Rastereography vs 3D ultrasound imaging system: when should we choose one instead of the other?

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Let’s start with the thing they have in common: to lower radiation exposure. Indeed, these two methods, although unable to accurately reproduce the Cobb angle, were both created to reduce the radiation exposure of patients being monitored for spinal disorders, especially during pubertal growth.

Non-invasiveness and absence of radiation exposure are huge advantages of these methods, used for evaluating the curves of the spine, physiological and otherwise; combined with clinical measurements and evaluations, they allow the specialist to decide on the course of the patient’s treatment. And in many cases without the need for a follow-up X-ray. 

We have already explored the features and peculiarities of these methods in one previous post and another one

THE ROLE OF 3D ULTRASOUND IMAGING IN THE CLINICAL DIAGNOSIS AND MONITORING OF SCOLIOSIS DURING GROWTH

So, when should we opt for one as opposed to the other?

Rasterstereography: In clinical practice, this method is mainly used to study changes in the patient’s sagittal plane since it appears to be much more reliable in this plane than in the frontal plane. 

Moreover, current scientific evidence has failed to show the reliable correlation between diagnostic measurements between radiography (Cobb angle) and rasterstereography (1,2). We use rasterstereography to evaluate and monitor, over time, postural and structural problems affecting the sagittal plane, such as various forms of hyperkyphosis, long kyphosis, hyperlordosis, and so on.

This method is also very useful for evaluating the effectiveness of bracing or specific exercises over time.

3D ultrasound imaging system: This is the first ultrasound imaging system capable of detecting and evaluating scoliosis. The only one currently available in Italy is at the Isico offices in Milan. 

Even though research (3) has shown very good correlations and agreements between ultrasound and radiographic measurements (respectively UCA – Ultrasound Curve Angle  and Cobb angle), the reliability of the system is not yet sufficient to allow the 3D ultrasound imaging system — and the same goes for rasterstereography — to replace radiography, which remains the diagnostic tool of reference for diagnosing scoliosis and for confirming its evolution.  

Based on our experience to date, we use the 3D ultrasound imaging system as a valuable ally in the frequent monitoring (every 3-4 months) of patients at increased risk of scoliosis progression, as it allows prompt detection of any worsening of the curves.

It should be recalled that this examination is suitable in patients with certain characteristics: e.g., for patients with a Risser sign of 0-1 who are undergoing either bracing or exercise-based treatment, for patients who are only being monitored for a possible scoliosis diagnosis, and finally for children over 5 years of age to reduce (annual) radiation doses/exposure.

Even though, according to current guidelines, standing anteroposterior and lateral-projection radiographs are the most reliable method for diagnosing scoliosis and sagittal deformities, both rasterstereography and 3D ultrasound imaging system can be considered valid and useful tools for monitoring the clinical condition over time, the first being used for more extensive assessments (of sagittal problems) and the second for targeted assessments (of scoliosis). Some authors suggest that they could be used for carrying out early screening in large populations (e.g., in schools) (2). 

1. Multicenter Comparison of 3D Spinal Measurements Using Surface Topography with Those From Conventional Radiography
DOI: 10.1016/j.jspd.2015.08.008

2. Is rasterstereography a valid noninvasive method for the screening of juvenile and adolescent idiopathic scoliosis?  DOI: 10.1007/s00586-018-05876-0

3. 3D ultrasound imaging provides reliable angle measurement with validity comparable to X-ray in patients with adolescent idiopathic scoliosis 10.1016/j.jot.2021.04.007

Full-time treatment: no stress!

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We talk of “full-time treatment” whenever a brace needs to be worn round (or almost round) the clock, i.e., for 23 or 24 hours a day.  When patients with scoliosis are treated using a brace, it is not unusual to have to wear the device full time in order to effectively address severe curves (those measuring more than 40 Cobb degrees) or high-risk situations (a pubertal growth spurt).  

Full-time treatment is a tough challenge, especially if you consider that it usually begins at between 11 and 15 years of age, in other words, just before or during adolescence, which is a notoriously tricky time that already brings plenty of changes. Youngsters of this age no longer see the world through children’s eyes. Instead, they begin to experience all kinds of doubts and insecurities, and sometimes they are unhappy about the changes in their appearance, or about having to wear dental braces or glasses. It is therefore entirely understandable that being prescribed bracing treatment can be upsetting for them, and also for their parents who would do anything to spare their child any suffering.

In the literature, it is suggested that the start of bracing treatment (the first 6 months) can negatively affect the patient’s quality of life.
Even though there is no scientific proof of this — on the contrary, research tells us that treatment, ultimately, does not negatively impact quality of life —, there can be no denying that the early stage of bracing is hard and must be overcome. In particular, it is crucial to avoid poor adherence to the treatment that might potentially lead to its early and total abandonment and thus expose the patient to all the risks, in terms of progression and consequent severity of the condition, that are associated with scoliosis in childhood and adolescence. 

“This is a very important issue for us at Isico”, remarks physiotherapist Lorenza Vallini. “We have long been aware of the difficulties youngsters face at the start of this experience, which we liken to a marathon rather than a sprint: our youngsters have to get to the finish line on their own two feet, but we healthcare professionals are alongside them all the way, guiding and helping them and their families.”

And what about friends? Well, friends are like fans on the terraces; if they feel involved, they will cheer the patient on.

All this is perhaps easy for us to say because the fact is that when full-time bracing is prescribed, which means 23 or even 24 hours a day, the patient can feel like their world is falling apart. That is why we at Isico like to make sure we always have a chat with the family and the youngster after their appointment.

“We know very well that this is a key moment, a watershed moment that needs to be addressed together”, Vallini continues. “Our therapists are trained to listen to doubts, answer a thousand questions, and provide all the necessary explanations. We try to get the youngsters involved, showing them videos of other young “brace wearers” doing all kinds of everyday activities, including sports, with their brace on. They are often visibly surprised to see their counterparts happily taking a dip in the sea or swimming pool.”

It is also important not to overlook the aesthetics of brace-wearing!

We at Isico are always careful never to overlook the aesthetic aspect. Many of our patients are girls who are of an age at which comparing yourself with others is a normal part of growing up: “We always stress that braces are hardly visible under clothes, and we give patients tips and advice about their appearance”, Vallini says. “This moment is an opportunity to start building an alliance with the patient. Obviously, our work and involvement don’t end with that one chat, which on the contrary is the starting point for a process that will continue over the monthly sessions we have with these youngsters thereafter. The first session after delivery of the brace is particularly important, as it is when we try to present this “intruder” as a friend, not the easiest to be sure, but a friend nonetheless.”

That is why this particular session is designed to be motivating as well as technical, an opportunity to tackle any issues or doubts that have arisen and gather the patient’s reactions – both the tears and the laughter. 

As soon as the brace arrives, it is tested by an Isico doctor, who provides a series of explanations in order to get the treatment off to a good start. As a rule, whenever possible, a meeting with the therapist is also arranged so that youngsters are not left to face their fears and doubts alone. When this is not possible, a telephone contact is offered and, after the first session, the patient is also contacted by email to find out if there have been any difficulties.

Availability, care and assistance are the cornerstones of our approach: “We never underestimate any request, from the simplest to the most complicated”, Vallini says. “We make sure patients realise we are always there for them, as we want them to be reassured that there is always someone available for them.”

The importance of listening
The Isico team includes all the specialists necessary to support and monitor young brace wearers, so not only doctors and orthopaedic technicians, but also therapists and a psychologist (who sees patients directly on the rare occasions when this is felt to be necessary, but usually intervenes through the other professionals). All the team members will accompany the patient for a part of their journey, to support them and ensure that the therapy is going as it should, particularly at the start.

Will there be any other particular crisis moments? Undoubtedly! In the course of a long and demanding treatment process, undertaken in the midst of a thousand other emotional interferences from the outside, this is only to be expected: “The main thing for us is to remain vigilant so that we know when a family might be needing extra help”, Vallini says. “Everyone is ready to add the right input at the right time to help patients reach the finish line. And when they do, the smiles and hugs we get from them are quite wonderful, as is their tangible sense of pride”.

Can leg length discrepancy cause or worsen scoliosis?

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Leg length discrepancy (LLD) is a common orthopaedic condition among children and adults, with a prevalence of 90% in the general population and 40% among athletes. LLD occurs when the lower limbs are of unequal length; the discrepancy is typically less than 10 mm and asymptomatic.
Individuals easily compensate for it through small adaptations of which they are very often unaware (such as bending or extending one leg more than the other). Some children are born with LLD; in other cases, the condition is acquired due to causes such as tumours, radiation, infections or injuries.

LLD can be classified as functional or structural depending on the aetiology, i.e., the underlying cause.

Functional LLD refers to an apparent asymmetry, in the absence of real shortening or elongation of the osseous components of the lower limb. It is typically a result of pelvic obliquity related to adaptive soft-tissue shortening, joint or muscle contractures, ligamentous laxity, or axial misalignment. As the pelvis rotates, the legs are pulled into apparent different lengths.

Structural LLD, on the other hand, is a primary disorder causing actual physical shortening or lengthening of a limb, with the osseous change occurring between the ilium and the foot. The causes of shortening are more common than those of lengthening, and they may be congenital or acquired: shortening is most often due to fractures along the physis (Salter-Harris fractures), which can stop bone growth and lead to LLD.

LLD can be associated with several musculoskeletal disorders, including scoliosis and resultant degenerative spinal changes. However, the degree of LLD required to cause such disorders is still debated. LLD has been shown to cause pelvic obliquity in the frontal plane. In order to maintain shoulder balance and compensate for the pelvic obliquity, the condition that most frequently occurs is lumbar scoliosis with convexity directed towards the shorter limb. Scoliosis caused by LLD is not true scoliosis.

Should scoliosis due to LLD be treated?

This type of scoliosis, termed functional scoliosis, is non-progressive and involves a structurally normal spine with an apparent lateral curvature: it is evident in the erect position, but reduced when the subject is seated, supine or prone. The greater the degree of LLD, the more apparent the functional scoliosis may be. 

This type of scoliosis regresses fully or partially when its cause (i.e., the LLD) is removed. 

A simple remedy is to use shoe lifts, which may be internal or external depending on the degree of LLD.

If, after clinical evaluation, the functional scoliosis is found to be reducible (in part or totally) with a shoe lift, this solution will also be useful for reducing the overloading of the spinal joints and for reducing the structural and disc changes that occur over the years in the presence of scoliosis due to LLD (particularly when the difference between the two limbs is greater than 9 mm), as various studies have shown.

In a patient with structural and functional (LDD-related) scoliosis, it is appropriate to carry out tests to evaluate the usefulness or otherwise of a shoe lift. A shoe lift does not treat true scoliosis and the decision on whether or not to use it is a complex and individual one that should be made by the specialist.

Applebaum A, Nessim A, Cho W. Overview and spinal implications of leg length discrepancy: narrative review.  Clin Orthop Surg. 2021;13(2):127-34.

Giles LG, Taylor JR. Lumbar spine structural changes associated with leg length inequality. Spine (Phila Pa 1976). 1982;7(2):159-62.

Adams MA, Hutton WC. The effect of posture on the role of the apophyseal joints in resisting intervertebral compressive forces. J Bone Joint Surg Br. 1980;62(3):358-62. 

Murray KJ, Azari MF. Leg length discrepancy and osteoarthritis in the knee, hip and lumbar spine. J Can Chiropr Assoc. 2015;59(3):226-37.

Why the therapeutic team is part of the treatment

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Scoliosis treatment, whether we are talking about exercises alone or also bracing, can be an uphill battle in which adherence to the therapy itself is always fundamental. 

“A famous study conducted in the US and published in 2013 (Weinstein SL, Dolan LA, Wright JG, Dobbs MB. Effects of bracing in adolescents with idiopathic scoliosis. N Engl J Med. 2013 Oct.) confirmed beyond doubt the effectiveness of brace therapy in arresting the evolution of idiopathic scoliosis. And the patient’s adherence to the treatment was the factor that most influenced the result,” underlines physiotherapist Alessandra Negrini.

To ensure that a youngster manages to be collaborative in carrying out this demanding therapy, especially considering that it is often undertaken during early adolescence which is a notoriously tricky time, it is essential that all those interacting with the patient and with their family make sure they are always on the same page, giving clear and consistent messages.

With this in mind, it is easy to see why the therapeutic team, by encouraging patient compliance, plays such an important role in achieving the goals set.

Educating children and parents means explaining the nature of the disease, together with its possible course and potential consequences, setting and explaining realistic therapeutic objectives and rules to follow while performing physical (including home-based) exercises, and ensuring that there is cooperation with the physiotherapist and physician supervising the treatment. Specific physiotherapeutic exercises should be conducted by a trained and certified physiotherapist operating within a therapeutic team that includes a psychologist, orthotist, orthopaedist, and medical rehabilitation specialist.  

The team that takes on the patient’s care needs to manage to lighten the burden of the treatment, and help the patient and their family to cope with the situation. 

Within the multidisciplinary team, the physiotherapist is the patient’s point of reference, the one who motivates and, when necessary, re-motivates them. The physiotherapist is also the linchpin of the team itself.

 “In view of this important role, the physiotherapist should always bear in mind three key rules that I always think of (in Italian) as the 3 As, explains physiotherapist Marta Tavernaro. The first “A” stands for addestrare (coaching), which reminds me of the need to explain to patients what is happening to them, what scoliosis actually means, and how we and they can prevent it from getting worse. The second “A” stands for approccio (approach), which in this case means being enthusiastic about what we are doing and conveying this to the patient; the third “A”, both in Italian and English, stands for “acquire”, in the sense of collecting the information you need to know whether the youngster in your care has been working effectively.”

During the rehabilitation process, the therapist may become aware of specific problems concerning the family and/or the young person that could jeopardise the treatment. The psychologist is the team member ideally placed to manage these difficulties.

In this regard, it is important to remember that this course of treatment is followed in what is already a difficult and delicate life stage, characterised by sudden changes that influence the young person’s developing personality and how they view their role in society: all of this can have important repercussions on the therapy.

“When we are working within a biopsychosocial model of care, we must of course also keep the psychological aspects in mind,” points out ISICO psychologist Dr Irene Ferrario. “In this case, adopting a person-centred approach means not only measuring the individual patient’s Cobb angle, but also taking into account their emotions and feelings at this particular time in their life. When the doctor or therapist senses that there is an underlying problem, they seek the intervention of the psychologist on the team, who, through individual counselling or psychotherapy, will probe and identify the factors responsible for the change.”

An ISICO study published a few years ago (Importance of team to increase compliance in adolescent spinal deformities brace treatment: a cross-sectional study of two different settings) highlighted the role of the therapeutic team. As pointed out by one of the authors, ISICO physiatrist Dr Andrea Zonta, “the concept of compliance has to be understood in a broad sense, and therefore as adherence not so much to the use of the brace or the prescribed programme of exercises, as to the entire therapeutic pathway, which can last years. After all, we will not obtain lasting results if we think we can intensify the exercises for a certain amount of time and then just abandon them”.
In our research, the population was split into two groups according to the setting in which the treatment was performed and the two groups were administered two questionnaires: the SRS-22 [3, 4], and another, specially developed, one (QT) with 25 multiple choice questions about adherence to treatment (sections: brace, exercises, team).In fact, since the population was chosen as having been treated by the same orthotist and physician, the only distinction between the two populations was in the physiotherapeutic and general team approach.

“If the therapeutic team is not working properly, and I refer particularly to the professionals involved, there is a great risk of pain and decreased QoL. The same is true with regard to compliance with bracing” concludes Dr Zonta. “Moreover, this study has shown that the SOSORT management criteria can be important for brace treatment. The results seem to confirm that the management of patients is sometimes neglected, probably because it is an aspect not understood or perceived by the people involved; nevertheless, effective patient management could (through increased compliance) be a main determinant of the final results and/or the patient’s immediate QoL”.

Scoliosis and back pain: physical activity is the best prevention

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In the world’s richest countries, low back pain is so common that it has become one of the leading causes of disability and healthcare expenditure. Back pain in children should be taken seriously as it can reduce the amount of physical exercise they get, result in absences from school, and limit them in their everyday activities.

These brief opening remarks prompt a series of questions that our physiotherapist, Martina Poggio, here tries to answer in the light of the latest published data regarding a possible link with adolescent scoliosis.

How prevalent is low back pain in children and adolescents? 

In recent decades, a high prevalence (39.9%) of low back pain has been found in children and adolescents: one study found back pain to be associated with age (>12 years), a family history of the condition, spending more than two hours a day studying or watching TV, having an uncomfortable desk at school, suffering from generalised pain, and sleep problems. Evidence on the impact of heavy backpacks is conflicting.2

How common is idiopathic scoliosis among adolescents with back pain? 

Aetiologically speaking (in other words, when examining the possible causes of the condition), one retrospective study, conducted in almost 2000 patients under the age of 21 years, found the following underlying conditions: scoliosis, followed by Scheuermann’s disease and spondylolisthesis.1 However, since the role of spinal deformities in back pain is unclear, we reviewed recent literature on the association between pain and the most common adolescent spinal deformity, i.e., idiopathic scoliosis, which affects 1 to 3% of adolescents. Although idiopathic scoliosis was considered painless condition until a few decades ago, more recently patients seem to show a higher prevalence of back pain. What is not clear, however, is whether there is a marked association between this symptom and the spinal deformity. In studies specifically exploring its prevalence in adolescents with scoliosis, the rates range considerably: from 23% to 85%.

Does the severity of the curve correlate with pain intensity? 

One of main reasons for scepticism over a possible association between pain and scoliosis is the current debate in the literature on the link between the severity of the deformity and the intensity of the pain, and the association, more convincing, between pain and psychological factors (such as self-image and mental health status). Indeed, some patients with less pronounced curves showed more intense pain and vice versa, suggesting that spinal morphology is not the only factor at play.4

Some evidence from the literature suggests that the association between pain and scoliosis is not strongly linked to a biomechanical problem. Indeed, in most studies, pain did not correlate strongly with the magnitude of the curve (Cobb angle); untreated cases did reasonably well from a back pain perspective; epidemiological data revealed a much greater gender difference in scoliosis as opposed to back pain incidence; and patients’ self-image was found to be related to their pain. All these findings argue against a strong aetiological role of idiopathic scoliotic deformity in adolescent back pain.1 

Does back pain in adolescents with idiopathic scoliosis predispose them to pain in adulthood? What factors predispose adolescents with scoliosis to developing back pain?

In adolescents, early onset and persistence of back pain appear to be predictors of future back pain. A retrospective study showed that patients with thoracic scoliosis noted in their medical records were four times more likely to experience thoracic pain than those with no thoracic curve.5 Patients with scoliosis and back pain, compared with asymptomatic scoliosis patients, showed poorer physical function and sleep problems. Given that back pain has multiple causes, it is necessary to take into account depression, anxiety, catastrophising (i.e., having an exaggeratedly negative mindset towards actual or anticipated pain), and level of physical activity: all these factors can influence the perception and perpetuation of pain. 4,5 

In conclusion

“What recent studies show is that it is crucial to evaluated the youngster’s overall health in order to correctly evaluate back pain or possible risk factors,” explains Martina Poggio. “That means not just performing a physical assessment and encouraging the patient to get regular physical exercise, but also a psychological one, evaluating their self-perception and looking for anxiety, depression and drowsiness. These factors, although they may seem secondary in a case of scoliosis, could predispose the individual to the onset of back pain. Finally, it’s important to remind youngsters and their families that current data show no clear correlation between the deformity and pain, only that some people are more predisposed to pain”.

  1. “Prevalence of low back pain in adolescents with idiopathic scoliosis: a systematic review” Jean Théroux, Norman Stomski, Christopher J. Hodgetts, Ariane Ballard, Christelle Khadra, Sylvie Le May  and Hubert Labelle Chiropractic & Manual Therapies (2017)
  2. “Adolescent idiopathic scoliosis and back pain” Federico Balagué and Ferran Pellisé Scoliosis and Spinal Disorders (2016)
  3. “Back Pain in Children and Adolescents” Suraj Achar, Jarrod Yamanaka. Am Fam Physician (2020).
  4. “Back pain in adolescents with idiopathic scoliosis: the contribution of morphological and psychological factors” Alisson R. Teles, · Maxime St‐Georges, · Fahad Abduljabbar, · Leonardo Simões, · Fan Jiang, Neil Saran, · Jean A. Ouellet, · Catherine E. Ferland. European Spine Journal (2020)
  5. “How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis?” Arnold Y. L. Wong , MPhil, Dino Samartzis , Prudence W. H. Cheung, Jason Pui Yin Cheung  Clin Orthop Relat Res (2019)
  6. “Prevalence of low back pain in adolescents with idiopathic scoliosis: a systematic review” Jean Théroux, Norman Stomski, Christopher J. Hodgetts, Ariane Ballard, Christelle Khadra, Sylvie Le May and Hubert Labelle. Chiropractic & Manual Therapies (2017)
  7. “Adolescent idiopathic scoliosis and back pain” Federico Balagué and Ferran Pellisé. Scoliosis and Spinal Disorders (2016)
  8. “Back pain in children and adolescents” Suraj Achar, Jarrod Yamanaka. American Family Physician (2020)
  9. “Back pain in adolescents with idiopathic scoliosis: the contribution of morphological and psychological factors” Alisson R. Teles, Maxime St‐Georges, Fahad Abduljabbar, Leonardo Simões, Fan Jiang, Neil Saran, Jean A. Ouellet, Catherine E. Ferland. European Spine Journal (2020)
  10. “How Common Is Back Pain and What Biopsychosocial Factors Are Associated With Back Pain in Patients With Adolescent Idiopathic Scoliosis?” Arnold Y. L. Wong, Dino Samartzis, Prudence W. H. Cheung, Jason Pui Yin Cheung. Clinical Orthopaedics and Related Research (2019)

Adult Scoliosis: look after yourself!

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Adults with scoliosis are often convinced there is nothing more that can be done for their problem, partly because it has long been thought that scoliosis, in any case, doesn’t get any worse once you have finished growing. Unfortunately, now it has been shown not to be the case. We at ISICO, as well as monitoring patients through periodic checks, know that there is treatment available that may improve these patients’ conditions.

We frequently tell our patients that they will only be able to effectively manage their back and their scoliosis if they have a clear understanding of their condition and how to address it, which means: keeping fit, regularly doing appropriate exercises, and implementing strategies to avoid overstraining their back in everyday life. 

“Scoliosis in adults, treated or otherwise, may be one of three types: scoliosis that was discovered in adolescence, scoliosis that came to light in adulthood, and so-called de novo scoliosis. This latter form, typically seen in old age, is associated with often significant clinical symptoms, says our orthopaedic specialist, Dr Monia Lusini. For adolescent-onset scoliosis (which may have been discovered either in adolescence or in adulthood), the severity threshold beyond which the condition may worsen in adulthood is 30°, while curves greater than 50° are obviously much more likely to go on evolving, so much so that 50° is considered the cut-off point for surgery. Scoliosis worsens much more gradually in adulthood (by around 0.5-1 degree per year on average) often leading to the lateral and forward bending of the trunk typically seen in old age. The severity of de novo scoliosis, on the other hand, is generally mild to moderate, with the curve not normally exceeding the 30° threshold; nevertheless, this form can be associated with quite marked clinical symptoms.”

According to the data we have, mild curves (measuring less than 30°) are generally stable, whereas more severe scoliosis needs to be monitored, as a precautionary measure, through regular checks every 1-5 years.

And what happens if these checks show that the condition is worsening? “In that case, it may be useful to have a specific exercise programme drawn up by experienced and expert professionals in order to keep the situation stable” replies ISICO physiotherapist Alessandra Negrini. “Scoliosis is associated with several problems: a risk of back pain, aesthetic issues, progressive deformity, and problems with the internal organs (these are usually significant only in patients with curves greater than 70° and those with childhood-onset scoliosis)”.

This is why we at ISICO encourage our patients to do as much physical activity as they can, and to work out with their physiotherapist, a programme of specific exercises designed to strengthen the muscles that support the spine and combat the pain.

It has been scientifically proven (in two studies published by our group: Adult scoliosis can be reduced through specific SEAS exercises: a case report and Scoliosis-Specific exercises can reduce the progression of severe curves in adult idiopathic scoliosis exercises: a long-term cohort study) that appropriate and specific exercises tend to slow down or arrest the evolution of scoliosis.

Alongside physiotherapy, we at ISICO are currently trying out, in patients with scoliosis pain and ascertained progression of the condition, an elastic brace called Spinecor: when patients feel their back “giving way”, this device, even though it cannot be expected to lead to an improvement visible on X-rays, provides extra external support and can give them a few hours relief.

“I have had scoliosis surgery. Do I face any risks with pregnancy?”

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Let’s imagine the case of a healthy, active young woman who, as a teenager, had challenging scoliosis treatment, to the point of requiring surgery. Now, a few years on, she faces a new challenge: she wishes to become pregnant in order to fulfil her dreams of becoming a mother. 

Pregnancy is a period that naturally brings worries as well as lots of new information that needs to absorbed in order to be able to enjoy this special time. Those with scoliosis might start wondering “Will I have problems in pregnancy because of my scoliosis and the surgery I had? Or the reverse: “Could pregnancy aggravate my back condition?”.

Let’s try and help this mother-to-be, by providing answers based on the best available scientific evidence.

Several studies in the literature have investigated the topic “Pregnancy and surgery”, examining how one might influence the other.
Let us begin by underlining one reassuring aspect: as far as has been demonstrated so far, pregnancy (be it one pregnancy or more) has no consequences (in terms of a progression or deterioration of the curve) either on the surgically fused portion of the spine or on the vertebrae that were left free (https://pubmed.ncbi.nlm.nih.gov/32272267/;  https://pubmed.ncbi.nlm.nih.gov/2948962/). 

Nevertheless, it is always a good idea, when possible, to seek the opinion of the surgeon who performed the surgery, in order to have answers to your queries and precise instructions to follow.

Moreover, if the patient chooses epidural pain relief and/or chooses or requires to deliver by caesarean section with epidural anaesthesia, the anaesthetist might wish to avoid the surgically-treated portion of the spine (https://pubmed.ncbi.nlm.nih.gov/32578160/ ; https://pubmed.ncbi.nlm.nih.gov/30610987/ ), even though this decision by the medical team, made in agreement with the patient, seems to be taken more as a precaution.

In general, the use of epidurals in women with previous scoliosis surgery is comparable to what is observed in scoliosis patients who have not had operative treatment. Furthermore, according to the available data, anaesthesiologists seem reluctant to perform an epidural if the surgically treated portion of the column is below the third lumbar vertebra, preferring instead to opt for general anaesthesia (https://pubmed.ncbi.nlm.nih.gov/26131384/ ; https://pubmed.ncbi.nlm.nih.gov/32578160/ ; https://pubmed.ncbi.nlm.nih.gov/30610987/ ).

With regard to possible pain or complications during pregnancy and delivery, some studies have shown that there are no differences between women who have and those who have not had scoliosis surgery (https://pubmed.ncbi.nlm.nih.gov/9391799/ ).
On the other hand, low back pain during pregnancy seems to be more frequent in surgically treated patients, although it disappears relatively quickly after delivery. ( https://pubmed.ncbi.nlm.nih.gov/30610987/ ).
All in all, then, a mother-to-be can face this exciting new chapter in her life with complete peace of mind, even though she should not forget to seek the opinion, regarding her back, of both her family doctor and a spine specialist. In this way, it is possible to prevent any pain and have the best possible experience of pregnancy and childbirth

Scoliosis: why prevention matters

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About spinal disorders like scoliosis, it is often said that prevention is just as important as treatment.

Before we go any further, let’s clarify a few things, starting with the definitions of screening and scoliosis. Screening is an activity involving rapid tests, examinations or other procedures, and its purpose is to detect the possible presence of a disease or defect that the patient didn’t know they had.

Scoliosis, on the other hand, is a three-dimensional spine deformity.There are different forms, depending on the age at which it was first diagnosed: infantile (diagnosed between 0 and 3 years), juvenile (between 3 years of age and puberty), adolescent (between puberty and the completion of bone growth), and adult-onset. Scoliosis affects 3% of the population, prevalently females; 80% of cases are diagnosed in adolescence.

Two aspects in particular make scoliosis an insidious disease: first, it causes no symptoms of any kind during childhood and adolescence, which makes it difficult to identify young people who are at increased risk of developing spinal deformities; second, in most cases, it is idiopathic, which means we don’t know what causes it. 

Therefore, early diagnosis of scoliosis, i.e., at an age when there is a considerable risk of the condition progressing, allows the patient to receive adequate, less invasive and more effective treatment. This, as far as possible, will prevent it from worsening to the point of causing, in adulthood, pain, progressive deformity and sometimes cardiorespiratory problems that will negatively impact their quality of life.  

Screening: when and by whom?

Scoliosis screening’s importance is widely recognised, also by the scientific community (ref. Screening for adolescent idiopathic scoliosis: an information statement by the Scoliosis Research Society international task force). 

Scoliosis screening should target all girls in their last year of primary school/first year of secondary school and all boys in their second year of secondary education. This is the age at which they reach puberty and are therefore most at risk of progression of scoliosis, if affected by the disease. 

Youngsters should be screened by a spine expert who, through specific tests, can identify those at risk of a spinal deformity.

Screening results are given to the patient directly so that they can decide how to proceed with their doctor. In this way, if necessary, a diagnostic-therapeutic pathway can be planned.

What does Screening involve?

The first thing to do when evaluating whether or not a youngster may have scoliosis is to observe their bare back. The presence of more or less obvious asymmetries at trunk level, such as a difference in the height of the shoulders, or the hips, or a difference between the two shoulder blades, is the first sign of a possible case of scoliosis.

Then, the Adams test is performed, which is crucial: standing with their knees straight, the patient has to bend their trunk forwards, keeping their head down and letting their arms hang limply. This position has the effect of emphasising any hump due to scoliosis. If a hump is observed, it will be measured at the point where the height difference between the two sides of the patient’s back is greatest.

This measurement is taken using the Bunnell method, using a scoliometer to determine the angle of trunk rotation. If this angle measures 5° +/- 2° or more, it is advisable to have a specialist consultation. 

A patient with an angle of 3° or more should be checked every six months if they are approaching or have entered puberty, otherwise at yearly intervals. If a patient’s measurement is below this threshold (between 0 and 2°), but they have one hip or one shoulder higher than the other, or a protruding shoulder blade, then they need to be seen after six months and referred to a specialist if the asymmetries persist; otherwise, they can be referred back to their general practitioner/paediatrician.

How to screen a child online

Visit https://screening.isico.it to carry out a rapid screening for scoliosis or a curved spine, free of charge.
After watching the brief explanatory video, follow the steps and carry out the assessment. This will involve taking a few measurements. Depending on the data you provide us, we can tell you whether it would be a good idea to consult a spine specialist or whether there is currently no reason for concern.

Different specialists, different prescriptions: how should we choose?

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Most parents of a child with scoliosis embark on a similar journey: once they have received the initial diagnosis, they start consulting other specialists, seeking second or third opinions that might provide them with the confirmation and reassurance they need, and/or simply answers to further questions and doubts that have cropped up in the meantime. 

Often, though, parents who do this find themselves left with more questions than answers. This is because different specialists, faced with the same scoliosis case, can make different diagnoses and prescribe different courses of treatment.

Why is this? There may be different reasons. Before going any further, though, it is important to remember that only a specialist with specific training in vertebral pathologies can treat scoliosis. Once a timely and correct diagnosis has been made, it is necessary to decide how to treat the condition. 

The SOSORT guidelines on conservative treatment of scoliosis are an important resource in this regard. Taking into account the best current scientific evidence, as well as the extent of the curves and the degree of bone maturation, they provide suggestions on the most effective treatment. 

What the guidelines offer is not a single, specific course of treatment, but rather a series of options, ranging from the most conservative to the most aggressive, that could conceivably be prescribed in a given patient. 

However, science alone cannot meet all the needs of a long and complex course of treatment of the kind required in scoliosis. The evidence-based medicine approach brings together and combines scientific knowledge, the expertise and experience of the specialist, and the values and desires of the patient, and therefore makes it possible to formulate the most appropriate prescription for the individual case. 

Bearing all this in mind, then, it may well be that one doctor, considering the data collected during the examination and the discussion with the patient and the patient’s family, decides to prescribe a brace where another doctor might instead recommend only specific physiotherapy or even a wait-and-see approach, which consists of monitoring the situation for a few months to see how the scoliosis evolves.
These are very different prescriptions, but they are all valid. The patient will in any case be monitored following the prescription in order to make sure that the type of treatment, and the dose, are correct.
In this way, it is also possible to make any changes needed to avoid under-treatment (insufficient to contain the progression of the disease) or over-treatment (too taxing for the patient).

The big question remains: how do we parents go about choosing? There’s no easy answer. Given that our children will need to be on this therapeutic journey until they have finished growing, the important thing is to find someone we feel we can trust. In other words, we need to choose the specialist — and it must be someone with expertise in the conservative treatment of scoliosis — who we, and our child, felt to be the most reassuring and empathetic.

Once we have made our choice, we need to place our child’s care in the doctor’s hands. It is important to follow the instructions we are given, and not to change anything without the doctor’s agreement, as to do so could undermine the success of the treatment. 

Curves measuring less than 10 degrees: should we treat them?

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As suggested by the Scoliosis Research Society (SRS), a scoliosis diagnosis is confirmed when a patient presents a Cobb angle measuring 10° or more and axial vertebral rotation. Maximum axial rotation is measured at the apical vertebra. (1) The SRS established this threshold in 1977, replacing the previous one of 7°. Ever since, 10 ° has conventionally been accepted, worldwide, as the threshold for diagnosing scoliosis.
However, structural scoliosis, with a potential for progression, can also be observed in the presence of Cobb angles measuring less than 10°. In fact, initial wedging of the vertebral bodies and disks can sometimes be registered with curves of 4°–7°. (2)

Idiopathic scoliosis, being a developmental disorder, most commonly arises and progresses during periods of accelerated growth (growth spurts).

The first such period occurs in infancy/early childhood, generally between 6 and 24 months of age, and the second between the ages of 5 and 8 years; finally, there is the pubertal growth spurt, which generally occurs at 11–14 years of age. (1)

Although the later stages of development are obviously not risk free, after puberty the rate of growth usually slows down, reducing the risk of progression of scoliosis. 

Can the risk of scoliosis progression be predicted in the case of curves measuring less than 10°?
There is, of course, always a chance that these curves will become more pronounced as the youngster grows, even, in some cases, to the point of requiring the use of a brace. But it is also true that most of them will remain stable over time without reaching the minimum criteria for a diagnosis of scoliosis. Certain factors may possibly be associated with an increased risk of scoliosis progression: a positive family history of scoliosis, laxity of ligaments, flattening of physiological thoracic kyphosis, a greater than 10° angle of trunk rotation (ATR), and growth spurts. All these factors should be evaluated by the attending physician. 

So, should we be treating these youngsters? In short, no. First of all, it is worth remembering, that the main aim of conservative treatment of scoliosis is to improve the patient’s appearance, but curves as mild as this rarely have an aesthetic impact; at most there may be some slight asymmetry of the trunk, but nothing that can be considered to exceed physiological parameters. With very rare exceptions, the only advice necessary in these cases is to opt for clinical monitoring of the patient, which can be considered to all intents and purposes a treatment, in the sense that it allows us to overcome the critical phases of development (which also correspond to the periods of greatest risk of progression of scoliosis) and also to intervene if any progression does occur. Monitoring is the first step in an active approach to idiopathic scoliosis, and it consists of clinical evaluations performed at regular intervals, ranging from every 2-3 months to every 36-60 months depending on the single case. 

In conclusion, any active treatment in this population of patients is actually overtreatment. Even just specific exercises, whose prescription constitutes first therapeutic step after monitoring alone, would cost these youngsters in time and effort, as well as being an economic cost.

A further aspect, not to be underestimated, is the psychological impact: starting a treatment amounts to confirming that the individual has a disease that needs to be treated, and this can lead them to start thinking of themselves as “sick”.

Furthermore, even though an exercise programme is not a particularly arduous undertaking, starting a treatment when there is no real need for one could compromise the youngster’s collaboration and commitment should a treatment be needed later on. This is an important consideration, because if their scoliosis does progress as they grow, specific exercises, rather than being useful, could become crucial, in order to avoid bracing for example.  

1 – 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth

https://pubmed.ncbi.nlm.nih.gov/29435499/

2 – Radiographic Changes at the Coronal Plane in Early Scoliosis. Xiong, B., Sevastik, J. A., Hedlund, R., & Sevastik, B. (1994). Spine, 19(Supplement), 159–164. doi:10.1097/00007632-199401001-00008

https://pubmed.ncbi.nlm.nih.gov/8153824/