Scoliosis | Diagnosis, treatment, and finding a doctor

Leading Medicine Guide Editors
Leading Medicine Guide Editors

In scoliosis, the spine is curved laterally and rotation of the individual vertebral bodies may occur. Viewed from behind, the spine is almost straight in healthy individuals. In scoliosis, the spine bends to the side; this can occur at any part of the spine. This often results in the formation of a so-called rib hump and lumbar bulge. In an advanced stage of scoliosis and especially with twisted vertebrae, symptoms and pain occur. 

Here you can find additional information and recommended specialists and centers for the treatment of scoliosis.

ICD codes for this diseases: M41

Recommended specialists

Brief overview:

  • What is scoliosis? Lateral curvature of the spinal column, occasionally associated with the rotation of the individual vertebral bodies.
  • Types: The most common type is adolescent idiopathic scoliosis (AIS). Congenital scoliosis occurs much less frequently. In this technical article, only AIS will be discussed in detail.
  • Who is affected? Women are affected significantly more often than men. The symptoms appear from the age of 10-12 years, usually after a significant growth spurt.
  • Causes: Presumably, there is a family history of the disease, but more precise findings are not available. Apparently, the disease often skips a generation.
  • Diagnosis: Experienced pediatricians can detect early signs through a physical exam. Upon a suspected diagnosis, the physician orders an X-ray.
  • Progression: After diagnosis, its progression is regularly monitored. Scoliosis does not always worsen, very rarely it can also regress.
  • Treatment: Therapy depends on the severity of the disease. Physiotherapy is often prescribed along with respiratory therapy. However, surgery is often necessary to correct the malformation.

Article overview

Most common type of scoliosis: Adolescent idiopathic scoliosis (AIS)

Scoliosis occurs in about 3-5% of the population. A distinction must be made between idiopathic and congenital scoliosis, with the idiopathic type being the most common type of scoliosis.

Congenital scoliosis results from malformation and/or maldevelopment of individual vertebral bodies. 

Adolescent idiopathic scoliosis (AIS) is a change in the normal shape of the spine which occurs in all three planes of the spine: coronal, sagittal, and transverse.

Scoliosis is most easily recognized by the curvature to the side (coronal plane). This curvature in the coronary plane is always associated with rotation of the vertebrae. Since the ribs are attached to the individual vertebrae, this rotation results in the formation of a more or less pronounced rib bulge, which depends on the extent of the rotation, or the formation of a lumbar bulge.


Left: Schematic drawing of scoliosis. Right: Healthy spine © Koterka Studio| AdobeStock

However, when describing scoliosis, the sagittal profile (view of the spine from the side) must not be forgotten. This is because AIS is also often accompanied by a strong change in the sagittal profile, especially in terms of the formation of a flat back.

At what age does AIS occur?

Women are affected by scoliosis significantly more often than men in a ratio of 80:20. Scoliosis usually does not become apparent until the age of 10-12, often after a significant growth spurt. 

The most striking features that play a role in the recognition of AIS are the lateral bending and rotation of the vertebral bodies with the formation of the above-mentioned deformities in the thoracic and/or lumbar spine. 

Cause of scoliosis

Today, we assume that AIS develops based on a genetic disease, although the "scoliosis gene" has not yet been discovered. This hypothesis is also supported by the fact that in families where cases of scoliosis have occurred, AIS often develops in subsequent generations, often skipping a generation. 

AIS diagnosis

If it is suspected that a curvature of the spine is forming, the following medical exams are necessary.

During the clinical examination, the doctor looks at the child from behind and palpates the spinous processes of the spine. Here, a deflection of the spine, either in the thoracic spine or lumbar spine, is visible at a relatively early stage. 

If rotational malalignment of the vertebral bodies has already occurred at this point, a more or less pronounced rib or lumbar bulge is present.

In an early diagnosis of scoliosis, this rib bulge is of considerable importance, since the scoliosis often becomes more pronounced during an actively performed inclination movement (forward tilt of the trunk), with the rib bulge becoming more prominent. The reason for this is that during prevention, the lateral curvature is partially compensated for, but not the axial rotation, which then makes the rib bulge clearly visible. 

During the clinical examination, it is important to note whether the gap between the arm and trunk is greater or smaller. In the case of scoliosis in the lumbar spinal segment, the deflection of the spine, mostly to the left, results in a greater waist gap to the left side and a smaller waist gap on the opposite side. 

When these clinical changes are apparent, radiologic diagnosis should be performed as soon as possible. Care should be taken to ensure that a spinal X-ray is always taken from the first X-ray examination, both in the coronal and sagittal planes (viewed from the side). 

It is important that the first radiological diagnosis is already made in the two planes because the changes in the lateral profile can already give very good indications of the further development of AIS. 

Progression: How does scoliosis develop?

Once clinical and radiological evidence of AIS has been established with certainty, regular follow-up examinations are necessary to detect progression.

Not every mild scoliosis worsens during further growth. There are three possibilities at this point, i.e., scoliosis curvature measured radiologically between 15 and 20°: 

  1. The scoliosis remains as is. 
  2. The scoliosis worsens with an increase in the curvature of all three planes. 
  3. In a smaller percentage, scoliosis of the above-mentioned magnitude even results in regression of the curvature. 

Treatment: Further diagnostics and therapy for scoliosis

If a scoliosis of 15-20° is detected, physiotherapeutic treatment is initiated as soon as possible and many patients are recommended brace treatment.

However, in the case of scoliosis with an angular degree of 30° or more, muscle development produced by physiotherapy can no longer achieve any improvement. Nevertheless, further targeted exercise is useful, and physiotherapy should also be combined with appropriate respiratory therapy

Physiotherapy, including the Schroth method, is definitely not able to stop the progression of scoliosis. Furthermore, the patient and the attending physician should know that brace therapy is never able to stop the progression of scoliosis. 

However, one should be warned against the often unreflective initiation of brace treatment; there are various reasons for this:

  1. To date, there is no evidence that brace treatment can permanently halt the progression of scoliosis. It is already considered a very favorable outcome if the scoliosis does not become more curved, although I have already referred to the possible development of scoliosis above.
  2. A major reason against brace treatment is the negative influence of brace treatment on the sagittal (lateral) profile of the spine, which in most cases is already altered in the sense of a lordosis (in most cases thoracic scoliosis) in the sense of a de-kyphosis of the spine (apical, thoracic lordosis). 
  3. The third important point is that the brace treatment is based on the fact that yes, there is not a direct corrective intervention on the spine, but is supported by the ribs of the spine. As a result, long-term brace treatment, which can often last 4-5 years if the spine condition is detected early, leads to significant changes in the area of the rib insertion, namely in the costotransverse and costovertebral joints (the ribs are connected to the associated vertebral body via two joints).

This pressure-induced change in the region of the costovertebral joints leads to a significant increase in rigidity. If, after many years of brace treatment, surgical measures should or have to be initiated after all, these changes are a clear problem during surgical correction. 

Increasing ankylosis (stiffening of the vertebral joints) is a very significant problem in the surgical treatment of scoliosis. 

Surgical therapy for scoliosis

When is surgery necessary?

Surgical treatment is necessary depending on the progression (progressive deterioration) of the scoliosis. Subject to the speed of growth, the peak age is between the ages of 12-16 years.   The timing of the surgery should be delayed as much as possible in order to minimize the negative influence of the operation on further linear spine growth. 

A rough indication for surgery is an angulation of more than 40° in the coronary plane. 

However, the progression of scoliosis is expressed not only in the coronal plane, but also in the sagittal and rotational planes, so that these two planes must always be considered in the indication for surgery. An indication for surgery may be, e.g., scoliosis with an angulation of 30° with a very strong rotation, since it can be predicted with a high degree of certainty that the scoliosis will significantly worsen in its progression. 

The indication for surgery should also take into account that the progression of scoliosis does not end with the completion of spinal growth (16/17 years). This is quite easy to explain because the scoliotic bad posture causes a massive misloading of the intervertebral discs (pressure increase in the intervertebral disc on the concavity of the scoliosis) especially in the lumbar spine, which then leads to an early, unphysiological degeneration of the intervertebral discs. In turn, this is accompanied by a worsening of the curvature.

This is particularly evident in thoracolumbar or lumbar scolioses, where an increase in scoliosis is predictable with an increase in pain by the above mechanism. 

The purpose of the surgery that corrects the malposition in all three planes is not only to improve the cosmetic appearance, which in the case of a pronounced form can also lead to psychological stress, but also to avoid secondary damage (early degeneration of the scoliosis with the result of considerable pain in adulthood), which then often results in a bigger and more complicated surgery in adulthood. 

Surgical techniques

Various access routes are possible in order to achieve surgical correction of scoliosis: 

  • The most commonly used is the posterior approach to the spine, but it is associated with several disadvantages (longer instrumentation, inadequate correction of rotational malposition, and sagittal malposition). 
  • The anterior approach to the spine is an anterior, lateral approach. If the indication is appropriate, this approach allows very good correction in all three levels of the spine, combined with generally shorter instrumentation into the lumbar spine. The shortest possible instrumentation and stiffening in the lumbar spine are of great functional importance since about 70-80% of the total movement results from the spine. 
  • In the case of very rigid scolioses or even double curves, a double approach (laterally from the back and front) may be necessary to achieve an optimal cosmetic, but also functional result. 

In the context of ventral access (from the front), it is also necessary to mention the technique of tethering, which has been performed for about five years. In this procedure, an attempt is made to correct the scoliosis without fusion (stiffening) via an anterior, lateral approach. This is to achieve correction by reining in growth on the convexity of the scoliosis and further growth on the concavity of the scoliosis. 

The first medium-term results show partially good corrections. However, it is important to note that this technique does not have a significant effect on the lateral profile and on the axial rotational malposition; it predominantly achieves a correction in the frontal plane. 

At this point, this "tethering technique" cannot be assessed conclusively. However, it offers an interesting approach that allows for a limited degree of critical optimism.

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