Adolescent Idiopathic Scoliosis
The most common type of scoliosis in children is adolescent idiopathic scoliosis. It mostly occurs during adolescence when children grow the fastest, often during the growth spurt. It may worsen before stabilising, often within a few years. As the skeletal system matures, the condition may cease to deteriorate. Idiopathic scoliosis is caused by mutation of genetic factors, while there are common misconceptions about it being caused by poor sitting or standing postures, heavy school bags, or prolonged video gaming. These factors are not related to structural scoliosis, which is a pathological condition not caused by postural changes.
Q2. Who are more likely to develop idiopathic scoliosis? Does scoliosis only affect appearance?
Idiopathic scoliosis is usually asymptomatic in childhood. It may not become apparent until one grows and enters puberty. In Hong Kong it mostly affects girls, with a girl-to-boy ratio of about six to one. Girls usually begin to grow at age 10, exhibit sexual characteristics and begin menstruation at around 11 or 12. The growth period ends at age of 14 and a half to 15. Scoliosis often occurs during this period, with deterioration coming to an end within these 4 to 5 years. Therefore, early detection is essential.
Scoliosis should be detected while still mild in the early stages for proper treatment. If left untreated, the most noticeable effects are cosmetic. It poses no direct threat to physical health unless severe. Some cases may worsen during the growth period, affecting one’s cardiopulmonary function if severe. If it impacts the lower back, one may experience early degeneration as one grows older. While most people may experience lower back pain as they age, degenerative issues may arise even earlier if the spine is deformed.
Q3. How do I know if my child has scoliosis? What are the treatment options?
Idiopathic scoliosis usually causes no pain. Patients may not feel worried as long as they are not in pain, and are thus less proactive in seeking treatment or spinal check-ups. As the condition often appears during adolescence, detection is important while it is still mild. Do not procrastinate until it becomes obvious even to family members or PE teachers. In this case, it is already in a later stage.
How is early detection possible? In Hong Kong, since 1995 the Government has been conducting free health checks for students under the “Student Health Service”. Besides checking height, weight and vision, it also covers spine examination. If the scoliosis did not occur at age 9, it can still develop at age 10. Therefore, we need to conduct these checks annually until their growth is complete. The examination is arranged by schools annually, and needs only an experienced nurse or general practitioner. Typically, students are asked to bend forward for any sign of back asymmetry or unevenness in the initial assessment. If there are any concerns, further optical examinations will be arranged. Currently, there are various types of non-irradiating examinations available. In view of X-ray radiation, we prefer to spare children any unnecessary exposure. X-ray is thus recommended only after clear symptoms are identified by doctors after several stages of examinations to check for scoliosis.
Early examinations are crucial as the sooner the children are diagnosed with scoliosis, the earlier we can prevent its deterioration. And it can be done by wearing a brace. A brace can prevent deterioration of scoliosis during one’s growth period. It works like a train track that a train can move along without deviation. Patients should start wearing a brace while scoliosis is still in its early stage, not to wait until it is too late. As the spine has deviated, patients must understand that the aim of bracing is to prevent further deterioration, not to restore the spine to a perfect alignment. The treatment is considered successful as long as no deterioration occurs. The purpose is achieved when the curvature of the scoliosis does not increase.
Q4. Will wearing the brace cause any discomfort to the children? What should they pay attention to in daily life?
Braces are made of a semi-rigid material to stabilise the spine. The longer the children wear it every day, the better the outcome, as concrete scientific evidence shows that increased wear time leads to improved results. It is recommended that children should wear the brace for 20 to 22 hours a day, except for activities like bathing, exercising, or swimming. Many children resist wearing the brace, and even parents as well. Although the posture is corrected after use, children may feel uncomfortable at first. They may not be able to relax completely, or can no longer sit idly on their sides and backs. However, this is the exact purpose of brace wearing. It takes time to adapt, usually about a week, and most patients are able to do so. We often try to tell the children that once they wear the brace, they will become invincible. It makes them happy and more willing to wear it.
Q5. Can wearing a brace cure scoliosis?
If children have been wearing a brace for some time and show no change in their condition, they can stop wearing it at around age of 14 or 14 and a half when the growth is complete. However, if the spinal deformity continues to worsen and cannot be controlled by brace wearing, surgical treatment may be considered. If the diagnosis is made too late and the scoliosis is too severe for bracing at the time of initial diagnosis, surgery may be necessary to prevent further deterioration and to correct the deformed part as much as possible. However, even with surgical correction, it is impossible to completely straighten the spine. One should not expect the spine to return to a perfectly straight position after surgery.
In addition, surgery is performed to fuse the deformed spine section(s), which means joining multiple vertebrae together as a single unit to prevent further deformation. But it will eliminate the movement of that fused section. “Internal Fixation” like screws or metal rods, will be implanted during surgery to maintain the correction. It is followed by bone grafting, as vertebrae will be fused together one by one. After two to three months, these bones will fuse with each other into a solid block.
Currently, there are some new options suitable for certain patients, known as “Non-fusion Surgeries”. Although non-fusion is a surgical method, it uses a flexible form of fixation to correct the deformity, which can be removed or adjusted as needed. This method can preserve some spinal mobility after the implantation of the flexible "internal fixation," especially in mild scoliosis. All of these are the more innovative approaches. Parents should consult their doctor to find out whether these procedures are appropriate for their children, as they may not be suitable for every patient.
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