Spine

Scoliosis is a condition in which the spine curves sideways instead of appearing straight when viewed from behind. Doctors usually define scoliosis as a spinal curve of more than 10 degrees on an X-ray. In many people, especially children and teenagers, if the curves are mild, it may not cause any symptom, limit daily life or present with obvious truncal asymmetry. However, some curves can worsen during growth, which is why early recognition and regular follow-up are important.

Scoliosis can affect people of any age, but the most common type appears around the start of adolescence. This is called adolescent idiopathic scoliosis. “Idiopathic” means that no single clear cause has been found. Research suggests that growth, genetics, hormones, and body development may all play a role. Non-idiopathic scoliosis can also be linked to conditions present at birth, nerve or muscle disorders, or certain syndromes, but most childhood cases have no obvious underlying disease.

Many children with scoliosis feel well, so the first signs are often changes in posture or body shape. A parent, teacher, friend, or doctor may notice uneven shoulders, one shoulder blade that sticks out more, an uneven waist, one hip appearing higher than the other, or one side of the ribs becoming more prominent when the child bends forward. This forward-bending check helps doctors look for the twisting of the spine that often comes with scoliosis.

An X-ray is used to confirm the diagnosis and measure the size of the curve, known as the Cobb angle (Figure 1). This measurement helps doctors decide whether the curve should be monitored, treated with a brace, or considered for surgery. Most children do not need advanced scans, but an MRI may be recommended if there is unusual pain, nerve symptoms, or an atypical curve pattern.

Treatment depends mainly on three things: the size of the curve, whether the child is still growing, and whether the curve is getting worse. Mild curves are often monitored with regular checkups. Moderate curves in children who are still growing may be treated with a brace. A brace does not usually make scoliosis disappear, but it can help prevent the curve from worsening if it is worn as recommended.

Surgery is usually considered only when a curve is large, continues to progress, or is likely to cause problems later in life. The goal is to straighten and stabilise the spine while keeping as much normal movement as possible (Figure 2). Like all operations, scoliosis surgery carries risks, so the decision should be made carefully by the patient, family, and a specialist team. For most young people, scoliosis can be managed well, and many continue to lead active, healthy lives.

The most important message for the public is that scoliosis, while not uncommon, is often mild and usually manageable. Families should seek medical advice if they notice uneven shoulders, a rib hump, or a visible posture change in their children, especially during their growth spurt. Early assessment gives doctors the best chance to monitor the spine, guide treatment if needed, and help the child stay confident and active.

Patients often report chronic mechanical back pain, neurogenic claudication, or radicular symptoms due to foraminal or central stenosis. Pain is usually worse while standing or walking, and is relieved by sitting or leaning forward. Progressive stooping, difficulty maintaining horizontal gaze, and impaired walking endurance are key functional clues. A detailed neurological examination is essential to identify motor deficits or sensory loss, which may indicate severe stenosis or instability.

Standing full length spine radiographs (AP and lateral) are the cornerstone for evaluating and documenting spinal deformity. Flexion–extension radiographs help assess segmental instability. MRI provides high resolution evaluation of neural compression, disc degeneration, facet arthropathy, and ligamentum flavum hypertrophy. It is indispensable for correlating symptoms with anatomical pathology. Bone mineral density testing is sometimes helpful, especially for patients who are being considered for surgery.

Non operative treatment is appropriate for many patients, especially those with mild deformity or predominant axial pain. This includes targeted physiotherapy focusing on core strengthening and postural training, analgesia, anti inflammatory medications, and activity modification. Epidural steroid injections or nerve root blocks may provide temporary relief for radicular symptoms. Bracing has limited long term benefits but may help selected patients with postural fatigue.

Surgical intervention is considered when patients have disabling pain, progressive neurological deficits, severe stenosis, or significant sagittal imbalance that impairs function (Figure 2a & 2b). The goals of surgery are decompression of neural elements, correction of deformity, restoration of sagittal alignment, and stable fixation. Surgical options range from limited decompression in frail patients to multilevel fusion with osteotomies in those with fixed deformity. Ultimately, managing degenerative spinal deformity requires a personalised, multidisciplinary approach integrating radiographic parameters, patient frailty, bone quality, and functional goals. Early recognition and tailored intervention can significantly improve quality of life and maintain independence in an ageing population.