The Spine Curves

                            by Louise Fenner

                              FDA CONSUMER

                DEPARTMENT OF HEALTH AND HUMAN SERVICES
                         Public Health Service
                      Food and Drug Administration
                           5600 Fishers Lane
                          Rockville, Md. 20857
                        Office of Public Affairs

                     REPRINTED FROM SEPTEMBER 1984

                   HHS Publication No. (FDA) 85-4198

The young girl's spine was not growing straight. In her shoulder area it
curved to the right. In her lower back it curved to the left. Instead of
forming a straight line from neck to hips, the spine was taking on the
contours of a top-heavy letter S.

The doctor's diagnosis was scoliosis--an abnormal curvature of the spine
that usually shows up during adolescence. In most people the curvature
is so mild that no treatment is needed. In her case, however, the spine
would continue to grow in a curve unless it could be coaxed along a
straighter path.

At 13, the girl was fitted with a body brace that she would wear almost
constantly for the next four years. She kept it on 22 hours of every
day, tapering off only in the last year. By the time she reached 17 her
spine had stopped growing, the susceptibility to curvature had passed,
and the brace could be abandoned. It had been a difficult time, but the
alternatives would have been worse--surgery or, if untreated, a possible
deformity and a lifetime of pain and other health problems.

Scoliosis is more common than people may realize. It generally appears
between the ages of 10 and 15, when a child's spine is growing rapidly,
and it affects 5 to 10 percent of all adolescents to some degree. Very
mild scoliosis occurs at the same rate in both sexes, but adolescent
girls are seven to nine times more likely to develop clinically
detectable spinal curvature that requires treatment. The reason for this
is not known.

Everyone's spine has normal curves that produce a slight rounding of the
shoulder area and an inward curve of the lower back, but in scoliosis
the spine also curves laterally (sideways). It may resemble a letter "S"
or a long letter "C," depending on the number and types of curves
involved. The curvature described above is the most common type.

Another problem in scoliosis is that as the spine grows, it gradually
rotates (twists) on its own axis. The rotation slowly pulls the rib cage
around so that, in the back, one side of the rib cage becomes higher and
sticks out farther than the other. Furthermore, the ribs on the inward
(concave) side of the spinal curve are gathered together, while those on
the outward (convex) side are spread apart. This distortion of the rib
cage can restrict the lungs, causing breathing problems and possibly
heart disease in later years.

Progressive scoliosis may produce a cosmetic deformity and
incapacitating back pain during adult life. Research has shown that, on
the average, adults with advanced (untreated) scoliosis tend to retire
earlier and die younger than the general population.

Most adolescent scoliosis is "idiopathic," which means the causes are
unknown. It is also a mystery why some curves increase rapidly while
most remain stable. A tendency toward scoliosis can be inherited, and
the disorder frequently runs in families. If one child is diagnosed, all
other growing children in the family should be examined. A few special
cases of scoliosis can be traced to neurological disorders such as
polio, spinal cord injuries, cerebral palsy and muscular dystrophy.

It is important that scoliosis be identified as early as possible, since
prompt treatment of progressing curves provides the best chance of
slowing or halting a progressive curvature. The most common treatment is
a body brace worn until the child reaches physical maturity and bone
growth has stopped, at about age 16 or 17. As an alternative, some
physicians are using a new technique that employs an electrical muscle
stimulator. If the curvature continues to increase despite these
efforts, corrective surgery is called for.

Many states have established school screening programs to monitor
students around the ages of 10 to 15 for scoliosis. In addition, parents
may notice signs, particularly when the child is wearing underwear or a
bathing suit.

An adolescent with a spinal curvature may appear to lean or list to one
side, and even when standing as straight as possible, his or her spine
is still not "straight." A shoulder blade may be prominent on one side,
with one shoulder higher than the other. One hip can also appear higher
or be more prominent. From the back, the rib cage may appear to stick
out or form a hump on one side of the spine (usually the right side).
When the arms are hanging loosely at the sides, there may be more space
between the arm and body on one side. Other clues are repeated tilting
of the head to one side, uneven hems and waistbands, uneven bra straps,
or one pant leg hem riding higher than the other.

An easy test for scoliosis--done in school screening programs--is to
have the adolescent bend forward from the waist. This makes both the
sideways curve of the spine, plus any rib protrusions, more visible. It
helps differentiate scoliosis from poor posture, which can be corrected
merely by straightening up. (The bending test can also reveal a
condition called kyphosis, a rounded back caused by excessive curving of
the upper spine. Kyphosis is found in about 10 percent of the
population. Some people with kyphosis also have mild scoliosis.)

Parents who suspect something may be wrong with their child's spinal
development should talk to a doctor. If scoliosis is indeed the problem,
the child should be referred to an orthopedic surgeon who specializes in
the disorder.

If scoliosis is suspected in a growing patient, X-rays are usually taken
to determine the type and extent of curvature. In mild scoliosis--a
curve that measures 20 degrees or less and does not progress--regular
observation by a physician may be all that is required. Most adolescents
with scoliosis fit into this category.

However, adolescents with spinal curvatures of approximately 20 to 40
degrees are usually candidates for a body brace. Studies have shown that
the greater the curve, the more likely and the more rapidly it will
progress. The main function of a brace in scoliosis therapy is to guide
the spine while it is still growing. Most braces must be worn day and
night for several years until maturity (depending on the age of the
patient), with one or two hours off daily for exercise and bathing.
Patients are encouraged to participate in virtually all physical
activities except competitive contact sports.

A brace is preventive medicine. It will usually keep an existing curve
from worsening and may help reduce it to some extent, thus avoiding the
need for surgery. Some braces are more cumbersome than others, but the
choice is based on the type of curvature being treated. For instance,
the first successful brace for scoliosis was the "Milwaukee" brace,
introduced in 1945 and still used today. It has a leather or plastic
pelvic girdle, straps, and a ring that circles the patient's neck to
hold the support bars of the brace in position. However, some newer
types of braces made from molded plastic are less obtrusive because they
hug the torso beneath the underarm and can be concealed by normal
clothing. These appear to be effective with moderate spinal curvatures
involving the lower thoracic and lumbar portions of the spine.

Instead of wearing a brace virtually 24 hours a day, some patients with
moderate scoliosis are spending their nights wired to an electrical
muscle stimulator. This form of therapy for scoliosis became available
in 1983 following approval by the Food and Drug Administration. The
electrical muscle stimulator causes muscles near the spine to contract
several times a minute. These muscles, located on the outer or convex
side of the spinal curve, provide a counteracting force against other
muscles that are pulling the spine out of line.

An electrical muscle stimulator is used only at night while the patient
sleeps. Like the more widely used brace, it must be continued until the
patient reaches bone maturity. FDA is requiring manufacturers of
electrical muscle stimulators to conduct follow-up studies of some
patients to assess long-term safety and effectiveness.

When a spinal curvature measures 40 to 45 degrees or more, surgery is
usually required to prevent future health problems and to correct any
spinal deformity. Some curvatures may not be detected until they become
this severe; in other cases, a moderate curve continues to progress
despite bracing or other treatment. In addition to adolescent patients,
a growing number of adults who have severe curvatures are undergoing
surgery to help relieve back pain and improve their appearance.

The most common surgical procedure involves attachment of a thin
stainless steel rod to straighten the spine, along with fusion to hold
the spine in a corrected position. The rod--called a Harrington rod
after its inventor--is attached to the exposed spine with hooks. One or
more rods may be used. Then fusion is effected by grafting small strips
of bone, usually taken from the back of the pelvis, over the affected
vertebrae (sections of the spinal column). As this heals, the fused
section of spine becomes solid in a straightened position while the rest
of the spine stays flexible.

Other types of instruments may be used instead of Harrington rods,
depending on the patient's needs. Since problems rarely result from
permanent implantation of these instruments in the back, they are
removed at a later date only if necessary.

Generally, the patient must wear a body cast around the ribs and pelvis
for about six months after surgery, succeeded by a brace worn for
another three months. Once the spine is completely healed, a brace is no
longer needed. The patient is left with few limitations on his or her
physical activity.

Scoliosis surgery, and the subsequent recovery period, can be traumatic.
It carries certain risks, as does any major surgical procedure. Early
detection and preventive treatment are obviously preferable.
Unfortunately, scoliosis is painless in its beginning stages and parents
may not be aware their child has a spinal problem until it has
progressed to a significant curvature.

School screening programs often pick up scoliosis cases that parents
miss, and they can catch them early enough for nonsurgical treatment to
be successful. The screening programs in the United States and Sweden
have been so successful that there has been a significant reduction in
the number of children who required surgery recently for "idiopathic"
scoliosis, according to the Scoliosis Research Society, an association
of physicians and scientists. "Their curves have been detected early and
have been managed successfully by appropriate bracing."

An FDA study ascertained that some or all school districts in 18 states
and the District of Columbia have mandatory school screening programs
that generally cover grades 5 through 9. In addition, more than 20 of
the remaining states have voluntary scoliosis screening programs at the
state, county or local level.

"Screening programs have dramatically reduced both the number and
complexity of surgical procedures that are performed for scoliosis,"
notes the American Academy of Orthopedic Surgeons. "The real benefit of
school screening programs for scoliosis, of course, can be expressed in
more human terms: the increase in psychological and physical well-being
for the children who do not progress to spinal deformity."

Louise Fenner is a member of FDA's publications staff.

Scoliosis X-Rays

The growing emphasis on school screening for scoliosis has probably led
to an increase in the number of X-ray examinations of the spine. After
an initial physical examination, suspected cases are generally referred
to a health practitioner to confirm the diagnosis and to evaluate the
condition. Many children with mild curvatures who do not require
treatment are periodically monitored using X-rays to ensure that
curvatures are not increasing. Scoliosis patients are usually examined
at least once a year and some as often as every three or six months. One
or more X-rays may be needed each time.

Health professionals are becoming increasingly aware of the need to
minimize radiation exposure during these X-ray examinations, especially
for girls. Past studies indicate that developing breast tissue is
particularly sensitive to the effects of radiation and that repeated
exposure of the breast during adolescence can increase a woman's risk of
breast cancer in later life.

Fortunately, there are ways to significantly reduce radiation exposure
of the breast without compromising the quality of the X-ray picture.
These include the use of compensating filters, fast screen/film
combinations, and breast shields. Each of these techniques by itself can
lower radiation exposure markedly. When they are used together, the
exposure reduction is even greater.

Compensating Filter

This filter is made of aluminum, stainless steel, or transparent lead
acrylic. It fits onto the X-ray tube by means of magnets, special
holders, or slots. The filter absorbs much of the X-ray beam directed to
the chest area, improves the X-ray image and, most importantly, reduces
breast tissue exposure by two to five times.

Fast Screen/Film Combinations

The "faster" or more sensitive the film and intensifying screen used,
the lower the radiation exposure of the patient. A particular type of
fast screen/film combination, called "rare-earth," is frequently used in
scoliosis X-rays because it requires less radiation exposure without
significantly affecting image quality. This technique reduces breast
tissue exposure from two to six times.

Breast Shielding

There are two types of shields that can be used to protect the breast
during an X-ray examination. Contact shields are vests or stole-like
garments with lead inserts that are worn by the patient to cover the
breast area. Shadow shields are adjustable metal plates attached to the
X-ray machine and cast a "shadow" over the breast area. Breast shielding
reduces radiation exposure to the breast tissue by three to 10 times.
Another method of breast shielding is to turn the patient around so that
she faces away from the X-ray machine. The body then acts as a shield
for the breast tissue.

If your child needs an X-ray examination for scoliosis, remember the
importance of radiation exposure reduction. Although there is less cause
for concern about breast cancer when the patient is a boy (and thus no
need for a special breast shield), it makes good sense to keep radiation
exposure to a minimum for all patients.

So Ask Your Doctor

   * "What radiation-reduction techniques will be used when my child is
     X-rayed? Will you use a compensating filter? A fast screen/film
     combination?"

   * And, for girls, "Will you use breast shielding?"

If you or your doctor would like more detailed information on reducing
radiation exposure, you may request a copy of the technical pamphlet
Reducing Patient Exposure During Scoliosis Radiography by writing to:
FDA, HFZ-240, Rockville, Md. 20857.

"Growing The Wrong Way"

Dr. Moravia smiled. "Now Deenie . . . I'd like you to bend over and
touch your hands to your toes."

     "My gym teacher made me do the same thing."

     Dr. Moravia pressed his hand against my side.

     "I really do try to stand up straight," I said.

     "It has nothing to do with that," he told me. "You can come up now,
     Deenie. "

     "It's not my posture?" I asked, straightening my clothes.

     "No. It's your spine, I think. . . . Something might be growing the
      wrong way.

     "I heard all about your spine.

     "Who told you?"

     "A lot of kids."

[Graphic Omitted]

     "I guess practically everyone knows."

     "Yeah, I guess so. Now I know what you meant when you said you had
     a lot on your mind. Does [the brace] hurt?"

     "No, it's just a little uncomfortable."

     "You can take that thing off sometimes, can't you?"

     "I'm supposed to wear it all the time," I told him. "Except for
     swimming."

     "You even have to sleep in it?"

     "Yes," I kind of smiled then, to show how brave I am.

Reprinted with permission of Bradbury Press, Inc., from Deenie by Judy
Blume. Copyright 1973 by Judy Blume.