Scoliosis: Everything You Need to Know

You can’t spell “scoliosis” without an “S” or a “C,” and if you have this condition that’s what your spine looks like.

Scoliosis causes the spine to curve to the left, the right or both. Up to 3% of Americans—that’s 6 million to 9 million people—have scoliosis, and although it can affect people of all ages, children and adolescents are far more likely than adults to be diagnosed.

Symptoms of scoliosis, when they do appear, can range from a purely cosmetic deformity to mild discomfort to life-threatening breathing disruptions. Most cases are easily correctable. The vast majority of people with scoliosis—with a little knowledge and the help of spine specialists—won’t let the condition even slow them down.

Have you or your child been diagnosed with scoliosis? You’ve come to the right place. Here’s everything you need to know about scoliosis symptoms, causes, diagnosis and treatment.

To understand scoliosis, you first need to know what a healthy spine looks like. There are four regions in your spine:

• Cervical spine: This is your neck, which begins at the base of your skull. It contains seven small spinal bones (called vertebrae), which doctors label C1 to C7 (the "C" means cervical). The numbers one to seven indicate the level of the vertebrae. C1 is closest to your skull, while C7 is closest to your chest.

• Thoracic spine: Your mid-back has 12 vertebrae that are labeled T1 to T12 (the "T" means thoracic). Vertebrae in your thoracic spine connect to your ribs, making this part of your spine relatively stiff and stable. Your thoracic spine doesn't move as much as the other regions of your spine do.

• Lumbar spine: In your low back, you have five vertebrae that are labeled L1 to L5 (the "L" means lumbar). These vertebrae are your largest and strongest vertebrae, responsible for carrying a lot of your body's weight. The lumbar vertebrae are also your last "true" vertebrae; down from this region, your vertebrae are fused. In fact, L5 may even be fused with part of your sacrum.

• Sacrum and coccyx: The sacrum has five vertebrae that usually fuse by adulthood to form one bone. The coccyx—commonly known as your tail bone—has four (but sometimes five) fused vertebrae.

Normal Spinal Curves: Lordosis and Kyphosis

The spine has both inward and outward curves. Kyphosis refers to the thoracic and sacral spines’ outward curvature toward the back of the body, and lordosis refers to the cervical and lumbar spines’ inward curvature toward the front. These curves help your back carry your weight and are important for flexibility.

According to Baron Lonner, M.D., chief of minimally invasive scoliosis surgery at Mount Sinai Hospital in New York City and professor of orthopedic surgery at the Icahn School of Medicine at Mount Sinai, humans evolved with two types of spinal curves—lordosis and kyphosis—to “allow us to adapt to various movements and forces on us in a way that allows us to stand upright. We evolved from quadruped animals that were on four legs to bipedal animals, so we stand on two feet.”

Although everyone has a little kyphosis and lordosis in their spines, too much of either can cause trouble. Abnormal lordosis is an extreme inward spinal curve. Abnormal kyphosis is a condition that results in a hunchback or slouching posture.

Scoliosis is a condition in which the spine curves laterally and rotates, or twists vertically. The two main types of scoliosis are adolescent idiopathic scoliosis (AIS) and adult degenerative scoliosis (ADS).

To receive a medical diagnosis of scoliosis, a person must have curves that meet or exceed 10 degrees of lateral curvature as determined by X-ray imaging. AIS causes disfigurement and disability in over 10% of people who have it.

Over time, if the scoliosis progresses, the combination of lateral curvature and twisting of the spine puts pressure on the vertebral discs. This can cause pain and spinal osteoarthritis in adults. Adults with scoliosis are also at risk for spondylolisthesis, a disorder in which the vertebrae slip out of place.

ADS occurs most commonly in the lumbar spine (lower back) and usually affects people 65 and older. ADS is often a result of untreated (or unsuccessfully treated) AIS. It’s often seen in conjunction with spinal stenosis, which is a narrowing of the spinal canal. All of this can lead to degeneration of facet joints, joint capsules, discs, and ligaments.

Scoliosis may be diagnosed at any point in life, but the most common age of onset is between 10 and 15 years old and it is the most common spinal deformity in school-age children.

There are a variety of types and causes of scoliosis, such as idiopathic, degenerative, congenital, neuromuscular, thoracogenic, and syndromic.

Idiopathic—meaning there is no specific cause—is the most common form, accounting for 80% of all pediatric scoliosis cases. Degenerative scoliosis is also fairly common; one 2020 study found it affects roughly 38% of the population older than 40, including up to 68% of those who are 60 and older. Rarer forms include congenital scoliosis, which affects one in 10,000 newborns.

Idiopathic

• Infantile idiopathic scoliosis is diagnosed in children ages 0 to 3.

• Juvenile idiopathic scoliosis is diagnosed in children ages 4 to 10.

• Adolescent idiopathic scoliosis (AIS) is diagnosed in young people ages 11 to 18, and accounts for as many as 85% of cases. Girls experience this much more frequently than boys, at a ratio of 10:1.

• Adult idiopathic or degenerative scoliosis is diagnosed in people older than 18.

Degenerative

Degenerative scoliosis results from asymmetrical disc degeneration over time. According to Dr. Lonner, “this type of scoliosis tends to affect the lumbar spine and is milder in magnitude, typically creating a curvature of about 30 to 40 degrees.”

This population tends to walk with “their hip and their waistline shifted and their hips thrust to one side or another.” If you have degenerative scoliosis you may experience difficulty standing fully upright as well as back pain, including sciatica, which is pain and weakness that radiate from your low back down one or both legs and can interfere with walking.

Many cases of adult scoliosis do not need treatment. Your doctor may recommend waiting to see if your curvature progresses over time. Meanwhile, you should do all the “healthy” things you’re supposed to do: exercise regularly, maintain a good diet, avoid smoking, and be mindful of your posture, your gait and your lifting technique to keep your back as healthy as possible.

Congenital

Congenital scoliosis occurs when the spine does not develop properly in utero. Malformations may include:

• hemivertebra, where only one side of the vertebral body develops

• failure of segmentation, which happens when parts of the spine are fused

• rib fusion, where ribs are fused together

Neuromuscular

Neuromuscular scoliosis is caused by brain, spinal cord, and muscular system disorders. Such conditions include:

• cerebral palsy (CP)

• spinal muscular atrophy (SMA)

• Angelman syndrome

• Arnold-Chiari malformation/syrinx or spinal cord trauma

Thoracogenic

Thoracogenic scoliosis is seen in patients whose spinal development has been asymmetric due to radiation treatment of childhood tumors or surgery to address a congenital heart defect.

Syndromic

Syndromic scoliosis develops as part of an underlying syndrome or disorder such as:

• Muscular system disorders including muscular dystrophy, poliomyelitis, arthrogryposis, or spina bifida

• Connective tissue diseases including Marfan syndrome and Ehlers-Danlos syndrome

Scoliosis symptoms can vary widely, depending on the severity of the curves. In mild cases, symptoms may be purely cosmetic and can include:

• Visible difference in hip and shoulder height

• One or both hips are raised or noticeably high

• Uneven shoulders one or both shoulder blades may stick out

• Head is not centered right above the pelvis

• Asymmetry between rib cage heights on either side.

• Waistline appears uneven

• Changes in the appearance or texture of the skin overlying the spine changes, such as dimples, hairy patches, or color abnormalities

• The entire body leans toward one side

More serious cases of scoliosis may cause:

• Back pain

• Inability to stand upright

• Leg pain, numbness, and/or weakness due to radiculopathy, or pressure on nerves in the lumbar spine

• Height loss in adults

• Bowel or bladder dysfunction in more severe cases

What Can Happen If You Don’t Seek Scoliosis Treatment?

Like all conditions, the sooner you treat scoliosis, the better you’ll live with it. And with scoliosis, the amount of grief you deal with will depend on the degree of your curvature.

Those with mild curves of 20 degrees or less may experience nothing more than back strain or fatigue with prolonged sitting or standing. However, those with more pronounced curves may experience a variety of complications.

According to Dr. Lonner, particularly for those with curves that are 50 degrees or more in the thoracic region and 40 degrees (and sometimes even less) in the lumbar spine, untreated scoliosis can create a number of structural and functional problems. These may include:

• Spinal instability, which can increase the risk of back problems such as herniated discs, spondylolisthesis, and others

• Ribs jutting out on either side

• Humpback

• Limp caused by a discrepancy in leg length

• Nerve damage or radiating pain, depending on where the scoliosis curves are found

• Sciatica

• Difficulty sitting, standing, or walking

• Spinal rigidity and stiffness

• Cardiopulmonary (heart and lung) issues

Bottom line? No matter the severity of your or your child’s scoliosis, speak with a spine specialist to see what type of treatment, if any, is needed.

While the spine does have normal curves when viewed from the side, when viewed straight-on, it should not have any apparent curves. According to Dr. Lonner, while “a small degree of curvature is not uncommon,” anything over 10 degrees would be considered scoliosis.

Often you’ll receive a diagnosis of scoliosis after seeing your doctor for back pain. A 2019 study in The Spine Journal found that roughly 40% of adolescents who were diagnosed with scoliosis presented with low back pain.

This isn’t always the case, however. Because the condition tends to worsen over time, children and those who are in the early stages and have mild curvatures are less likely to experience symptoms if they get treated in a timely fashion.

For adults and youths, regular checkups are important. However they’ll be more frequent if your spine is still growing.

If your child has scoliosis, expect to take them to the doctor every four to six months for an exam. According to Dr. Lonner, during your child’s visit, their specialist will ask how they’re doing and whether their clothes are fitting differently.

They will also ask female patients whether they’ve menstruated since their last visit, as the onset of a girl’s period signals her growth is slowing down. The physician will also perform a physical exam using a scoliometer to determine whether the spinal curvature has grown more severe.

Screening

Regardless of whether symptoms are present, your child’s pediatrician typically performs a scoliosis screen during the annual check-up, says Dr. Lonner. Additionally, some states mandate that schools screen students for scoliosis annually.

During this type of routine test, practitioners look out for any asymmetries between shoulder blade prominence—meaning if one shoulder blade sticks out more than the other—and shoulder and hip height. If your spine is normal, you should be able to draw a horizontal line between the tops of your shoulders, and another across your waist; if you have scoliosis, those lines will be diagonal.

Physical Exam

If your preliminary screen raises any concerns, your physician will examine you with a tool that’s similar to a carpenter’s level, known as a scoliometer. While you’re bending forward from the waist with your knees straight, your torso parallel to the floor and your arms hanging down, your doctor places the scoliometer, atop your back at the maximally rotated or most prominent area of your ribs or low back. Then they’ll use the scoliometer to determine the angle of the curvature.

Imaging

If your doctor’s clinical examination indicates you have scoliosis, the next step is imaging.

X-Ray

You will usually need to go to a radiology clinic to get standing X-rays. According to Dr. Lonner your specialist will review them to measure the curves, define their exact location, and identify any degenerative changes, particularly in the adult patient whose condition may have been gradually worsened over time. Your specialist will also look for other findings, such as spondylolisthesis or spondylosis; though they affect the opposite plane, they can give more information.

Magnetic Resonance Imaging (MRI)

An MRI is far less commonly used than an X-ray, however it may be indicated if your physical exam reveals neurological abnormalities, if you have moderate to severe pain, or the shape of your curve is "atypical.”

Scoliosis brings up images of braces and perhaps memories of being tested for it in grade school by the school nurse. Bracing is one of the most common treatment options for scoliosis because it may fix the curve without spine surgery.

Sometimes, though, the curve is too extreme and bracing doesn't help enough. In that situation, you can have scoliosis surgery to correct the curve.

Although technological advancements have led to innovative new surgical options over the past decade, there has also been a sea-change in the medical community, which has shifted toward a more patient-centered care model, says Dr. Lonner.

The new paradigm uses your X-rays and measurements as well as personal interactions with you and your family, taking your lifestyle and values into account, when creating a treatment plan. Today, says Dr. Lonner, “there's more of a reliance on the back and forth and assessment of the patient's and family's goals.”

Treatment plans are also increasingly drawing on input from a multi-disciplinary team. This is particularly true for adults with chronic health conditions such as high blood pressure, heart disease, and diabetes. For these individuals, overall risk profile plays a large role in determining their care plan.

Bracing

Bracing has historically been, and remains, the most common option and generally the best nonsurgical option for a growing child with a curvature of 20 to 40 degrees, says Dr. Lonner.

Bracing aims to minimize the progression of your curvature and is meant to be worn until you stop growing. Most are designed to be worn 16 to 23 hours per day, depending on your curvature and the type of brace. While your spinal curvature will diminish while you’re wearing it, it will most likely go back to its original size once you’re out of it. If you and your care team decide a brace is the best option for you, you will see your doctor for a check-up every four to six months.

Nonsurgical Exercise

Your ability to participate in some sports may be limited, depending on the severity of your curvature and your pain level. That said, while exercise has not been shown to remediate scoliosis, it can help manage symptoms in patients of all ages.

Dr. Lonner recommends exercises such as core strengthening and stretching as well as low-impact activities including swimming, biking, and the elliptical machine. Whether you can safely engage in higher impact workouts like running and kickboxing depends on your pain level.

Physical Therapy

Physical therapy may include therapeutic exercises, biomechanics education, aquatic therapy, and/or any of the modalities listed below.

Schroth Method

According to Dr. Lonner, literature suggests the Schroth method can help slow the progression of scoliosis, particularly in patients with smaller curves.

Using this method, your physical therapist trains you in a series of personalized exercises that help return the spine to a more neutral position. These exercises aim to de-rotate, elongate, and stabilize the spine in a three-dimensional plane by strengthening certain muscles around the spine and in the torso while stretching others.

Breathing is a key aspect of the Schroth method. Using a special technique called rotational angular breathing, the goal is to rotate the spine, allowing breathing to help restructure the rib cage and surrounding soft tissue.

Physical therapists who obtain advanced certification in this method focus on teaching patients how to perform postural corrections independently and engage in activities of daily living with correct posture. They also educate patients and their families on scoliosis and the rationale behind the therapy.

Passive Therapies

In addition to a home exercise program, your physical therapist may also employ a number of other techniques, such as:

• Manual Therapy. Using their hands, your PT mobilizes your joints and stretches your muscles to improve your range of motion and alleviate pain.

• Electrical Stimulation. Also known as “E-stim” or Transcutaneous Electrical Nerve Stimulation (TENS), this modality delivers a painless electrical current to specific nerves through your skin to improve range of motion and alleviate pain.

• Myofascial Release. This is a form of massage that addresses tightness in the fascia, or connective tissue that supports your muscles, bones, and organs.

• Ultrasound. During this painless procedure, your PT first applies a gel to your skin to create a frictionless surface and then goes over the affected area with an ultrasound probe to promote blood circulation and decrease pain.

• Ice and Heat Therapies. Low tech and easy to use at home, ice and heat help to promote circulation, combat inflammation, and improve range of motion. A barrier (such as a towel) is placed between the heat or cold pack to protect your skin.

Pain Management

In addition to physical therapy and engaging in regular exercise as mentioned above, there are a variety of other non-surgical strategies that can help with pain management, including:

• Non-steroidal anti-inflammatory medication (NSAIDs)

• Massage

• Injections, such as nerve blocks, epidural steroid injections, and radiofrequencynerve ablation. Candidates for injection therapy are generally those who also have a diagnosis of degenerative disc disease.

Surgery is generally a good option for those who have tried more conservative measures and whose quality of life is compromised by back and/or leg pain and spinal imbalances that limit their mobility and their ability to engage in activities of daily living. Surgery may be appropriate for children or adolescents with severe curvatures and adults with idiopathic or degenerative scoliosis.

Spinal Fusion

Spinal fusion is the most invasive and most common surgical scoliosis treatment. It uses bone from another part of your body (called an autograft), or from a cadaver or a synthetic bone substitute (both known as allograft) to stabilize a section of the spine.

While the procedure is not new, many surgeons are now using innovative multimodal strategies that lead to better outcomes. These include spinal cord and nerve root monitoring during surgery, GPS-guided robotics surgery, and the use of tranexamic acid during surgery to limit blood loss and decrease surgery times.

Vertebral Body Tethering

This minimally invasive, thoracoscopic surgical procedure, also known as anterior scoliosis correction, is appropriate for the pediatric patient whose spine is still growing and was FDA approved in August 2019.

During this procedure, your surgeon makes small incisions in your side through which they place screws and anchors across multiple vertebrae along the convex (outward) aspect of your spinal curve. A strong, flexible cord is then attached to the hardware and is tightened to the appropriate tension to correct your curvature.

ApiFix

Also known as posterior dynamic distraction, according to Dr. Lonner, ApiFix “has been approved for skeletally immature patient as well as the mature patient who is no longer growing.”

During this minimally invasive thoracoscopic procedure your surgeon will make small incisions along your spinal column through which they’ll place three screws and a device that sits vertically along your spine. The screws are then ratcheted to correct the spinal curve during surgery and can be adjusted post-surgically to make further corrections. Apifix was FDA approved in September 2019.

For children, especially, it can be frightening to learn they have scoliosis. Having that label makes them different at a time in their lives when they don't want to be all that different. They might not like the idea of wearing a brace, either. But scoliosis is nothing to be scared or ashamed of. With the proper treatment, scoliosis doesn't have to define your life.

The challenges of living with scoliosis vary depending on the individual, their age, and the severity of their condition. Scoliosis is not only a physical impairment; it can also have implications for mental health and it can affect your ability to engage in activities. There are, however, many resources available to help you or your child cope with the diagnosis and live a full life.

For many people, particularly adolescent girls with idiopathic adolescent scoliosis (IAS), the diagnosis comes with body image concerns. While negative body image can certainly affect males and females at any point in their lives, IAS disproportionately affects girls.

“It’s a very difficult time as it is,” explains Dr. Lonner. Scoliosis can make some adolescents even more self-conscious than usual, he says. For younger people, even a milder deformity with little or no pain can have serious mental health implications.

“It might be a moderate curve, but for them, it’s a mountain,” he says. Not surprisingly, Dr. Lonner says, there is evidence showing a positive association between AIS and anxiety and depression. According to Dr. Lonner, based on a patient outcomes questionnaire known as the SRS, surgery has been found to buoy adolescents’ self-image.

However, there are other effective approaches for those who aren’t surgical candidates. If your SRS score meets a minimum threshold, your specialist should refer you for counseling, which can be a valuable resource. Additionally, non-profit organizations such as Setting Scoliosis Straight and Curvy Girls offer people with scoliosis both educational tools and the chance to connect with and support one another.

Although it’s possible for scoliosis to interfere with your health and your quality of life, it doesn’t have to. With the help of trained professionals and an array of non-surgical and minimally invasive approaches to help manage your condition, finding relief could be a lot easier than you think. If you have scoliosis or are concerned that you may, seek treatment today.

The incidence of scoliosis in males and females seems to be subject to debate. Although some research shows that the incidence of scoliosis is the same among males and females, others found a higher prevalence in females. Regardless of overall incidence, the current consensus is that females are at a higher risk of severe idiopathic curve progression.

Lumbar lordosis, the exaggerated inward curve of the spine, is associated with a higher risk of developing idiopathic scoliosis. There is also evidence that children who have undergone cardiothoracic operations are more at risk for developing scoliosis, as are people who have cerebral palsy. Recent research has also identified a genetic component connected to AIS. Teenage growth spurts are also highly correlated with developing AIS and tend to affect girls more severely than boys

Although researchers have not reached a specific set of conclusions, there is growing evidence that abnormal levels of many hormones—such as estrogen, melatonin, growth hormone, leptin, adiponectin, and ghrelin—may play a role in the development of AIS.

There is currently no definitive way to prevent AIS. But there are measures that may reduce the negative impact of this disorder. For example, early screening for AIS, beginning in late elementary school or early middle school, should be standard procedure for pediatricians, family doctors, and school nurses

Early intervention is also connected to better outcomes for people with AIS. Specifically, exercise-based therapies focused on increasing flexibility and range of motion may be helpful in reducing the progression of scoliosis. For prepubescent girls especially, participating in weight-bearing activities and having a diet rich in calcium may reduce the risk of bone mass loss.