Scoliosis

What is scoliosis?

Scoliosis, a condition usually diagnosed during adolescence, is the sideways curvature of the spine. Scoliosis is often seen in people with muscular dystrophy and cerebral palsy, but the reason for its occurrence in children is unknown. 

Most cases of scoliosis are mild. However, the curvature may increase and worsen as patients age. Severe scoliosis can lead to disability. Particularly in patients with significant curvature, the narrowed space in the chest area makes it difficult for the lungs to function properly.

In children with mild scoliosis, the condition is closely monitored. Most mild cases require no intervention. However, if the condition is expected to worsen, bracing is recommended. In some patients, surgery is suggested. 

Scoliosis diagnostic criteria

During the diagnosis of scoliosis, doctors first take a detailed medical history of the patient. Especially for children, questions are asked about their recent growth. Then a physical examination is performed. During this examination, it is checked whether one part of the rib cage protrudes more than the other. To determine this, the patient needs to stand up and then bend forward with their arms relaxed. Additionally, doctors will perform a neurological examination, testing for muscle weakness, numbness, and reflexes. Other tests that may be requested include:

Imaging tests

The primary imaging method used in the diagnosis of scoliosis is X-ray. X-rays help determine the presence and degree of scoliosis. If scoliosis is diagnosed, multiple X-rays may be needed over time to monitor the progression of the condition. However, due to radiation exposure, doctors may recommend alternative imaging methods.

Devices that can create a 3D image of the spine and use lower doses of radiation can be used to reduce the amount of radiation patients receive. Ultrasound imaging can also be used in the diagnostic stage, though it is less precise compared to other imaging methods.

After diagnosing scoliosis, it needs to be classified. This classification differs between children and adults. Once classified, the treatment plan is determined.

In children

Scoliosis in children is classified by age. This classification includes:

• Infantile: 0 to 3 years old
• Juvenile: 3 to 10 years old
• Adolescent: 11 years and older, up to skeletal maturity

In adults

The classification of scoliosis in adults differs due to the complete development of the bones. The categorization of adults with scoliosis is as follows: 

• Adults surgically treated for scoliosis during adolescence
• Adults with untreated scoliosis from childhood
• Degenerative scoliosis

Causes of scoliosis

The exact causes of scoliosis are unknown, but it is believed to be hereditary in people with a family history of the condition. Other potential causes of scoliosis include:

• Spinal abnormalities
• Cerebral palsy
• Muscular dystrophy
• Certain neuromuscular conditions
• Spinal injuries
• Spinal infections
• Birth defects affecting the development of spinal bones
• Surgery on the chest wall as an infant

Risk factors for scoliosis

The most common risk factors for developing scoliosis include:

• Age is a significant risk factor as complaints typically begin during adolescence.
• While both boys and girls are at the same risk of developing mild scoliosis, girls are at higher risk for worsening curvature. Therefore, gender is also considered a risk factor.
• Although most children with scoliosis do not have a family history of the condition, hereditary cases do exist. 

Symptoms of scoliosis

Symptoms of scoliosis may include:

• One side of the back protruding when bending forward
• Asymmetrical shoulders
• Protrusion of one side of the rib cage
• One shoulder blade being more prominent than the other
• One hip higher than the other
• Uneven waist

In many cases, the spine not only curves sideways but also rotates. This causes the muscles on one side of the body to protrude more than those on the other side. 

Scoliosis treatment methods

The treatment for scoliosis varies depending on the severity of the curvature. Very mild curvature in children typically requires no treatment, but regular monitoring is necessary to determine if the curvature worsens as the child grows.

In moderate or severe cases, treatment options need to be considered. These options include surgery, exercises, and bracing.

Scoliosis surgery

The following factors need to be evaluated to recommend surgery for scoliosis:

• If a child's bones have stopped growing, the likelihood of scoliosis progression is very low. 
• Severe spinal curvature in childhood has a higher likelihood of worsening over time.
• Finally, girls are more likely to experience worsening scoliosis compared to boys.

In patients with severe scoliosis during childhood, the spinal curvature tends to worsen over time. Therefore, scoliosis surgery is recommended to correct the spinal curvature or prevent the condition from becoming more serious. 

Different methods can be used in scoliosis surgery, including:

• In spinal fusion, surgeons connect two or more vertebrae together, preventing them from moving independently. Bone grafts or bone-like materials are used to fuse the vertebrae together. Typically, metal rods, screws, hooks, and wires are used for this purpose.
• Expandable rods are used for patients with rapidly progressing scoliosis at a young age. Surgeons place a rod in the patient's spine that can lengthen as the child grows. The rods need to be lengthened every 3 to 6 months in a clinical setting.
• Vertebral body tethering is a minimally invasive procedure involving screws placed along the outer curve of the spine. A flexible but strong cord is threaded through the screws and tightened to straighten the spine. 

Posterior approach

The posterior approach is the most common type of surgery for adolescent scoliosis cases. In this procedure, performed with the patient lying on their back, bone grafting, instrumentation, and posterior spinal fusion are used. 

In the posterior approach, the spine is first straightened with rigid rods and then spinal fusion is performed. Spinal fusion involves applying bone grafts to fuse two or more vertebrae in the curved parts of the spine. The rods attached to the spine help keep it straight and ensure the effectiveness of the spinal fusion. 

In children, posterior approach surgery typically takes a few hours, but it takes much longer in adults. Thanks to advancements in this field, most patients can be discharged one week after surgery. It usually takes 2 to 4 weeks for patients to return to school or work, and within 4-6 months, they can resume all activities they did before surgery. 

Anterior approach

In this approach, patients lie on their side during surgery. The procedure begins with an incision on the patient's side. Then, the lung is deflated, and a rib is removed to provide more working space for the surgeons. Video-assisted thoracoscopy is used, making this approach less invasive than open surgery. 

Also known as anterior spinal, this approach offers advantages such as better deformity correction, faster rehabilitation, fewer segments fused, and improved spinal mobility. However, there are some disadvantages, including the need for a brace for a few months after surgery and a higher risk of morbidity. 

Decompressive laminectomy

This approach is used to create more space for the nerves passing through the spine by removing the roof of the vertebrae. It is applied in the presence of scoliosis and spinal stenosis, often recommended with or without spinal instrumentation for spinal fusion. Various screws and rods are also used to enhance fusion and support the unstable parts of the spine.

Minimally invasive surgery

Also known as MIS, this method involves fusion through small incisions to minimize tissue trauma. The use of advanced fluoroscopy and endoscopy increases the success rate of this method. However, it is not applicable to all cases. 

Risks of scoliosis surgery

The risks of scoliosis surgery are similar to other surgical procedures. Specific risks associated with scoliosis surgery include:

• Bleeding
• Infection
• Nerve damage

Scoliosis brace

If a patient has moderate scoliosis and rapid bone development, bracing may be recommended. However, wearing a brace does not cure or reverse scoliosis; it prevents the curvature from worsening. 

The most commonly used type of scoliosis brace is made of plastic and shaped to fit the body. It fits under the arms, around the chest, lower back, and hips, making it inconspicuous under clothing.

Most scoliosis braces are worn for 13 to 16 hours a day. Depending on the type of brace and duration of use, most patients can participate in their desired activities with minimal restrictions.

When patients' growth periods end, brace use is discontinued. For girls, this is usually around age 14, and for boys, around age 16. 

Scoliosis exercises

Exercises may be recommended to increase spinal flexibility, control pain, and prevent further curvature in scoliosis treatment. The recommended exercises are tailored to the patient's condition and the type of scoliosis. Commonly used exercises for scoliosis patients include:

• Pelvic tilts help relieve tension in the hips and lower back. 
• Lying on the stomach and lifting arms and legs, also known as the superman exercise, strengthens the muscles in the lower back. 
• The cat-cow pose from yoga helps maintain spinal flexibility and control pain. 
• Another yoga pose, bird-dog, is also a spinal movement exercise. 
• Wide back stretches target the largest muscle group in the upper body. 
• Crunches strengthen the abdominal muscles, improving posture and reducing pressure on the back muscles. 

Exercises recommended for children include:

• Improving posture
• Plank
• Cat-camel
• Pelvic tilts 
• Double-leg raises

Post-scoliosis surgery process

The recovery process after scoliosis surgery varies depending on the severity of the curvature and other factors. The recovery process is generally divided into initial recovery and full recovery, as it takes time for the fusion between vertebrae to solidify. 

The hospital stay after surgery usually lasts about 7 days. During this time, patients' pain is controlled, and their health is closely monitored. To prevent fluid accumulation at the surgical site, a drainage system and a urinary catheter are used during the hospital stay.

Since surgery slows digestion, it becomes difficult to keep food in the stomach. Therefore, patients do not consume food for the first few days after surgery. They start with clear liquids, progressing to small and frequent meals as recovery continues. Given the increased need for nutrients during the recovery process, it is important to make healthy food choices during this time.

After discharge from the hospital, patients enter the initial recovery period, during which they can engage in limited activities such as walking and bathing. This period usually lasts 2 to 4 weeks. Full recovery, allowing patients to resume all pre-surgery activities, typically takes 6 months to 1 year. Certain movements should be avoided during this period, but gradually, patients can start engaging in these activities. By the end of the full recovery period, patients return to all their pre-surgery activities. 

What not to do after scoliosis surgery

The doctor will provide detailed information about when normal activities can be resumed after surgery. However, certain movements should be strictly avoided during the recovery process. These include:

• Standing for long periods
• Movements that cause the spine to bend or twist
• Long or frequent travel
• Lifting heavy objects

How can patients sleep comfortably after surgery?

After scoliosis surgery, patients need to sleep on their back or side. To facilitate comfortable sleep, patients can follow these tips:

• Sleeping in a reclining chair
• Bending the knees and placing a pillow between them
• Supporting the back and shoulder area with pillows to sleep on the back

What should scoliosis patients pay attention to?

Due to chronic pain from postural disorders and the progressive nature of the disease, scoliosis patients need to pay attention to certain aspects of their daily lives. 

Physical therapy process

Physical therapy is very important for scoliosis patients, especially in relieving pain, slowing the progression of scoliosis, and alleviating postural disorders. Therefore, it is important for patients to start physical therapy early and continue their sessions without interruption. 

Avoid lifting weights

The spine is the center that supports the body's weight. Therefore, people with scoliosis should avoid activities that add extra load to this center. Lifting weights can increase existing pressure on the spine and exacerbate the curvature. Therefore, it is important to pay attention to certain points when lifting heavy objects in daily life, such as:

• Ensuring that the weight is distributed evenly between the legs and back when lifting
• Not lifting objects heavier than what patients can handle, and regularly performing back and abdominal muscle exercises to strengthen the spine. This helps the spine handle the pressure more effectively when it bears weight. 

Do not stay in the same position for a long time

Recent studies on scoliosis indicate that poor posture and sitting positions do not directly affect scoliosis progression. However, poor posture and sitting positions can exacerbate scoliosis-related pain. Therefore, scoliosis patients are advised not to stay in the same position for long periods. 

For correct sitting posture, pay attention to the following points:

• Feet should be flat on the ground while sitting.
• Supporting the lower back with a cushion or lumbar support helps maintain the natural curve of the spine. 
• The computer or television screen should be at eye level.
• Taking a break every 30 minutes to relax the spine.

Adopt an active lifestyle

Adopting an active lifestyle positively impacts general health and benefits scoliosis patients. Physical activity helps strengthen muscles, which can control scoliosis symptoms, including pain. 

Regular exercise also helps maintain spinal health. Additionally, it can slow or even halt the progression of scoliosis.

Choose the right mattress and pillow

Choosing the right mattress and pillow is crucial for a healthy spine. Making the right choices can significantly reduce symptoms and halt the progression of scoliosis. For scoliosis patients, the best sleeping position is on the back. The following points should be considered:

• Patients should choose medium-firm mattresses. This supports the natural curve of the spine and allows for comfortable sleep.
• The pillow should prevent the head from tilting forward. Therefore, very firm and high pillows should not be used.
• Patients who prefer to sleep on their side should place a pillow between their legs to align the pelvis and spine.

Avoid high-impact sports

While physical activity is crucial for scoliosis patients, high-impact sports can strain the spine, worsening the curvature and symptoms. High-impact sports include running, jumping, or sports requiring strong physical contact. The negative effects of these sports on the spine include:

• These sports can put excessive pressure on the natural curve of the spine.
• Severe jolts during sports can increase pain.
• Sudden and severe movements increase the risk of injury in scoliosis patients. 

Scoliosis patients are recommended to opt for the following sports instead:

• Swimming
• Pilates
• Yoga
• Walking

Routine check-ups

Since scoliosis is a progressive disease over time, it must be continuously monitored. Therefore, it is important for patients to not miss their routine doctor check-ups, which are crucial for planning the next steps in treatment.

Lifespan of scoliosis patients

The complications caused by scoliosis affect the life expectancy of patients. Scoliosis, especially when it affects the heart and lungs, can shorten patients' lifespans by an average of 14 years. 

Scoliosis degrees

Scoliosis grading is typically used for adolescent scoliosis patients. The grading is based on the degree of spinal curvature.

Mild

Patients with spinal curvature between 10 and 25 degrees fall into this group. Measurements are taken using the Cobb angle. The main treatment approaches for mild scoliosis patients vary among ideologies.

Traditional treatment

In traditional scoliosis treatment, no intervention is applied to patients in the mild class. However, the progression of the disease is closely monitored. Patients are recommended to undergo check-ups every 3, 6, and 12 months. The frequency of check-ups is determined based on the patient's age. 

Functional treatment

In functional treatment, it is believed that waiting for the disease to progress is unnecessary. Therefore, it advocates determining the cause and degree of curvature and starting treatment immediately. Since each scoliosis case progresses at varying rates, this approach aims to address the cause and provide timely intervention. 

Moderate

Patients with spinal curvature between 25 and 40 degrees, measured using the Cobb angle, fall into the moderate scoliosis classification. Different treatment options are offered at this stage, varying among ideologies.

Traditional treatment

Traditional treatment is divided into two parts. Some patients are advised to continue monitoring, while others are recommended options like bracing. Bracing is used not for treatment but to prevent the condition from worsening. 

Functional treatment

In functional treatment, the goal is to ultimately correct the curvature. Identifying the cause of scoliosis is crucial for this approach. Treatments aim to reduce curvature and support and stabilize the spine. The goal is to stay ahead of the disease, reducing the need for surgery in the future.

Severe

Patients with spinal curvature between 40 and 60 degrees fall into this group. Severe scoliosis cases exhibit significant postural disorders, making scoliosis noticeable and causing many adverse symptoms.

Traditional treatment

At this stage, monitoring and bracing are prioritized. However, if the curvature progresses, surgery is recommended. Surgery is the best treatment option for patients at high risk of progression. However, the surgeries are extensive, with long recovery periods.

Functional treatment

Functional treatment continues various approaches to correct curvature at this stage. The goal is to bring patients below the surgery threshold. These methods include chiropractic treatment, home exercises, rehabilitation, and corrective supports.

Difference between scoliosis and kyphosis

Spinal curvature is seen in scoliosis or kyphosis. Although the conditions may appear similar, they are not identical. In scoliosis, the spine curves sideways, often forming an S or C shape. Kyphosis, however, is the forward curvature of the spine, causing patients to stoop.

Scoliosis is typically seen and diagnosed during childhood, while kyphosis affects all ages but is more common and diagnosed in adults. 

Scoliosis has various causes, with familial inheritance and neuromuscular causes being prominent. Kyphosis, on the other hand, results from degenerative changes in the spine as part of the aging process. The bones and ligaments of the spine naturally wear down over time, leading to kyphosis. 

While scoliosis can also occur in adulthood, these cases are rare. Kyphosis can be seen in young people, known as Scheuermann's disease, where several consecutive vertebrae become wedged. The cause is still unknown. 

Both conditions can be painful, but kyphosis tends to cause more severe pain.

Postural positions for scoliosis patients

Poor posture in scoliosis patients requires more energy, disrupting the healing process and exacerbating symptoms like pain. Although poor posture does not affect scoliosis progression, it is crucial for reducing the severity of scoliosis symptoms. 

Standing posture

• When standing, scoliosis patients should ensure that the weight is evenly distributed between both legs, so all joints bear equal weight. Another important point is to keep the neck straight and avoid tilting the head forward.
• The hips should be in a straight position, and the pelvis should be neutral.
• The knees should generally be straight, though one knee may be slightly bent at times. 
• Imagine a string attached to the top of the head to achieve the correct posture.

Sitting posture

Scoliosis patients also need to pay attention to their sitting posture. Important points to consider include:

• Weight should be distributed to the hips and thighs.
• The back should be straight and supported by the chair.
• Avoid sitting on the edge of the chair.
• The pelvis should be neutral.
• The chair height should be proportional to the patient's height.
• Knees should be slightly lower than the hips. 
• Feet should be flat on the ground and shoulder-width apart.
• Use a cushion or lumbar support to support the lower back.
• Avoid sitting for long periods.

Sleeping posture

Since approximately 8 hours of the day are spent sleeping, the sleeping position is extremely important. The correct sleeping position is crucial for maintaining general health and ensuring quality sleep. 

When choosing a mattress, it should be between 18 and 22 inches high to make it easier for patients to get in and out of bed. The mattress should not be too firm or too soft. A quilt is easier to use during sleep compared to a blanket or sheet. The bed base should not be slatted. Finally, patients should use pillows that support the neck.

Steps to follow when getting into bed include:

• First, sit on the bed.
• Then, rest on the arms and pull the legs onto the bed.
• Finally, lie back with the legs together and turn onto the back.

When getting out of bed, follow the above steps in reverse order.

Do not sleep on the back with the legs straight, as this puts pressure on the lower spine. Avoid using too many pillows and do not sleep on the stomach.

Keeping the pelvis neutral

The pelvic area is located at the lower part of the spine, where the legs are attached. Keeping the pelvis neutral means the pelvic bone is not tilted forward or backward. It may not always be possible for scoliosis patients to maintain this position, but they should strive to do so as much as possible.

Scoliosis and sexuality

Most studies on scoliosis patients and sexuality focus on female patients. These studies have observed that one-third of female scoliosis patients experience sexual issues. The main reasons include self-awareness about physical appearance and the inability to participate in physical activities. 

Research shows that 25% of scoliosis patients who use braces or undergo surgery experience sexual issues. The type of brace used does not affect this outcome. 

Pregnancy and childbirth in scoliosis patients

Comparing scoliosis patients to the general population, the rates of having children are the same. However, there are some differences during pregnancy and childbirth in scoliosis patients, including:

• Some women experience increased back pain during pregnancy.
• Patients with fused lower spine may face challenges with epidural anesthesia, as the fusion makes it difficult for the needle to access the spinal cord.
• Complications during childbirth and postpartum are the same as in the general population.
• Pregnancy does not increase the curvature of the spine.

How should scoliosis patients eat?

Patients diagnosed with scoliosis need to adjust their diet to boost their healing power and energy levels. While no diet alone can cure scoliosis, adopting a proper diet can help reduce structural curvature and improve patients' responses to treatments. 

The positive effects of healthy eating habits on scoliosis include:

• Patients maintaining a healthy weight are more responsive to treatment, especially for idiopathic scoliosis, the most common type. 
• Scoliosis is linked to vitamin B12. A diet rich in B12 increases neurotransmitters like dopamine and serotonin in the body. Additionally, B vitamins aid detoxification, supporting the healing process and boosting patients' energy and morale.
• Scoliosis is also associated with reduced neurotransmitter production, so a diet rich in amino acids is essential to increase neurotransmitter production.
• Scoliosis patients often have low bone density. A diet rich in vitamin D strengthens bones and improves overall health. 
• Low melatonin levels are linked to scoliosis progression. Therefore, melatonin supplements are recommended, as they do not cause dependency.
• Adequate water consumption is crucial for scoliosis patients to maintain the fluid levels in the discs between vertebrae, ensuring optimal spinal function. 

What scoliosis patients should avoid

Scoliosis patients should eliminate the following foods and drinks from their diet:

• Fast food
• Artificial sweeteners
• Candies
• Overly sugary foods
• Overly salty foods
• Alcohol
• Coffee
• White flour

Patients should not make significant dietary changes all at once, as this can be dramatic and unsustainable. Instead, they should start with small steps to develop healthy eating habits gradually. 

Recommended foods

Foods that scoliosis patients should include in their diet are:

• Fresh fruits
• Fresh vegetables
• Lean protein sources
• Foods rich in amino acids
• Foods rich in calcium
• Foods rich in vitamin D
• Water

Complications of scoliosis

Scoliosis is usually mild, but severe cases can cause various complications. Complications of scoliosis include:

• In severe scoliosis, the rib cage puts pressure on the lungs, causing respiratory problems.
• In cases untreated during childhood or with severe curvature, chronic back pain is seen in adulthood.
• As spinal curvature increases, physical changes occur in the position of the hips and shoulders, and the sideways movement of the ribs and waist. Many patients are concerned about their appearance. 

Classification of scoliosis

Scoliosis is one of the diseases classified according to its etiology. 

Idiopathic scoliosis

Idiopathic scoliosis is a type of scoliosis where all other causes have been excluded. It is usually diagnosed during adolescence and accounts for 80% of cases. The most common type within idiopathic scoliosis is Adolescent Idiopathic Scoliosis. 

Congenital scoliosis

Congenital scoliosis can occur in any part of the spine and results from one or more vertebrae malformations during embryonic development. This abnormality causes the spine to curve as one part of the spine develops more slowly than the rest. 

The location and geometry of the vertebral anomaly also determine how much the curvature will progress over time. Since the vertebral anomaly can be diagnosed from birth, congenital scoliosis is diagnosed earlier than idiopathic scoliosis.

Children diagnosed with congenital scoliosis are more likely to have other congenital conditions, commonly involving the spinal cord (20%), genitourinary system (20-33%), and heart (10-15%). Therefore, these patients should also be monitored for these conditions. 

Neuromuscular scoliosis

Neuromuscular scoliosis results from neurological and muscular disorders. It progresses more rapidly than idiopathic scoliosis and often requires surgical intervention.

Degenerative scoliosis

Degenerative scoliosis is generally seen in the lower back and commonly affects people over 65. It is often accompanied by spinal stenosis or narrowing of the spinal canal, which can compress spinal nerves, preventing their normal function. 

Degenerative scoliosis patients experience gradual back pain, often occurring after activities. The spinal curvature in this type is smaller than in other types, and conservative treatments are recommended. If conservative treatments are insufficient for pain management, surgery may be suggested.