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Lumbar Scoliosis

What does “Scoliosis” mean?

The word “scoliosis” comes from the Greek word “scolios” which means “crooked”. A spinal scoliosis is a “crooked” spine.

What is a Scoliosis?

A Scoliosis is a deformity of the spine where the spine looks “S-shaped” or “C-Shaped”, rather than straight when looking at it from behind. Looking at it from the side it is normal to have an S-shaped curvature.

How common is a Scoliosis?

Scoliosis affects approximately 2% of the population. There is a strong genetic component. If there is a family history of scoliosis, there is a 20% chance of passing it on.

What are the different types of Lumbar Scoliosis?

Scoliosis curvatures can be divided into 4 groups:

  1. Congenital: those which are present at birth
  2. Idopathic: those which for reasons unknown
  3. Neuromuscular: those which are due to diseases of the nerves or muscles
  4. Degenerative (pseudoscoliosis): those which develop a part of spine degeneration

Congenital and Neuromuscular scoliosis are rare. Idiopathic scoliosis are common in adolescents, while Degenerative scoliosis are common in adults.

What is an Idiopathic Scoliosis?

Even though idiopathic scoliosis does not have a known reason, it is suspected that it is genetic in nature. However, the exact gene is not known. Adolescent (middle, late childhood) idiopathic scoliosis is the most common form of scoliosis overall. This disease is self-limiting, meaning it comes to an end when we stop growing. It is more common in girls than boys.

What are the symptoms from a Lumbar Idiopathic Scoliosis?

In children, the beginning of a scoliosis is usually at ages 6-8. Scoliosis is typically a “silent disease”, meaning it is typically not painful and the parents may not be aware.

Here are some possible observations parents can make to be suspicious of a scoliosis:

  1. The child is leaning to one side when standing or walking
  2. The waist seems higher on one side
  3. The shoulders seem uneven when standing or walking
  4. One shoulder blade seems to stick out more than the other, especially when bending forward

What is a Degenerative Scoliosis?

A degenerative scoliosis is a curvature of the spine which develops over the long-terms when the spine degenerates. When this degeneration happens more on one side of the spine than the other, the spine can partially collapse on the side of the most degeneration and begin to curve. Typically this happens when discs lose more height on one side than the other.

What are the symptoms of a Lumbar Degenerative Scoliosis (Pseudoscoliosis)?

Here are some of the common symptoms of a Lumbar Degenerative Scoliosis:

  1. Low back pain
  2. Low back spasms, usually worse on one side
  3. Pain referring from the low back to the hip and thigh
  4. Pain radiating into the leg
  5. Walking with a limp

How is a Lumbar Scoliosis diagnosed?

Spine specialists use the information from the patient history, physical examination and special tests to make the diagnosis of a Thoracic Scoliosis:

  1. History

a. Idiopathic Scoliosis

Usually the patient is brought to the spine specialist because either a parent or the school has noticed some of the changes listed just above.

Sometimes there is a family history and the parents are concerned about the possibility of a scoliosis.

At times, children will complain about pain or tightness in the spine.

b. Degenerative Scoliosis

These patients often complain about pain on one side of the spine, which radiates to the hip or buttock. They may notice that one hip is higher than the other, or than one leg appears shorter than another.

  1. Physical Examination

Here are some physical examination techniques spine specialists may use to confirm the presence of a scoliosis:

  1. Visual inspection of the spine with the patient undressed
  2. Gait testing
  3. Forward bending at the waist, looking for a “hump” on one side of the spine (Adam’s Forward Bend Test)
  4. Touching or pushing on the spine (palpation) to feel a deformity
  5. Sensation (sensory) testing in the legs
  6. Strength testing (motor) in the legs
  7. Reflex testing

 

      2. Imaging

a. X-Rays

  1. Idiopathic Scoliosis:

The best way to confirm a scoliosis is through X-Rays. There are special “scoliosis films” which show the entire spine from head to tailbone. This allows the doctor to evaluate the whole spine. The degree of the scoliosis is usually measured (Cobb angle) and used as a means to follow the progression of the curvature as well as to make a decision for surgery. X-Rays are often repeated every 3-12 months to look for any changes.

     2. Degenerative Lumbar Scoliosis:

This diagnosis does not typically require “scoliosis films” of the whole spine. A plain AP/Lat X-Ray of the Lumbar Spine will show the degenerative curvature. Often the one-sided collapse of disc spaces can be seen.

b. CT-Scan

Even though CT scans can show the bone anatomy of the spine in great detail, they are often not necessary to diagnose a scoliosis due to the high dose of radiation.

c. MRI Scan

  1. For idiopathic scoliosis, MRI scans are usually not needed to establish the diagnosis of a scoliosis. An exception is a scenario where a neuromuscular scoliosis is suspected. In this situation, the spinal cord and spinal nerves as well as the spinal muscles can be evaluated.
  2. For Degenerative scoliosis, MRI scans can be helpful to see the individual discs, facet joints and the spinal canal. This can shed light on why the scoliosis happened and to assess the overall degree of degenerative disease of the spine.

How is a Lumbar Scoliosis treated?

    1. Idiopathic Scoliosis

The majority of idiopathic adolescent scoliosis do not require any type of treatment, but rather observation and periodic X-Rays. For patients with a severe scoliosis, rapidly progressing scoliosis, or who have significant symptoms, here are some treatments available:

  1. Non-Surgical

A. Alternative Health Care

Alternative Health care options can often complement conventional medical care. Massage Therapy, Acupuncture, Meditation exercises and Herbal Remedies can all help with the pain from this condition.

B. Nutrition and Weight Loss

Proper nutrition and weight loss can have a positive impact on many spine conditions. Excess weight on the spine often contributes to the symptoms of pain and spasms (Spine and Obesity).

C. Chiropractic Care

Chiropractic care including manipulation and adjustments of the spine can help with the pain and spasms from this condition.

D. Brace

Orthopaedic Bracing is sometimes recommended in moderate-severe or worsening cases of scoliosis. It can be useful when the bones are still growing. The hope is often to avoid a surgery.

E. Spine Exercises

Spine exercises can help with the muscle pain and tightness from this condition. Exercise also increases the amount of oxygen delivered to the spine which can help with healing. Pilates, Yoga and T’ai Chi can help maintain the spine’s flexibility.

F. Physical Therapy (PT)

PT has many modalities to offer for this condition. They can range from Manual Therapy and Exercises to Traction and Ultrasound Treatments. There is a “Schroth Method” of specific physiotherapy and targeted exercises which has been shown to be helpful. This method has actually been shown to significantly reduce a scoliosis.

G. Self Help Tools

Self Help Tools are items which can be purchased to help with back pain. They range from Back Braces to Back Mattresses and Ergonomic Devices such as chairs and computer accessories.

H. Spine Medications

Here are some of the common groups of medications which are available for this condition:

  1. Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
  2. Muscle Relaxants
  3. Pain Killers
  4. Nerve Pain Medications
  5. Antidepressants
  6. Topical Medications

 

      2. Surgical Care

Surgery is considered after the bones have stopped growing and the curvature is severe. Generally a scoliosis in the range of 45 to 50 degrees is considered a surgical condition.

The surgery can be accomplished as an anterior (front) or posterior (back) surgery. The anterior approach is actually done from the side of the spine but targets the vertebrae and discs on the front of the spine. The posterior approach is done from the back with screws and rods inserted into the vertebrae.

 

Here are some surgical options:

1. Lumbar Fusion

2. Lumbar Osteotomy and Fusion

 

 

2. Degenerative Scoliosis (Pseudoscoliosis)

Degenerative scoliosis are common in patients with advanced degenerative spine disease. Few patients will require surgery. The surgery is typically not done due to the curvature, but rather the symptoms from the curvature or other underlying spine issues.

 

  1. Non-Surgical

A. Alternative Health Care

Alternative Health care options can often complement conventional medical care. Massage Therapy, Acupuncture, Meditation exercises and Herbal Remedies can all help with the pain from this condition. Massage Therapy techniques can help with the muscle discomfort of this condition

B. Nutrition and Weight Loss

Proper nutrition and weight loss can have a positive impact on many spine conditions. Excess weight on the spine often contributes to the symptoms of pain and spasms (Spine and Obesity).

C. Chiropractic Care

Chiropractic care including manipulation and adjustments of the spine can help with the pain and spasms from this condition.

D. Spine Exercises

Spine exercises can help with the muscle pain and tightness from this condition. Exercise also increases the amount of oxygen delivered to the spine which can help with healing. Pilates, Yoga and T’ai Chi can help maintain the spine’s flexibility. Exercising the spine can be a form of “preventative maintenance” over time. The focus should be on spine mobility and stability.

E. Physical Therapy (PT)

PT has many modalities to offer for this condition. They can range from Manual Therapy and Exercises to Traction and Ultrasound Treatments. PT can be helpful. Keeping the spine’s mobility, strength and stability are often goals of PT. Spine traction can be a useful treatment. As the disease progresses, the disc and its spine segment may stiffen to a point where traction may not be helpful any longer.

F. Self Help Tools

Self Help Tools are items which can be purchased to help with back pain. They range from Back Braces to Back Mattresses and Ergonomic Devices such as chairs and computer accessories. Back braces can add stability to the spine. However this must be balanced against relying too much on the brace, which could weaken the muscles over time.

G. Spine Medications

Similar to other degenerative spine conditions such as degenerative disc and facet disease, medications can help with the symptoms from a degenerative scoliosis. While there is no “best medication”, the spine specialist can prescribe one or a combination of the medications below. Here are some examples of groups of medications:

1. Non-Steroid Anti-Inflammatories Drugs(NSAIDS)

2. Muscle Relaxants

3. Pain Killers

4. Nerve Pain Medications

H. Injections

Spine injections can help in some patients with a Degenerative Scoliosis. If disc inflammation at the outer ring (annulus fibrosus) is the problem, epidural steroid injections can deliver medication to this part of the anatomy. If the spine joints (facet joints) of the spine are inflamed as a result of the loss of disc height and subsequent pressure placed on these joints, they can also be injected.

Muscle injections for chronic spasms may also be effective.

Here are some of the injections which can be used depending on which part of the degenerative scoliosis is causing symptoms:

  1. Lumbar Interlaminar ESI
  2. Lumbar Transforaminal ESI
  3. Lumbar Nerve Root Block
  4. Lumbar Facet Joint Injection
  5. Lumbar Medial Branch Block
  6. Lumbar Radiofrequency Rhizotomy of the Facet Joint
  7. Lumbar Trigger Point Injection
  8. Lumbar Muscle Block

 

     2. Surgical Care

Surgical care for a lumbar degenerative scoliosis is reserved for patients who have severe symptoms and a poor quality of life.

The surgical treatment could focus on just one aspect of the degenerative scoliosis, or have the goal of correcting the whole scoliosis. Here are some potential surgical options for this condition:

  1. Lumbar Fusion
  2. Lumbar Dynamic Stabilization