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Let's Get The Terms Straight

On January 5, 1990, at our request Ann Landers reprinted a 1983 letter from NSF's Vice President, Kenneth Love. As a result of that letter appearing in her syndicated column, we've received numerous letters and phone calls concerning a variety of subjects, including infantile, juvenile and adolescent idiopathic scoliosis, not to mention kyphosis and kypho-scoliosis. In order to clarify these and other terms, we interviewed Dr. John B. Emans, of Children's Hospital Medical Center in Boston, Massachusetts. We thank him for helping us "get the terms straight."

Q: Dr. Emans, let's begin our discussion by talking about the difference between scoliosis and idiopathic scoliosis.
A: The term "scoliosis" is used to describe a spinal deformity that is characterized by a lateral (side to side) curvature and vertebral rotation. As described, scoliosis can be caused by a birth defect, a severe accident, or neuromuscular disease such as muscular dystrophy and polio, but in 80 percent of all cases, it is "idiopathic", it occurs for no apparent reason.

Q: Since we're now talking about the idiopathic (cause unknown) variety, will you explain the difference between infantile, juvenile, and adolescent idiopathic scoliosis?
A: Infantile idiopathic scoliosis is extremely rare. It occurs from birth to three years of age and is found mostly in males and usually results in a left thoracic (upper spine) curve. Many infantile idiopathic curves correct themselves spontaneously without treatment but should be monitored. Juvenile idiopathic scoliosis usually occurs from about age 4 to the onset of puberty-roughly age 10 or 11 for girls, age 12 for boys. Most of these curves, which can occur both in males and females, are right thoracic curves. Adolescent idiopathic scoliosis usually occurs during early puberty, with the most rapid worsening occurring during the early adolescent growth spurt. For unknown reasons, this variety strikes females more than males-at a ratio of roughly 5 to l. The most common curve pattern among adolescents is right thoracic.

Q: Most of our readers are generally familiar with the kinds of treatment available for adolescent idiopathic scoliosis-i.e., rigid bracing until bone maturity, or spinal fusion surgery, depending on the severity of the curve. Is treatment different for those who have infantile or juvenile scoliosis?
A: On the rare occasions when we do see a child with infantile idiopathic scoliosis that requires treatment, we might consider rigid bracing or fusion without instrumentation. Of course, our, choice would depend on the severity of the child's curve. For juveniles whose cases warrant it, we would select from any number of surgical techniques available today. For juveniles, the threshold for bracing is lower than that for adolescents. We are more likely to brace a 7-year-old with a 20-degree curve because of the high likelihood of worsening of the curve with remaining growth. For the sake of comparison, we would not brace the 20-degree curve of the 14-year-old or 15-year-old who has little growth left.

Q: What is kyphosis?
A: Before answering that question, let's talk about the normal spine for a moment. When you look at a person with a normal spine, viewing him or her from the side, you see that the back is anything but straight. In the cervical (neck) area, the spine curves slightly forward (a lordosis), then slopes gently backward (a kyphosis) through the chest area, then forward again in the lumbar (lower back) area toward the sacrum (tailbone). In other words, everyone has some kyphosis of the spine (and some lordosis). Normal thoracic kyphosis will be centered in the chest area and range in size from 20 to 45 degrees. An abnormal kyphosis may exceed 45 degrees or may be centered at the thoraco-lumbar (mid- spine) area. Often there is wedging of the vertebra on x-ray in an abnormal kyphosis. "Scheuermann's kyphosis" is a generally progressive abnormal kyphosis, which occurs most frequently in adolescent males.

Q: How is abnormal kyphosis treated?
A: Most abnormal thoracic kyphosis in growing individuals of less than 70 to 75 degrees can be successfully treated with rigid bracing. Often a Milwaukee type brace is needed. Unlike bracing in idiopathic scoliosis, the brace treatment of Scheuermann's kyphosis can often result in actual correction.

Q: What is kypho-scoliosis?
A: Most idiopathic scoliosis in the thoracic spine is "lordo-scoliosis" or "hypo-kypho-scoliosis" (less than the normal kyphosis). There is usually a flattening of the normal thoracic kyphosis associated with idiopathic thoracic scoliosis. The old outmoded term for scoliosis in general was "kypho-scoliosis." This term was employed before physicians realized the three dimensional nature of most scoliotic deformities. There is also true kypho-scoliosis in which the spine is de- formed both in the direction of scoliosis and kyphosis. It is treated in the same way as idiopathic scoliosis.

Q: What are congenital scoliosis and kyphosis?
A: Congenital scoliosis and kyphosis are caused by birth defects in the spine itself. Abnormally formed vertebra produce the spinal deformity. Both congenital kyphosis and scoliosis can worsen drastically during the first few years of growth and often need extremely early surgical treatment. Bracing is rarely used for either type of congenital curve. Some individuals with congenital curves experience no worsening of the curve with growth and need no treatment.


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