Neuromuscular scoliosis Definition Scoliosis is a sideways curvature of the spine that occurs most often during the growth

spurt just before puberty. While scoliosis can be caused by conditions such as cerebral palsy and muscular dystrophy, the cause of most scoliosis is unknown Types of Scoliosis Abnormal curvature of the spine can occur in children in a wide range of ages and through a variety of causes. Therefore, scoliosis has actually been categorized into a number of different types, each with its own clinical characteristics. More importantly, each type of scoliosis is managed, or treated, by orthopaedic surgeons slightly differently than the others, so it is important to classify the distinct conditions in this manner. Idiopathic Scoliosis The most common type of scoliosis is idiopathic scoliosis, which means that it occurs without known causes. Because this type of scoliosis can affect children at different ages, it has been further broken down into an even more specific set of conditions. There are therefore three sub-types of idiopathic scoliosis that affect children: infantile, juvenile, and adolescent. Infantile idiopathic scoliosis Pathophysiology Infantile idiopathic scoliosis occurs before the age of 3 and is seen more frequently in boys than girls. Most cases resolve spontaneously, but some may progress to more severe deformity. Treatment may include observation, physical therapy, bracing and, under rare circumstances, surgery. For more in-depth information on infantile scoliosis, click here. Juvenile idiopathic scoliosis Juvenile idiopathic scoliosis is defined as scoliosis occurring between the ages of 3 and 9. It is found more frequently in girls than boys. The abnormal spinal curvatures in children with juvenile scoliosis are generally at a high risk for progression to more severe curves. They usually require bracing and many will go on to require surgery. Adolescent idiopathic scoliosis Adolescent idiopathic scoliosis occurs between the age of 10 and young adulthood. This condition, also called AIS, is by far the most common type of scoliosis, as well as the type with the best prognosis. AIS may begin to manifest itself at the initial onset of puberty or become apparent or worsen during an adolescent's growth spurt. Girls, or young women, are at higher risk than boys, or young men. Most children with AIS do not develop worsening curvature, and therefore treatment usually begins only with observation. Congenital scoliosis While most cases of scoliosis are considered 'idiopathic' and occur during childhood without a clear cause, a small number of children develop a lateral curvature of the spine even before birth, during the period of fetal growth in the womb. These cases are referred to as congenital scoliosis, which means that abnormal development is the cause of the condition. Congenital scoliosis occurs when bony portions of the spine fail to form properly or normally separated segments fuse together during fetal development. The defects in the spine can be minor, involving only one segment of the vertebral column, or the condition can involve nearly every level and result in a more severe deformity. Treatment ranges from observation to surgery, depending on the appearance of the spinal curvature. The pathophysiological process behind the development of adolescent idiopathic scoliosis (AIS) is also not known. The observation that curve development and progression correlate with the period of rapid adolescent growth appears to support a biomechanical contribution. However, multiple theories exist that attempt to explain the process by which the development takes place, and while each makes sense from a biomechanical standpoint, it has been difficult to directly correlate these theories to the in vivo adolescent scoliotic spine. The general concept suggested by the collective literature is that the process begins with a multifactorial propensity towards the development of scoliosis that is accelerated through the complex biomechanical environment of the rapidly growing adolescent spine. Signs and symptoms of scoliosis may include: Risk factors By Mayo Clinic staff Risk factors for developing the most common type of scoliosis include: Another major type of scoliosis is neuromuscular scoliosis, which means that it is caused by the presence of a neurological or muscular disease, such as cerebral palsy or muscular dystrophy. Because there is such a wide variety of these types of diseases that may cause neuromuscular scoliosis, the clinical presentation and severity of this condition is extremely variable. Unlike the other types of scoliosis described here, treatment of neuromuscular scoliosis is very unpredictable, mostly because the abnormal curves of the spine are also unpredictable.

Age. Signs and symptoms typically begin during the growth spurt that occurs just prior to puberty. This is usually between the ages of 9 and 15 years. Sex. Although both boys and girls develop mild scoliosis at about the same rate, girls have a much higher risk of the curve worsening and requiring treatment. Family history. Scoliosis can run in families, but most children with scoliosis don't have a family history of the disease.

Uneven shoulders One shoulder blade that appears more prominent than the other Uneven waist One hip higher than the other

If a scoliosis curve gets worse, the spine will also rotate or twist, in addition to curving side to side. This causes the ribs on one side of the body to stick out farther than on the other side. Severe scoliosis can cause back pain and difficulty breathing.

Tests and diagnosis By Mayo Clinic staff The doctor will initially take a detailed medical history and may ask questions about recent growth. During the physical exam, your doctor may have your child stand and then bend forward from the waist, with arms hanging loosely, to see if one side of the rib cage is more prominent than the other. Your doctor may also perform a neurological exam to check for:

Muscle weakness Numbness Abnormal reflexes

body. Also called a thoracolumbosacral orthosis, this close-fitting brace is almost invisible under the clothes, as it fits under the arms and around the rib cage, lower back and hips. Underarm braces are not helpful for curves in the upper spine or neck.

Imaging tests Plain X-rays can confirm the diagnosis of scoliosis and reveal the severity of the spinal curvature. If a doctor suspects that an underlying condition such as a tumor is causing the scoliosis, he or she may recommend additional imaging tests, including:

Milwaukee brace. This full-torso brace has a neck ring with rests for the chin and for the back of the head. The brace has a flat bar in the front and two flat bars in the back. Because they are more cumbersome, Milwaukee braces usually are used only in situations where an underarm brace won't help.

Magnetic resonance imaging (MRI). MRI uses radio waves and a strong magnetic field to produce very detailed images of bones and soft tissues. Computerized tomography (CT). CT scans combine X-rays taken from many different directions to produce more-detailed images than do plain X-rays. Bone scan. Bone scans involve the injection of a radioactive material, which travels to the parts of your bones that are injured or healing.

Surgery Severe scoliosis typically progresses with time, so your doctor might suggest scoliosis surgery to reduce the severity of the spinal curve and to prevent it from getting worse. The most common type of scoliosis surgery is called spinal fusion. In spinal fusion, surgeons connect two or more of the bones in the spine (vertebrae) together, so they can't move independently. Pieces of bone or a bone-like material are placed between the vertebrae. Metal rods, hooks, screws or wires typically hold that part of the spine straight and still while the old and new bone material fuses together. Surgery is usually postponed until after a child's bones have stopped growing. If the scoliosis is progressing rapidly at a young age, surgeons can install a rod that can adjust in length as the child grows. This growing rod is attached to the top and bottom sections of the spinal curvature, and is usually lengthened every six months. Complications of spinal surgery may include bleeding, infection, pain or nerve damage. Rarely, the bone fails to heal and another surgery may be needed. Nursing Interventions

Treatments and drugs Most children with scoliosis have mild curves and probably won't need treatment with a brace or surgery. Children who have mild scoliosis may need checkups every four to six months to see if there have been changes in the curvature of their spines. While there are guidelines for mild, moderate and severe curves, the decision to begin treatment is always made on an individual basis. Factors to be considered include:

Sex. Girls have a much higher risk of progression than do boys. Severity of curve. Larger curves are more likely to worsen with time. Curve pattern. Double curves, also known as S-shaped curves, tend to worsen more often than do C-shaped curves. Location of curve. Curves located in the center (thoracic) section of the spine worsen more often than do curves in the upper or lower sections of the spine. Maturity. If a child's bones have stopped growing, the risk of curve progression is low. That also means that braces have the most effect in children whose bones are still growing.

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Braces If your child's bones are still growing and he or she has moderate scoliosis, your doctor may recommend a brace. Wearing a brace won't cure scoliosis, or reverse the curve, but it usually prevents further progression of the curve. Most braces are worn day and night. A brace's effectiveness increases with the number of hours a day it's worn. Children who wear braces can usually participate in most activities and have few restrictions. If necessary, kids can take off the brace to participate in sports or other physical activities. Braces are discontinued after the bones stop growing. This typically occurs:

Prepare the child for casting or immobilization procedure by showing materials to be used and describing procedure in ageappropriate terms. Promote comfort with proper fit of brace or cast. Provide opportunity for the child to express fears and ask questions about deformity and brace wear. Assess skin integrity under and around the brace or cast frequently. Provide good skin care to prevent breakdown around any pressure areas. Instruct the patient to examine brace daily for signs of loosening or breakage. Instruct patient to wear cotton shirt under brace to avoid rubbing. Instruct about which previous activities can be continued in the brace. Provide a peer support person when possible so the child can associate positive outcomes and experiences from others.

About two years after girls begin to menstruate When boys need to shave daily When there are no further changes in height

Braces are of two main types:

Underarm or low-profile brace. This type of brace is made of modern plastic materials and is contoured to conform to the