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Adolescent idiopathic scoliosis accounts for over 80% of all scoliosis cases and generally occurs between the ages of 9-14 years of age.  For unknown reasons, it targets females to males by an 8 to 1 ratio most of the curve progression occurs during times of rapid growth.  While the condition isn’t life-threatening, it can create massive permanent spinal and body deformity and particularly at a time when teenage girls are often already self conscious about body image.

Clinically speaking, approximately 80% of adolescent idiopathic scoliosis cases will not cause any significant medical issues (although they are at an increased risk of back pain and spine degeneration as adults), but even smaller, non-progressive spinal curvatures can and will have a negative impact on one’s quality of life.  The unfortunately 20% whose spinal curvatures progress though out adolescence are usually presented a very limited number of unattractive, uncomfortable, and ineffective scoliosis treatment options such as scoliosis brace treatment or scoliosis surgery; both of which only focus on treating the spinal curvature and not the neurological root cause of idiopathic scoliosis.

Brand new data supplied by the developers of the Scoliscore genetic test for scoliosis, Axial Bio-Tech, has raised new questions in regards to why certain idiopathic scoliosis cases become progressive curvatures and other don’t.  Only 1% of all idiopathic scoliosis cases are considered “genetically high risk” for scoliosis curve progression, yet approximately 20% of idiopathic scoliosis cases demonstrate progression.  While this would be illogical if idiopathic scoliosis was solely a genetic condition, researchers have long suspected adolescent idiopathic scoliosis to be a multi-factorial condition with both genetic pre-disposition and environmental influences.  Given the fact, that only a tiny percentage of cases are “genetically high risk” for severe progression, and in fact a large percentage of idiopathic scoliosis cases do experience significant scoliosis curve progression it would seem that environmental factors make the most significant role in the progression of idiopathic scoliosis curve progression. 

While teens are notorious for sitting and standing with bad posture (an environmental risk factor for scoliosis curve progression), there are a many other environmental factor/ lifestyle factors to consider as well.……

Sleeping on one’s stomach is not advisable for patients with thoracic scoliosis.  The prolonged position places un-due stress on the mid back and the head turned to one side can increase spinal rotation.

Repeated back bends in ballet or gymnastics can cause scoliosis curve progression.  The repeated hyper-extension of the mid back (back bends) can cause a flattening of the thoracic spine and the de-stabilization may allow a spinal curvature to progress father than it would otherwise.

Spinal trauma that results in ligament damage to the neck is common.  Most people don’t understand the bio-mechanics of ligament damage and think it requires a large amount of force to damage the ligaments in the cervical spine, when it fact it only requires a very “rapidly applied” force.  Minor fender benders are a prime example of trauma that causes ligament damage in the neck.  The resulting instability can change the patient’s head position with profound effects on the scoliosis spine curvature.

Scoliosis in teenagers is a challenging diagnosis to deal with and condition to treat, but new early stage scoliosis intervention therapies that are based on rehabilitating the automatic postural control centers in the brain are having amazing success in halting the progression of scoliosis and reversing the spinal curvature to a large degree.  This new focuses treatment on the reduction/elimination of the environmental factors that combine with the genetic pre-disposition to create the idiopathic scoliosis spine condition rather than only focusing on the spinal curvature.

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The effects of scoliosis on the spinal cord has always been relatively "poorly understood" not only in terms of bio-mechanical stress placed on the cord, but in regards to the symptoms of scoliosis and scoliosis pain it may cause.

It is important to note that idiopathic scoliosis is a 3 dimensional spinal distortion and the bio-mechanical stress placed on the spinal cord much be taken into account in the vertical, horizontal, and side view dimensions as a summation of the total amount of bio-mechanical stress placed on the spinal cord, because of a scoliotic curvature.

Here are all 3 parts of a study examining the effects of bio-mechanical stress on the spinal cord.

 Biomechanics_of_CNS_I.pdf

 Biomechanics_of_CNS_II.pdf

Biomechanics_of_CNS_III.pdf

While the scoliosis pain syndromes bio-mechanical stress on the spinal cord are varied and unpredictable, but perhaps the most important aspect on bio-mechanical stress on the cord caused by a scoliotic curvature may be increased risk of rapid progressive scoliosis.

Biomechanically speaking, the continuous axial tissue tract of the pons, medulla oblongata (the CNS postural control centers) and spinal cord are all functionally linked together and anchored vertically from the skull to the caude equina at the base of the spine. It is also anchored laterally through out the spine by dentiulate ligaments, nerve roots and nerve sleeves. Take home message: The spine is tied down in the spine pretty tightly.

Alf Breigs 1978 work shows changes in relative lengths of spinal canal and cord CAN lead to pathlogic axial tension. JD Reid's research confirms this when his reseach found physiological lengthening of the cord chiefly between C2-T1 up to a maximum of 17.6% in flexion (AKA: reversal of the normal cervical lordosis). Essentially, an aquired spinal cord tethering is the result from a loss of the normal cervical lordosis.

Roth build off this information in 1981 when he speculated that adolescent idiopathic scoliosis is a disproportion of vertebro-neuro growth due to either a short spinal cord or a too rapid growth spurt of the spine. In this spring/string model, he found that shortening of a string running though a spring model (think of a slinky with a string running though it) hindered elongation of the spring resulting in a scoliotic deformity.

Porter supported the uncoupled neuro-osseous growth concept of adolescent idiopathic scoliosis being a physical manifestation of the maladaption of the growing immature spine to the tether created by the short spinal cord. This evidence for this was the finding that the conus medullaris (the end of the spinal cord) position is NOT significantly different from that of a normal spine.

Dr. Chu re-examined the Roth-Porter theory via an MRI study (comparing adolscent idiopathic scoliosis patients with severe curvatures vs normal subjects) in 2007. They found the vertebral column in the adolescent idiopathic scoliosis population was significantly longer, yet the there was no detectable change in spinal cord length. The speculated that the initiation and progression of adolescent idiopathic scoliosis result from vert. column overgrowth through a maladapation of the spine to the subclinical tether of a relatively short spinal cord.

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What are the benefits of scoliosis bracing?  Well, there don't seem to be any considering the conclusions of the studies and orthopedic experts below.....

A 2007 article in SPINE by Drs. Dorlan and Weinstein studied the effect of rigid bracing vs. observation on surgical rates. Here is an excerpt from the abstract....the review of literature was based on 18 total studies (15 bracing and 3 observation)

"Observation only or bracing showed no clear advantage of either approach. Furthermore one can not recommend one approach over another to prevent surgery. They gave the recommendation for bracing a grade "D" relative to observation only because of "troublingly inconsistent or inconclusive studies on any level."

Compare/contrast the treatment gains (statistically insignificant) vs the costs (considerable financial and long-term psychological scaring) and it makes me wonder why spinal bracing is even still recommended for scoliosis treatment.

Adolescent idiopathic scoliosis: the effect of brace treatment on the incidence of surgery. Spine 2001 Jan 1;26(1)42-7 Children’s Research Center, Dublin, Ireland

"Since 1991, bracing has not been recommended for children with AIS at this center."

"If bracing does not reduce the proportion of children with AIS who require surgery for cosmetic improvement of their deformity, it cannot be said to provide a meaningful advantage to the patient or the community."

Furthermore, Dr. Ian Stokes' rat tail research is now demonstrating that full time scoliosis bracing creates a permanent deformity of the spinal disc wedge which actually causes an increased likelihood of curve progression in adolescence and adulthood.  Scoliosis brace treatment is contra-indicated in my opinion.

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The evidence and studies are proving time and time again that back bracing for scoliosis has no effect on the curvature or natural progression of the condition.  This study even compared the results of bracing vs. the genetic testing predicted outcomes.  The results clearly show that bracing for scoliosis provides no benefit to the patient. 

J Ogilvie , L Nelson, R Chettier and K Ward

Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA

author email corresponding author email

from 6th International Conference on Conservative Management of Spinal Deformities
Lyon, France. 21-23 May 2009

Scoliosis 2009, 4(Suppl 2):O59doi:10.1186/1748-7161-4-S2-O59

The electronic version of this abstract is the complete one and can be found online at: http://www.scoliosisjournal.com/content/4/S2/O59

Published: 14 December 2009

© 2009 Ogilvie et al; licensee BioMed Central Ltd.

Background

Orthotic treatment of children with AIS is a generally accepted treatment option. Failure of bracing to halt curve progression has been reported in 20% or more of patients, and it is known that some curves in children with AIS will not progress even if untreated. Success and failure rates of brace treatment vary considerably.

Purpose

We reviewed the response to brace treatment in patients who were also analyzed with a DNA-based adolescent idiopathic scoliosis progression test (AIS-PT) and compared this with the natural history of adolescent idiopathic scoliosis without treatment. Our purpose was to document the influence of orthotic care on the outcome at skeletal maturity.

Methods

Medical records and x-rays were reviewed, and DNA was collected with a saliva sample in two cohorts of Caucasian female AIS patients. A risk of progression score was calculated using 53 genetic markers with utility for calculating the risk of AIS curve progression from < 25° to > 40° before skeletal maturity or > 50° at maturity (1-200). Group A (2442 females) had no brace treatment and their outcome at maturity or surgery was known. Group B (308 females) were brace compliant for more than one year and their curve severity at maturity or surgery was known.

Results

There was little statistical difference in the curves representing risk of progression versus curve severity when the two groups were compared.

Conclusion

In this retrospective study of US Caucasian females, there was no statistically significant difference in the natural history of adolescent idiopathic scoliosis when comparing bracing treatment and no bracing treatment. At best, there was only a modest brace effect. Prospective trials with genotype homogeneity are needed to validate current assumptions about the efficacy of orthotic types and treatment regimens when bracing adolescent idiopathic scoliosis.