Scoliosis is a sideway curvature of the spine and often occurs secondary to a neuromuscular disorder, such as Cerebral palsy, spina bifida and spinal cord injury. People with a more severe condition are at higher risk of developing scoliosis, due to poor muscle control, weakness or paralysis and/or spasticity.

In this article we will highlight: 

    1. What is scoliosis? 
    2. Why does neuromuscular scoliosis occur? 
    3. What are the symptoms of neuromuscular scoliosis? 
    4. How is scoliosis diagnosed? 
    5. How is scoliosis managed? 

1. What is scoliosis? 

A scoliosis is a sideways curvature of the spine. The spine has natural curves at the top of the shoulder and in the lower back, but if your child have a curve from side to side or in an «S» or «C» shape it might be a scoliosis. 

Scoliosis are commonly describe in three categories: 

  • Idiopathic 
  • Congenital 
  • Neuromuscular  

Idiopathic scoliosis means that the cause is unknown or there is no single factor that contributes to the development of the scoliosis. The most common within this category is adolescent idiopathic scoliosis that typically develops within the age of 10-18 years. About 30% of these have a family history of scoliosis, suggesting that there might be a genetic link.   

Congenital scoliosis typically occurs during fetal development and is very rare.  

Neuromuscular scoliosis typically develops secondary to a disorder, such as cerebral palsy, muscular dystrophy, Rett syndrome etc. This type of scoliosis tends to be more severe and progressive. 

In this article the neuromuscular scoliosis will be described in more detail. 

2. Why does neuromuscular scoliosis occur?

Neuromuscular scoliosis typically develops secondary to a disorder and is caused by poor muscle control, weakness or paralysis and/or spasticity. For example, in children with CP it is known that the behaviour and development of scoliosis is closely associated with the severity of the diagnosis. Those children who are classified with Gross Motor Function Classification (GMFCS) IV and V, and severely affected, have the highest risk of developing scoliosis.  

Read more: What is GMFCS, and why is it used? 

The reason is that they often have little ability to change and correct a position both in lying, sitting and standing and are in need of extensive support to manage a position. Gravity is an enemy for these children, and they tend to lose that battle. The children do not have enough strength to counteract the force of gravity and often collapse into an asymmetric position. Asymmetrical positions may over time have negative effect on the body and can cause skeletal distortion like scoliosis. Development of neuromuscular scoliosis also seems to increase with age. 

3. What are the symptoms of neuromuscular scoliosis? 

Symptoms of neuromuscular scoliosis often appear early in a child’s life. Usually it is you as a parent who first notices changes in the spine. Typically symptoms you see are: 

  • Leaning to one side in sitting or in lying 
  • Uneven shoulder heights 
  • Uneven shoulder blades 
  • Uneven hips  
  • Head not centred  
  • Rib cage are at different heights  
  • Arms hanging unevenly 

If your child is diagnosed with a neuromuscular disease, regular follow-ups by a paediatrician and paediatric physiotherapist are common. They will examine the child’s spine clinically and with x-ray to follow the development of the spine and initiate necessary measures.  

4. How is scoliosis diagnosed? 

Scoliosis is typically diagnosed through a clinical examination in combination with X-ray, CT scan or MRThe curve of the spine is measured by the Cobb angle, and severity of the scoliosis is defined from the number of degreesA Cobb angle between 10-20 degrees is considered as a mild scoliosis. If the angle is between 20-4degrees it is moderate scoliosis and above 40 degrees it is severe. 

5. How is scoliosis managed? 

Recommended treatment of scoliosis will vary depending on the severity and age of your child and how the child is affected by the scoliosis. A multidisciplinary team will together with you as parents determine how the scoliosis affects the child’s function and quality of life. Doctors will also follow up with regular measurements to see how the scoliosis develops and adjust treatment in accordance to this.   

Here we will describe the most typical nonsurgical and surgical treatments: 

Nonsurgical treatment  

Nonsurgical treatment will not prevent your child’s scoliosis from developing, but it may slow down the progression of the curve. Treatment also intends to improve the child’s function and quality of life. 

Treatment includes:  

  • Positioning in lying, sitting and standing in a 24-hours perspective. This is an important approach to manage symmetry and alignment of the spine. Different types of assistive devices will be used to achieve this. It can be standard equipment, but in some cases custom-moulded chairs may be need, especially if the scoliosis is severe. 
     
  • Back brace is often used to support the spine and have the intention of improving sitting balance and trunk support. They provide head control and enhance better use and control of upper limbs. A back brace will not necessarily prevent the scoliosis from progressing, but will be important to use to improve function, independency and quality of life. 

Read more: Why 24-hour posture care management is key.

Surgical treatment  

Surgical treatment remains the only option for definitive management of scoliosis today, and is typically considered when the Cobb angle is greater than 40 degrees.  

During a spinal fusion surgery, rods will be inserted alongside the spine, which will correct the curvature, stabilize the spine and prevent further curvature of the spine.   

Performing surgery always comes with a risk. The decision to proceed with surgery relies not just on the severity of the scoliosis, but to what extend the scoliosis causes pain, affects respiration, in addition to function and dislocation of hips. Your child’s general condition will also influence the decision to do spinal surgery or not.  

Resources 

  • Horng M-H, Kuok C-P, Fu M-J, Lin C-J, Sun Y-N. Cobb Angle Measurement of Spine from X-Ray Images Using Convolutional Neural Network. Computational and Mathematical Methods in Medicine. 2019;2019:6357171.  
  • Pettersson K, Wagner P, Rodby-Bousquet E. Development of a risk score for scoliosis in children with cerebral palsy. Acta Orthopaedica. 2020;91(2):203-8.  
  • Cloake T, Gardner A. The management of scoliosis in children with cerebral palsy: a review. J Spine Surg. 2016;2(4):299-309 
  • Weigl DM. Scoliosis in Non-Ambulatory Cerebral Palsy: Challenges and Management. Isr Med Assoc J. 2019;21(11):752-5 
  • www.cpup.se 
  • www.nhs.uk  

24-hour postural care management

Rikke Damkjær Moen - Physiotherapist and Medical Manager

Rikke Damkjær Moen - Physiotherapist and Medical Manager

Rikke Damkjær Moen brings many years of experience as clinical physiotherapist to the Made for Movement team. Her mission is to ensure that everybody, regardless of mobility problems, should be able to experience the joy and health benefits of physical activity. As our Medical Manager, Rikke is passionate about sharing knowledge so that individuals with special needs, families, and clinicians can discover the possibilities and solutions provided by Made for Movement.