Juvenile

Juvenile scoliosis is an idiopathic scoliosis that affects children between the ages of 4 and 10. Like other types of scoliosis it is characterised by an abnormal sideways S or C curve of the spine.

Juvenile scoliosis is more often seen in girls than boys. In children between the ages of 4 to 6 years the rate is fairly equal between the two sexes. However between the ages of 6 to 10 years the rate is much higher among girls. It is seen more frequently than infantile idiopathic scoliosis, but it is less common than adolescent idiopathic scoliosis. Curves tend to bend to the right in children with juvenile scoliosis, however left curves tend to have a better prognosis. Children with juvenile scoliosis generally have a high risk of progression of their curve. Seven out of ten children with this condition will worsen and require active treatment. Juvenile curves almost never resolve spontaneously. They usually require bracing, and many will go on to require surgery.

What causes juvenile scoliosis?

The exact cause of juvenile scoliosis is unknown hence its classification as an “idiopathic” scoliosis. Idiopathic literally meaning “of unknown cause”. However the juvenile form has similar clinical features to adolescent scoliosis and the two conditions actually have a number of the same proposed causes. This has also led to juvenile idiopathic scoliosis sometime being referred to as “early onset adolescent idiopathic scoliosis”.

The most widely accepted theory about the development of juvenile and adolescent scoliosis is one involving genetic inheritance. These types of idiopathic scoliosis are often seen occurring in many members of a single family. Many scientists believe that a set of genes that cause scoliosis may be inherited. However, because the incidence of scoliosis does not occur in a traditional dominant pattern (i.e. not every child of parents who had scoliosis develops the condition, and vice versa), not everyone expresses these genes to the same extent. Research at several institutions has uncovered several different genes on that appear to be associated with scoliosis and genetic tests that can identify these genes are currently being trialed

How is juvenile scoliosis diagnosed?

Juvenile idiopathic scoliosis is usually first suspected by the parents of a child, who may notice a rib hump, or uneven shoulders or hips. Examination by a health professional can also discover a juvenile scoliosis. A common test used to screen for scoliosis is called the “Adams forward bending test”.

In this test the child or adolescent bends forward at the waist until the spine is parallel with the floor, while the examiner observes the shape of the spine as it bends. The main feature alerting the examiner to a scoliosis is the presence of a rib hump where the ribs on one side protrude more compared to the other side when bent forward. A special instrument that looks similar to a spirit level called a scoliometer can be used to measure the extent of the humping. In some cases the scoliosis is not in the upper part of the torso but in the lower back. Therefore screening should also consist of examination of the whole upright posture as well as the Adams test.

Mild scoliosis does not usually cause significant back pain in children. However some discomfort and stiffness is not uncommon. If a scoliosis is suspected a thorough neurologic exam and MRI should always be carried out to ensure that the scoliosis is not the result of a neurological condition and that the spinal cord is not being affected by another disease. Even with an MRI it is still normal for x-rays to be taken. Unlike MRI, x-ray give clear images of the bones and allow for more precise measurements of the curvature.

How is juvenile scoliosis treated?

In juvenile curves between 10 and 20 degrees there is some evidence to suggest that an intensive course of scoliosis specific physiotherapy may be able to make some correction or control the curve. However once the curve is greater than 20 degrees it is usually too large for physiotherapy alone to manage and physio in conjunction with bracing is recommended.

In curves greater than 20 degrees or in curves greater than 15 degrees where there is a family history of scoliosis, a dynamic brace may be recommended. A dynamic brace is able to help retrain and strengthen the spine, and in some juvenile cases can be used with curves as large as 45 degrees.

In juvenile curves greater than 45 degrees the prognosis is usually poor and the primary treatment goal becomes to control the curve slowing progression and delaying surgery until suitable maturity. An aggressive treatment approach where a hard brace is used in a similar fashion to serial casting in infantile cases is recommended. A rigid over-corrective brace offers an opportunity to work aggressively with large curves and potentially make some correction depending on the flexibility of the curve. If significant correction is made then there can be the opportunity to switch the child into a softer, dynamic brace to maintain the correction and manage the case through adolescents. In other cases maintenance of a hard bracing regime is required to try and stabilise the curve.

Occasionally with juvenile scoliosis, bracing may be discontinued for one or more years, with a return to observation, as described above. As the child begins an adolescent growth spurt, he/she will likely be re-braced to maintain the previously achieved correction of the curve. In other instances, curves worsen significantly after brace removal, which may mean a return to full-time bracing treatment or possibly surgery. For curves that continue progressing during bracing treatment, surgery is the most appropriate treatment option.

A small number of children have rigid curves at the time of diagnosis, which means that the spine is fixed in its abnormal position and cannot be temporarily straightened. In such cases, the most appropriate initial treatment is serial casting, which entails that a cast be applied and changed every 6 to 12 weeks, in an attempt to gradually correct the curvature. The cast is made of plaster and is applied in the operating room under general anaesthesia, which means that the child will be put to sleep through the application process so as to minimise discomfort. Casting treatment is followed up with bracing treatment which is needed to maintain the correction.

In juvenile cases, special rods called “growing rods” can be used in an attempt to maintain correction and allow growth. In this type of treatment a metal rod attached to the spine is periodically lengthened by a simple procedure. This correction without fusing the spine minimises the stunting of growth that can occur with spinal fusion. If the curve is large and the child is of reasonable maturity, a definitive spinal fusion may be recommended. This involves fixing rods to the spine to stop movement and may require a bone graft.