scoliosis scoliosis scoliosis is a condition in which a person's spine has a sideways curve. the curve is usually "s"- or "c"-shaped over three dimensions. in some, the degree of curve is stable, while in others, it increases over time. mild scoliosis does not typically cause problems, but more severe cases can affect breathing and movement. pain is usually present in adults, and can worsen with age. scoliosispronunciation/ˌskoʊliˈoʊsɪs/ specialtyorthopedic surgerysymptomssideways curve in the backusual onset10–20 years oldcausesusually unknownrisk factorsfamily history, cerebral palsy, marfan syndrome, tumors such as neurofibromatosisdiagnostic methodx-raytreatmentwatchful waiting, bracing, exercises, surgeryfrequency3% the cause of most cases is unknown, but it is believed to involve a combination of genetic and environmental factors. risk factors include other affected family members. it can also occur due to another condition such as muscle spasms, cerebral palsy, marfan syndrome, and tumors such as neurofibromatosis. diagnosis is confirmed with x-rays. scoliosis is typically classified as either structural in which the curve is fixed, or functional in which the underlying spine is normal. treatment depends on the degree of curve, location, and cause. the age of the patient is also important, since some treatments are ineffective in adults, who are no longer growing. minor curves may simply be watched periodically. treatments may include bracing, specific exercises, posture checking, and surgery. the brace must be fitted to the person and used daily until growing stops. specific exercises, such as exercises that focus on the core, may be used to try to decrease the risk of worsening. they may be done alone or along with other treatments such as bracing. evidence that chiropractic manipulation, dietary supplements, or exercises can prevent the condition from worsening is weak. however, exercise is still recommended due to its other health benefits. scoliosis occurs in about 3% of people. it most commonly develops between the ages of ten and twenty. females typically are more severely affected than males with a ratio of 4:1. the term is from ancient greek σκολίωσις (skolíōsis), which means "a bending". signs and symptoms a 20th-century illustration of a severe case of an "s" shaped scoliosis symptoms associated with scoliosis can include: pain in the back at the site of the curve, which may radiate to the legs respiratory or cardiac problems in severe cases constipation due to curvature causing "tightening" of the stomach, intestines, etc. the signs of scoliosis can include: uneven musculature on one side of the spine rib prominence or a prominent shoulder blade, caused by rotation of the rib cage in thoracic scoliosis uneven posture heart and lung problems in severe cases calcium deposits in the cartilage endplate and sometimes in the disc itself course people who have reached skeletal maturity are less likely to have a worsening case. some severe cases of scoliosis can lead to diminishing lung capacity, pressure exerted on the heart, and restricted physical activities. recent longitudinal studies reveal that the most common form of the condition, late-onset idiopathic scoliosis, causes little physical impairment other than back pain and cosmetic concerns, even when untreated, with mortality rates similar to the general population. older beliefs that untreated idiopathic scoliosis necessarily progresses into severe (cardiopulmonary) disability by old age have been refuted by later studies. causes an estimated 65% of scoliosis cases are idiopathic (cause unknown), about 15% are congenital, and about 10% are secondary to a neuromuscular disease. about 38% of variance in scoliosis risk is due to genetic factors, and 62% is due to the environment. the genetics are likely complex, however, given the inconsistent inheritance and discordance among monozygotic twins. the specific genes that contribute to development of scoliosis have not been conclusively identified. at least one gene, chd7, has been associated with the idiopathic form of scoliosis. several candidate gene studies have found associations between idiopathic scoliosis and genes mediating bone formation, bone metabolism, and connective tissue structure. several genome-wide studies have identified a number of loci as significantly linked to idiopathic scoliosis. in 2006, idiopathic scoliosis was linked with three microsatellite polymorphisms in the matn1 gene (encoding for matrilin 1, cartilage matrix protein). fifty-three single nucleotide polymorphism markers in the dna that are significantly associated with adolescent idiopathic scoliosis were identified through a genome-wide association study. adolescent idiopathic scoliosis has no clear causal agent, and is generally believed to be multifactorial; leading to "progressive functional limitations" for individuals. research suggests that posterior spinal fusion (psf) can be used to correct the more severe deformities caused by adolescent idiopathic scoliosis. such procedures can result in a return to physical activity in about 6 months, which is very promising, although minimal back pain is still to be expected in the most severe cases. the prevalence of scoliosis is 1% to 2% among adolescents, but the likelihood of progression among adolescents with a cobb angle less than 20° is about 10% to 20%. congenital scoliosis can be attributed to a malformation of the spine during weeks three to six in utero due to a failure of formation, a failure of segmentation, or a combination of stimuli. incomplete and abnormal segmentation results in an abnormally shaped vertebra, at times fused to a normal vertebra or unilaterally fused vertebrae, leading to the abnormal lateral curvature of the spine. resulting from other conditions secondary scoliosis due to neuropathic and myopathic conditions can lead to a loss of muscular support for the spinal column so that the spinal column is pulled in abnormal directions. some conditions which may cause secondary scoliosis include muscular dystrophy, spinal muscular atrophy, poliomyelitis, cerebral palsy, spinal cord trauma, and myotonia. scoliosis often presents itself, or worsens, during an adolescent's growth spurt and is more often diagnosed in females than males. scoliosis associated with known syndromes is often subclassified as "syndromic scoliosis". scoliosis can be associated with amniotic band syndrome, arnold–chiari malformation, charcot–marie–tooth disease, cerebral palsy, congenital diaphragmatic hernia, connective tissue disorders, muscular dystrophy, familial dysautonomia, charge syndrome, ehlers–danlos syndrome (hyperflexibility, "floppy baby" syndrome, and other variants of the condition), fragile x syndrome, friedreich's ataxia, hemihypertrophy, loeys–dietz syndrome, marfan syndrome, nail–patella syndrome, neurofibromatosis, osteogenesis imperfecta, prader–willi syndrome, proteus syndrome, spina bifida, spinal muscular atrophy, syringomyelia, and pectus carinatum. another form of secondary scoliosis is degenerative scoliosis, also known as de novo scoliosis, which develops later in life secondary to degenerative (may or may not be associated with aging) changes. this is a type of deformity that starts and progresses because of the collapse of the vertebral column in an asymmetrical manner. as bones start to become weaker and the ligaments and discs located in the spine become worn as a result of age-related changes, the spine begins to curve. diagnosis cobb angle measurement of a scoliosis people who initially present with scoliosis undergo a physical examination to determine whether the deformity has an underlying cause and to exclude the possibility of the underlying condition more serious than simple scoliosis. the person's gait is assessed, with an exam for signs of other abnormalities (e.g., spina bifida as evidenced by a dimple, hairy patch, lipoma, or hemangioma). a thorough neurological examination is also performed, the skin for café au lait spots, indicative of neurofibromatosis, the feet for cavovarus deformity, abdominal reflexes and muscle tone for spasticity. when a person can cooperate, they are asked to bend forward as far as possible. this is known as the adams forward bend test and is often performed on school students. if a prominence is noted, then scoliosis is a possibility and an x-ray may be done to confirm the diagnosis. as an alternative, a scoliometer may be used to diagnose the condition. when scoliosis is suspected, weight-bearing, full-spine ap/coronal (front-back view) and lateral/sagittal (side view) x-rays are usually taken to assess the scoliosis curves and the kyphosis and lordosis, as these can also be affected in individuals with scoliosis. full-length standing spine x-rays are the standard method for evaluating the severity and progression of scoliosis, and whether it is congenital or idiopathic in nature. in growing individuals, serial radiographs are obtained at 3- to 12-month intervals to follow curve progression, and, in some instances, mri investigation is warranted to look at the spinal cord. an average scoliosis patient has been in contact with around 50-300mgy of radiation due to these radiographs during this time period. the standard method for assessing the curvature quantitatively is measuring the cobb angle, which is the angle between two lines, drawn perpendicular to the upper endplate of the uppermost vertebra involved and the lower endplate of the lowest vertebra involved. for people with two curves, cobb angles are followed for both curves. in some people, lateral-bending x-rays are obtained to assess the flexibility of the curves or the primary and compensatory curves. congenital and idiopathic scoliosis that develops before the age of 10 is referred to as early-onset scoliosis. progressive idiopathic early-onset scoliosis can be a life-threatening condition with negative effects on pulmonary function. scoliosis that develops after 10 is referred to as adolescent idiopathic scoliosis. screening adolescents without symptoms for scoliosis is of unclear benefit. definition scoliosis is defined as a three-dimensional deviation in the axis of a person's spine. most instances, including the scoliosis research society, define scoliosis as a cobb angle of more than 10° to the right or left as the examiner faces the person, i.e. in the coronal plane. scoliosis has been described as a biomechanical deformity, the progression of which depends on asymmetric forces otherwise known as the hueter-volkmann law. management scoliosis curves do not straighten out on their own. many children have slight curves that do not need treatment. in these cases, the children grow up to lead normal body posture by itself, even though their small curves never go away. if the patient has a larger curve and they are still growing, it is important to monitor the curve for change by periodic examination and standing x-rays as needed. the rise in spinal abnormalities require examination by an orthopaedic surgeon to determine if active treatment is needed. the traditional medical management of scoliosis is complex and is determined by the severity of the curvature and skeletal maturity, which together help predict the likelihood of progression. the conventional options for children and adolescents are: observation bracing surgery physical therapy. evidence suggests use of scoliosis specific exercises might prevent the progression of the curve along with possible bracing and surgery avoidance. for adults, treatment usually focuses on relieving any pain: pain medication posture checking bracing surgery treatment for idiopathic scoliosis also depends upon the severity of the curvature, the spine's potential for further growth, and the risk that the curvature will progress. mild scoliosis (less than 30° deviation) and moderate scoliosis (30–45°) can typically be treated conservatively with bracing in conjunction with scoliosis-specific exercises. severe curvatures that rapidly progress may require surgery with spinal rod placement and spinal fusion. in all cases, early intervention offers the best results. a specific type of physical therapy may be useful. evidence to support their use however is weak. low quality evidence suggests scoliosis-specific exercises (sse) may be more effective than electrostimulation. evidence for the schroth method is insufficient to support its use. significant improvement in function, vertebral angles and trunk asymmetries have been recorded following the implementation of schroth method in terms of conservative management of scoliosis. some other forms of exercises interventions have been lately used in the clinical practice for therapeutic management of scoliosis such as global postural reeducation and the klapp method. bracing a chêneau brace achieving correction from 56° to 27° cobb angle bracing is normally done when the person has bone growth remaining and is, in general, implemented to hold the curve and prevent it from progressing to the point where surgery is recommended. in some cases with juveniles, bracing has reduced curves significantly, going from a 40° (of the curve, mentioned in length above) out of the brace to 18°. braces are sometimes prescribed for adults to relieve pain related to scoliosis. bracing involves fitting the person with a device that covers the torso; in some cases, it extends to the neck (example being the milwaukee brace). female adolescent (14 years old) patient wearing a milwaukee brace - with neck ring and mandible (chin) pad showing the most commonly used brace is a tlso, such as a boston brace, a corset-like an appliance that fits from armpits to hips