examination of the child. When looking at the bare spine from the front, asymmetry in the midline can be noticed. When the child bends forward, there is bending and curvature on one side and rib swelling on the other side. This appearance is called rip hump (rib pack). It may be difficult to notice this image in some cases of “balanced scoliosis”.
In the diagnosis of scoliosis, an x-ray is first taken. The aim is to confirm the curvature in the spine, determine its size and location, and determine whether there is an accompanying hereditary disorder of the bone structure. X-rays should be taken at six-month intervals and scoliosis should be monitored. On the other hand, other imaging examinations such as bone scintigraphy, computerized tomography (CT) or magnetic resonance (MRI) may be applied to patients with neurological disorders or who will undergo surgery.
The diagnosis is easily confirmed by plain radiographs taken with suspicion of scoliosis. Very rarely, an MRI is needed. Since radiological examination is frequently used in the follow-up and diagnosis of scoliosis, great care should be taken to protect the ovaries and breasts with lead plates in these developing children.
Scoliosis curvatures are defined as major and minor curvatures. The place where the curvature is most angulated, that is, where the vertebrae rotate most from the vertical axis and move furthest from the midline, is called the apex. Scoliosis is also named according to the level of the spine where the apex is located. If the apex is in the neck region, it is called cervical, if it is in the waist region, it is called lumbar, and if it is in the back, it is called thoracic scoliosis. Sometimes it can be seen in more than one area at the same time: For example, when it occurs in both the back and waist, it is defined as thoracolumbar scoliosis. It is generally more common in the dorsal (thoracic) region.
The form and degree of scoliosis are determined in the radiographs taken. The most commonly used method for this is the Cobb angle. Scoliosis is monitored with Cobb angle and growth age, and appropriate treatment methods are decided. Cobb angle is measured with the help of lines drawn between the upper border of the spine where bending begins and the lower border of the spine where bending ends. The perpendiculars drawn to these lines (that is, the angle between the axis of the vertebra where the curvature begins and the axis of the vertebra where it ends) is looked at.

Scoliosis Treatment

Scoliosis may very rarely regress on its own. It is not possible to predict what kind of progression will occur in scoliosis that occurs at the beginning of growth. Some studies conducted in recent years show that there may be progress in children carrying certain gene characteristics. Important follow-up criteria are used to determine treatment in scoliosis. However, in some cases, progression is common and the success rate of treatments is less. These;
  • – – High degree of curvature when first diagnosed
  • – Double curvature in both the back and waist
  • – Neuromuscular scoliosis
  • – Severe contracture and muscle shortening
The type of treatment to be applied is decided by taking into account the risk of progression of the spinal curvature. Accepted treatment methods in the treatment of scoliosis are as follows:
  • – Monitoring and continuous follow-up
  • – Corset applications
  • – Scoliosis exercises and special rehabilitation practices
  • – Surgery
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During puberty, when the first signs of growth are seen, that is, hair growth, voice change, increased height, the beginning of breast development in girls, or when menstruation occurs, extreme caution should be exercised and children should be treated. Since the bending speed and risk are higher in these children, the risk of progression rather than the degree of Cobb angle should be calculated and treatments should be planned accordingly. Children with high risk of progression should use corsets in addition to physiotherapy and rehabilitation practices. Corset treatment should be continued between 16 and 23 hours a day, depending on the growth status and the degree of bending, until growth is completed.
Surgical treatment can be applied if the Cobb angle is above 50 degrees in individuals with a high risk of progression listed above and in whom corset treatment is unsuccessful. In scoliosis surgery, the spine is moved to the midline with plates and screws, and sometimes these metals remain in their bodies permanently in these children. It should also be known that surgery will cause late-term problems.
The Role of Corset Treatment in Scoliosis and the Effect of Corsets with Different Features on Treatment
Skolyozda en çok tartışma yaratan konu korse uygulamalarıdır. Farklı konseptleri benimseyen uzmanlar korse tedavisinin etkinliğine ilişkin farklı görüşlere sahiptir. En önemli neden, skolyozun tipine göre belirlenmiş doğru dizayn edilmiş kontrollü korse uygulamalarının her ülkede yeterince bilinip uygulanılmamasıdır. Bir diğer neden ise gelişme çağındaki çocukların korse giymeye gösterdikleri dirençtir.
As in all matters, technology has advanced a lot in this field. Nowadays, corsets can be produced with very successful results, designed and produced with the help of computers, where the mistakes that can be made while producing corsets with classical techniques are eliminated.
Corsets generally used in scoliosis are called TLSO (Torako Lumbo Sacral Body Orthosis). These corsets can be produced in different types and models. Determining and applying the appropriate brace model for the patient with scoliosis also requires special expertise. The corset model should be determined by the physician who specializes in this field, and during frequent follow-ups, the necessary additional corrections should be applied in a timely manner and the supports should be increased. Of course, one of the most important factors is; The team includes technicians with expertise and experience in this field who will produce a corset based on the correct rules. So scoliosis treatment requires team work. The physician, technician, physiotherapist, family and child should act together in this treatment process, and every stage of the treatment should be monitored.

Scoliosis Exercises

It may be possible to stop scoliosis with exercise programs. These exercise programs are very effective, especially in children with scoliosis over 15 degrees, starting from the age of 7. In addition, scoliosis exercises give good results in patients with scoliosis over 40 degrees.
In exercise programs, classical stretching and strengthening exercises can be applied as well as techniques such as “Bobath”, “Vojta”, “Katharina Schroth”. Especially considering that psychological factors play an important role in scoliosis rehabilitation, intensified exercise programs have significant effects on adolescents. Young people who act with group psychology communicate at a high level with their peers who share their problems.

Physical Therapy and Rehabilitation Practices in Scoliosis

In developing children with a Cobb angle of 20-30 degrees, scoliosis rehabilitation programs are applied with or without a corset depending on the period. Adults with a 30-40 degree angle and those with pain also benefit from these programs.
There are many physiotherapy approaches that have come to the fore in the treatment of scoliosis. Such as Vojta therapy, acupuncture applications and the most studied Schroth therapy. Physical therapy details must be explained to children and families in detail, and the necessary cooperation must be provided on what needs to be done. Some of these programs can be implemented intensively or can be continued with 3-4 days a week sessions.

Intensive Scoliosis Rehabilitation-YSR (Scoliosis Intensive Rehabilitation-SIR)

The aim of the intensive special exercise program organized according to the direction of the curvature and the person; It is a three-dimensional scoliosis treatment based on sensorimotor and movement principles. These special exercises aim to correct the patient’s asymmetrical posture and have a proper posture during daily life activities.
Merkeze çeşitli yerlerden yönlendirilen hastalar 4–6 hafta süresince ve günde 4 saatlik yoğun bir egzersiz programlarına katılır. Grup egzersizleri olarak planlandığında; hastaların eğrilik yönleri, dereceleri ve yaşları benzer olanlar aynı gruplarda çalıştırılır. Gerektiğinde hastalar için bireysel programlar da yürütülür. Egzersizlerin temelinde; solunum egzersizleri, proprioseptif uyarılar ile doğru postürü öğrenmek ve korumak, farklı denge ve hareket egzersizleri ile eğrilik tarafını düzeltmek ve tekrar denge ve normal hareketi sağlamak vardır. Tedavilere yardımcı olarak osteopatik yaklaşımlar, germeler, masaj ve yüzme programları da ilave edilir.
These special exercise programs are carried out by physiotherapists who participate in the Katherina Scroth therapist certification program. The aim of this program is to educate the person about his/her condition, to prevent the degree of curvature from increasing and to ensure proper posture.

Scoliosis Surgery

Surgical treatment of scoliosis is applied in advanced cases, as well as in cases where the degree of scoliosis continues to increase or is predicted to progress despite exercise and brace treatment. In other words, if the Cobb angle increases and exceeds 50 degrees despite conservative approaches, scoliosis surgery may be required. Surgery should be decided not only by looking at the angle on the radiograph, but also by evaluating the patient’s psychological and sociocultural situation. Because scoliosis that occurs during adolescence does not usually reach the point where it damages the heart-lung system. There are basically two approaches adopted in scoliosis. These are rear interference and front interference. The back area is used in the posterior approach.
The surgical goal is to monitor all patients in the early period, stop the progression, eliminate cosmetic problems, and eliminate pain and neurological findings, if any. It may be possible to restore the spine with early interventions and simple surgical procedures in necessary patients. The most important point at this stage is to perform the right surgery at the right time and to protect the spinal cord while correcting the spine and bone structure. Success rates have reached extremely high levels with the imaging devices used during scoliosis surgery and special tools to prevent spinal cord and nerve damage. While doing these, it should not be forgotten that the patient and his/her family will be in communication with their physician for many years and that scoliosis treatment requires long-term follow-up.
After scoliosis surgery, the mobility of the spine is less. In the frontal approach, the intervention is performed by lifting the rib cage from the underarm area. The disadvantage of this operation is that it requires the use of a corset after the operation. Its advantages are that it ensures that the spine remains more mobile, and that the stitch marks remain under the arm, thus making it look more aesthetic.
There are some points that the patient should pay attention to after scoliosis surgery. As every surgery has risks, scoliosis surgeries also have certain risk rates. This rate is around 5%. If no complications occur, the patient can be discharged within 14 days. Undesirable consequences that may be observed after surgery are as follows:
  • – Infections can be controlled with the use of antibiotics.
  • – Respiratory distress after bleeding can be relieved by blood drainage.
  • – Breaks in the inserted screws or instrumentation require a second surgery.
  • – Nerve palsies observed in less than 1% (usually reversible)
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