Scoliosis in Children and Teens
What is scoliosis?
Scoliosis is a problem with the curve in the spine. Many people have some curve in their spine. But a few people have spines that make a large curve from side to side in the shape of the letter "S" or the letter "C." If this curve is severe, it can cause pain and make breathing difficult.
The good news is that most cases of scoliosis are mild, and the curves don't increase a lot over time.
What causes scoliosis?
In most cases, the cause of scoliosis is not known. Scoliosis usually starts in the preteen years. Scoliosis that is severe enough to need treatment is most common in girls.
What are the symptoms?
Scoliosis most often causes no symptoms until the spinal curve becomes large. You might notice these early signs:
- Your child has one shoulder or hip that looks higher than the other.
- Your child's head does not look centered over the body.
- Your child has one shoulder blade that sticks out more than the other.
- Your child's waistline is flat on one side, or the ribs look higher on one side when your child bends forward at the waist.
How is scoliosis diagnosed?
The doctor will check to see if your child's back or ribs are even. If the doctor finds that one side is higher than the other, your child may need an X-ray so the spinal curve can be measured.
A curve in the spine may get worse as your child grows. Many experts believe screening your child for scoliosis is important so that any curve in the spine can be found early and watched closely.
How is it treated?
Mild cases of scoliosis usually do not need treatment. The doctor will check the curve of your child's spine every 4 to 6 months. If the curve gets worse, your child may need to wear a brace until he or she has finished growing. In severe cases, or if bracing doesn't help, your child may need to have surgery.
Scoliosis and its treatment can be a severe strain on your child. Wearing a brace can feel and look odd. It also limits your child's activity. Your child needs your support and understanding to get through treatments successfully.
What increases the risk of scoliosis?
Your child may be more likely to have scoliosis if someone in your family has had it and if your child is a girl. Your child's chances of scoliosis increase if:
- One of the bones in your child's spine has moved forward out of place compared to the rest of the spine.
- Your child's arms or legs are missing or are abnormally short.
- Your child has a disorder that affects the nerves, muscles, or bones.
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In most cases, the cause of scoliosis is not known. This is called idiopathic scoliosis. It develops mostly in the preteen and teen years. It often runs in families.
There are two types of scoliosis: nonstructural and structural.
Nonstructural (functional) scoliosis
Nonstructural (functional) scoliosis involves a curve in the spine that is reversible because it is caused by a condition such as:
- Pain or a muscle spasm.
- A difference in leg length.
Structural scoliosis involves a curve in the spine that is irreversible. It is usually caused by an unknown factor (idiopathic) or a disease or condition such as:
- Disorders that were present at birth (congenital), such as spina bifida, in which the spinal canal does not close properly; or a disorder that affects the formation of bones. These curves can be harder to correct. They often get worse as the child grows, especially during the teen years.
- Nerve or muscle disorders, such as cerebral palsy, Marfan's syndrome, or muscular dystrophy.
In children and teens, scoliosis typically does not cause symptoms and is not obvious until the curve of the spine becomes moderate or severe. It may first become noticeable to a parent who observes that the child's clothes do not fit right or that hems hang unevenly. The child's spine may look crooked, or the ribs may stick out.
In a child who has scoliosis:
- One shoulder may look higher than the other.
- One hip may look higher than the other.
- The child's head is not centered over his or her body.
- One shoulder blade may stick out more than the other.
- The ribs are higher on one side when the child bends forward from the waist.
- The waistline may be flat on one side.
Most of the time scoliosis does not cause pain in children or teens. When back pain is present with scoliosis, it may be because the curve in the spine is causing stress and pressure on the spinal discs, nerves, muscles, ligaments, or facet joints. It is not usually caused by the curve itself. Pain in a teen who has scoliosis may be a sign of another problem, such as a bone or spinal tumor. If your child has pain with scoliosis, it is very important that he or she see a doctor to find out what is causing the pain.
Some other conditions, such as kyphosis, cause symptoms similar to scoliosis.
Idiopathic scoliosis, the most common type, does not have a known cause. Children who have this type of scoliosis usually first develop symptoms in the preteen years. Most cases of scoliosis are mild, involving small curves in the spine that do not get worse. Small curves usually don't cause pain or other problems. Usually a doctor examines the child every 4 to 6 months to watch for any changes.
In moderate or severe cases of scoliosis, the curves continue to get worse. During periods of growth, such as during the teenage growth spurt, the curves may get worse. Mild to moderate curves often stop progressing when the skeleton stops growing. Larger curves may get worse throughout adulthood unless they are treated.
Things that may point to the potential increase in a spinal curve include:
- The age of the child and the development stage, or maturity, of his or her skeleton when scoliosis is diagnosed. The less mature the skeleton is when scoliosis starts, the greater the chance that scoliosis will get worse. Skeletal age, as determined by the Risser sign, is also used to find out the risk that the curve will get worse.
- The size of the curve. The larger the curve, the greater the risk that it will get worse.
- The location and shape of the curve. Curves in the upper back are more likely to get worse than curves in the lower back.
Girls are more likely than boys to have larger curves and more severe scoliosis.
As scoliosis gets worse, the bones of the spine move toward the inside of the curve. If it happens in the upper part of the spine, the ribs may crowd together on one side and spread apart on the other side. The curve may force the spinal bones closer together. The spinal bones on the outer edge of the curve may also get thick.
Although it is uncommon, babies can be born with scoliosis (congenital) or can develop it during the first 3 years of their lives (infantile scoliosis). Scoliosis that is present at birth or that develops in infants may be worse in the long run than scoliosis that develops later in life. This is because the more growing the skeleton has to do, the worse the curve may get. But in some cases congenital curves do not get worse. And some curves that are present during infancy get better on their own without treatment.
What Increases Your Risk
Things that increase a person's risk for scoliosis include:
- Family history. Scoliosis is known to run in families.
- Being female. Girls are more likely than boys to have a significant curve that requires treatment.
Scoliosis is more common in people who have:
- A spinal bone that is pushed forward (forward displacement), usually in the lower back (spondylolisthesis).
- Missing or abnormally short arms or legs.
- Other disorders related to tissue development while in the womb.
When should you call your doctor?
Call your doctor to have your child evaluated for scoliosis if:
- You see a curve in your child's spine.
- You notice that something about your child's posture looks unusual. Examples are ribs that stick out, one shoulder that is higher than the other, one hip that is higher than the other, and an uneven waistline.
- You observe that your child's clothes don't fit properly or that his or her hems don't hang evenly.
- A school screening program recommends that your child see a doctor.
If you suspect that your child has a spinal curve, ask a health professional to look at it. Early detection could lead to early treatment and could prevent a curve from getting worse.
If the results of a school screening program suggest that your child may have a spinal curve, follow up with your doctor. Most curves that are found through school screening programs are normal variations in the spine or mild scoliosis, and these curves usually need only regular observation.
Who to see
The following health professionals could identify and monitor scoliosis:
A doctor who specializes in surgery of the bones (orthopedic surgeon) may be consulted if the person has a moderate curve or if the curve is getting worse. The orthopedic surgeon will evaluate the curve and may recommend bracing or surgery.
A health professional who fits people with specially designed assistive devices (orthotist) can build and fit a custom brace.
Exams and Tests
Scoliosis testing usually begins with a history and physical exam. This includes the forward-bending test, a simple test in which the child bends forward at the waist, arms hanging loosely and palms touching, and the examiner looks for unevenness in the child's back or ribs. A scoliometer can be used to measure and estimate the rotation of the spinal curve.
If the findings of the history and physical exam show a significant spinal curve, an X-ray of the spine may be taken to get a more precise measurement of the spinal curve.
Skeletal age, as determined by the Risser sign, is also a helpful measure to find out the risk that the curve will get worse.
If someone in your family has scoliosis, your children should be checked regularly.
Screening means doing a simple test to see if more testing might be needed. Some states require screening for scoliosis by law. But experts don't agree with whether or not to screen for scoliosis. Screening can lead to early treatment and may prevent curves from getting worse. But screening can also lead to more testing or treatment for children who would not have needed it. Some experts believe that children should be screened for scoliosis regularly throughout their preteen and teen years. If you are concerned about screening for scoliosis, talk to your child's doctor.
The goal of treatment for scoliosis is to prevent the spinal curve from getting worse and to correct or stabilize a severe spinal curve. Fortunately, few people who have spinal curves require treatment.
The type of treatment depends on the cause of scoliosis. Scoliosis that is caused by another condition (nonstructural scoliosis) usually improves when the condition, such as muscle spasms or a difference in leg length, is treated. Scoliosis that is caused by a disease or by an unknown factor (structural scoliosis) is more likely than nonstructural scoliosis to need treatment.
- Nonsurgical treatment. This includes either routine exams by a doctor to check for any curve progression or the use of a brace to stop a spinal curve from getting worse. Children typically have these checkups about every 4 to 6 months.
- Surgical treatment. Surgery can usually decrease the curve and stabilize the spine so the curve does not get worse.
Treatment is based on the child's age, the size of the curve, and the risk of progression. The risk of progression is based on age at diagnosis, the size of the curve (as measured using X-rays of the spine), and skeletal age (which can be determined by the Risser sign).
- Mild curves are usually checked by the doctor every 4 to 6 months until the bones stop growing, to be sure the curves aren't getting worse.
- Moderate curves may need to be braced until the bones stop growing, to keep the curves from getting worse.
- Severe curves or moderate curves that are getting worse may need surgery.
What to think about
Most cases of scoliosis are mild and do not require treatment.
The timing of surgery for scoliosis in children is controversial. Spinal fusion stops the growth of the fused part of the spine, so some experts believe that surgery should be delayed until the child is at least 10 years old and preferably 12. But even after surgery the rest of the spine will continue to grow normally in children who are still growing.
Scoliosis cannot be prevented. Treatment is aimed at preventing the curve from getting worse.
If your child or teen has been diagnosed with mild scoliosis, it is important that a doctor check the child's spine every 4 to 6 months to see whether the curve is getting worse. Most spinal curves do not progress to the point where treatment is needed. But it is important to check for curve progression, because early treatment can often stop it.
Impact of scoliosis on a child or teen
Treatment for moderate or severe scoliosis can dramatically impact your child's life. If your child has scoliosis, it is important that your family be sensitive to the difficulty of having scoliosis and wearing a brace. A scoliosis clinic, where other children are being treated, can provide a supportive environment for your child.
When back pain is present with scoliosis, it may be that the curve in the spine is causing stress and pressure on the spinal discs, nerves, muscles, ligaments, or facet joints. It is not usually caused by the curve itself. Some people may use nonprescription medicines such as naproxen or ibuprofen to treat back pain. While these medicines may relieve symptoms of back pain temporarily, they do not heal scoliosis or back injuries. And they don't stop the pain from coming back.
Surgery may be used to treat severe scoliosis. The goal of surgery is to improve a severe spinal curve. The result will not be a perfectly straight spine, but the goal is to balance the spine and to make sure the curve does not get worse. Surgery usually involves stabilizing the spine and keeping the curve from getting worse by permanently joining the vertebrae together.
Things that are considered before surgery include:
- The child's age.
- The size, direction, and location of the spinal curve(s).
- Whether other treatment, such as bracing, has failed.
Surgery may be considered if:
- Your child has a moderate to severe curve, and the curve is getting worse.
- Your child has pain or trouble doing his or her daily activities.
The main type of surgery for scoliosis involves attaching rods to the spine and doing a spinal fusion. Spinal fusion is used to stabilize and reduce the size of the curve and stop the curve from getting worse by permanently joining the vertebrae into a solid mass of bone.
Other techniques are sometimes used, including instrumentation without fusion, which attaches devices such as metal rods to the spine to stabilize a spinal curve without fusing the spine together. This is only done in very young children when a fusion, which stops the growth of the fused part of the spine, is not desirable. The child usually has to wear a brace full-time after having this surgery.
What to think about
The timing of surgery for scoliosis in children is controversial. Spinal fusion stops the growth of the fused part of the spine. So some experts believe that surgery should be delayed until the child is at least 10 years old and preferably 12. But even after surgery the rest of the spine will continue to grow normally in children who are still growing.
Surgical treatment in children and teens usually requires several days in the hospital and limitations on activity for about a year.
Treatment other than surgery for scoliosis includes observation. In a child who is still growing, a mild spinal curve may need only regular checkups every 4 to 6 months to see if the curve is getting worse.
There is no evidence that corrective exercises, electrical stimulation, or spinal manipulation are effective treatments for scoliosis.
Wearing a brace
For children with moderate curves, the research shows that wearing a brace generally works to keep curves from getting worse as the child grows. The more the child wears the brace, the better it works.
But wearing a brace can be emotionally hard on preteens and teens, who don't like to feel different. So family support is important. A common reason for bracing not working well is that the child doesn't wear it as prescribed, usually because he or she is embarrassed. A brace can also be uncomfortable.
Here's how family members and your child's friends can help:
- Encourage your child to talk about what he or she needs to feel comfortable during brace fittings. For example, fittings include chest measurements. Allow your child to request a same-sex technician, if one is available. This can help your child feel more involved and at ease during treatment.
- Treat the brace like a tool that's helping your child. Try to make it just a routine part of your child's—and your family's—life.
- Encourage your child to learn all he or she can about scoliosis and how the back brace can help. This knowledge may help your child deal with questions, or even teasing, at school and elsewhere.
- Encourage your child to talk about the brace with friends.
- Listen to your child when he or she talks about his or her concerns. Ask your child how you and his or her friends can help.
- Show your child how to find online forums where preteens and teens talk about their experiences with a back brace. These forums can help give your child the courage to keep going. Your child can take part in online discussions and learn all kinds of advice, from what kinds of clothes work best to what to say on a date.
- Observe your child's frame of mind. If you think your child may feel isolated or depressed because of the back brace, ask your doctor for help.
- U.S. Preventive Services Task Force (2018). Screening for adolescent idiopathic scoliosis: U.S. Preventive Services Task Force recommendation statement. JAMA, 319(2): 165–172. DOI: 10.1001/jama.2017.19342. Accessed July 2, 2018.
- Hresko MT, et al. (2016). Early detection of idiopathic scoliosis in adolescents. Journal of Bone and Joint Surgery. American Volume, 98(16): e67(1)–e67(4). DOI: 10.2106/JBJS.16.00224. Accessed July 3, 2018.
Other Works Consulted
- American Academy of Orthopaedic Surgeons and American Academy of Pediatrics (2010). Scoliosis. In JF Sarwark, ed., Essentials of Musculoskeletal Care, 4th ed., pp. 1164–1169. Rosemont, IL: American Academy of Orthopaedic Surgeons.
- Erickson MA, Caprio B (2014). Orthopedics. In WW Hay Jr et al., eds., Current Diagnosis and Treatment: Pediatrics, 22nd ed., pp. 862–883. New York: McGraw-Hill.
- Negrini S, et al. (2015). Braces for idiopathic scoliosis in adolescents (Review). Cochrane Database of Systematic Reviews (6). DOI: 10.1002/14651858.CD006850.pub3. Accessed July 10, 2015.
- Paul SM (2010). Scoliosis and other spinal deformities. In WR Frontera, ed., DeLisa's Physical Medicine and Rehabilitation, 5th ed., vol. 1, pp. 883–906. Philadelphia: Lippincott Williams and Wilkins.
- Rowe DE, et al. (2002, updated 2014). SRS bracing manual. Scoliosis Research Society. http://www.srs.org/professionals/online-education-and-resources/srs-bracing-manual. Accessed January 29, 2016.
Current as of: June 26, 2019