Back curves

Definition

Back curves in adults, also called adult scoliosis, curvature of the spine, adult idiopathic curves, and kyphosis, are spinal deformities. Scoliosis is a deformity in which the spine bends to one side or the other, usually in the middle to lower back. Kyphosis is a back curve that can be seen as rounding of the back, hunchback, “Dowager's hump” or some degree of slouching posture (postural kyphosis).

Description

Normal adult standing posture involves a straight back with the head centered over the hips and pelvic

area, a position described as being aligned. Any noticeable curving of the spine to the left or right, inward or outward at any point on the back is abnormal.

The spine is made up of stacked circular discs (vertebrae) divided into the sacrum that forms the pelvis, thoracic spine or lower back, lumbar spine or middle back, and cervical spine of the upper back and neck region. In a straight spine, vertebrae sit almost parallel to the floor. When vertebrae curve out, it is called kyphosis, and tilting inward of vertebrae is called lordosis. Some natural curving of the back is part of normal development, including rounding or kyphosis of the thoracic spinal region in infants prior to walking and curves in the lumbar and cervical regions that develop with upright posture between ages 5 and 15, including some normal and slight lordosis of the lumbar vertebrae. After age 20, a sideways curving of the spine (scoliosis) may develop in some individuals, which may not be noticed or diagnosed until it becomes more pronounced in the older adult. This developmental form of curvature or crooked back is called idiopathic scoliosis, indicating that no specific cause has been identified. A degenerative form of scoliosis involves progressive deformity in the spine that may eventually cause pain as well as difficulty walking and maintaining balance.

Adult kyphosis or outward rounding of the back can be as simple as poor posture or as pronounced as a hunched back or humpback. Although both men and women can have kyphosis, progressive development of the backward curves of kyphosis is found to occur more quickly in women between the end of active growth in young adulthood and into advanced age. Rapid development is associated with the greater frequency of osteoporosis in women, and the associated altering of the spine's structure by breakage of vertebrae (compression fractures), a common result of osteoporosis. Compression fractures occur when vertebrae are squeezed together, creating a wedge-like deformity that, in turn, alters the shape of the spine and usually reduces height of the individual.

Demographics

Adult idiopathic back curves or adult scoliosis occurs in 3 to 30% of male and female adults and is the most common form of scoliosis, with prevalence increasing with age. Ninety percent of scoliosis is idiopathic with no known cause. Degenerative scoliosis is less common, occurring in less than 10% of older adults of which 60% are female. Postural kyphosis is the most common type of kyphosis. Kyphosis occurs in both males and females, but progression is more rapid in women, making it more prevalent among older females.

Causes and symptoms

Scoliosis

Curvature of the spine diagnosed in early growth years or adolescence usually stems from unknown or idiopathic cause, although it could have been present at birth (congenital or infantile scoliosis) and not have been noticed. When this developmental curvature first becomes noticeable in older adults it is described as idiopathic scoliosis. Scoliosis that develops in the older adult and was not present in early development is referred to as adult-onset scoliosis and is most often the degenerative form with progressive symptoms. Scoliosis can develop in adults from congenital conditions such as malformed vertebrae; disease-related causes such as degenerative disc disease; connective tissue disease such as arthritis; or from tumors, spondylosis, and neuromuscular disease such as muscular dystrophy.

The symptoms of scoliosis depend on the severity of the curve and where it occurs on the back. No symptoms usually develop with a slight curvature. A severe curve to one side or the other may produce pain, a raised shoulder or hip, differences in left and right breast sizes, and psychological responses such as loss of self esteem or depression . Lower lumbar region scoliosis may result in lower back pain. Curving greater than 60 degrees from normal upright posture can induce shortness of breath, and weakness or numbness of limbs from pressure on nerves. Individuals may lack energy and physical activity may be reduced because of the energy required to maintain standing posture.

Kyphosis

The rounded back of kyphosis in older adults is usually the result of degenerative disease such as arthritis or osteoporosis, or it can originate with an injury or trauma such as an accident that occurred earlier in life and caused disks to degenerate. Other causes of kyphosis can be infectious diseases such as tuberculosis , the presence of tumors pressing on the spine, or the result of diseases such as polio or muscular dystrophy. Kyphosis may also develop in conjunction with the sideways curves of scoliosis present in an individual since adolescence.

The main characteristic of kyphosis is the rounded back, which is disfiguring but in itself not painful. Mild back pain may be experienced as a result of muscle fatigue, and general fatigue may be present because of energy spent maintaining posture. The spine may become stiff and tender, especially when the individual leans forward. Low back pain may occur if inward-curving lordosis is present in the lumbar region, developed as compensation for a back curve above it. Individuals with more severe back curves may have difficulty breathing.

Limitations common to scoliosis and kyphosis

The back curves of scoliosis and kyphosis may both be associated with loss of mobility in the spine and associated limitations in physical activity. Deformities may involve restricted forward and side-to-side vision, which can affect walking and driving, among other activities. Reaching upward may not be possible. Even sitting, standing or walking for any period of time may not be possible. Balance may be disturbed, especially with pronounced kyphosis. If the individual experiences serious loss of independence and self-image associated with the degree of deformity,

anxiety , depression or psychosocial withdrawal may result.

QUESTIONS TO ASK YOUR DOCTOR

1. What caused my back problem?
2. What type of treatment is best for my back curve?
3. What does “progressive” mean regarding pain and other symptoms?
4. How many patients have you treated for back curves?
5. How many of your patients have had surgery?

Diagnosis

Physical examination is usually all that is needed to diagnose back curves of scoliosis or kyphosis. The examining physician looks for asymmetry of the back, differences from one side to another, rotations or twisting of the ribs, extent of the curvature by degrees variance from a straight line, and more subtle differences such as differences in size of breasts on each side, differences in height of shoulders and hips, and length of legs. Minor curving is more difficult to detect by appearance alone; however, spinal curvature can often be seen if the patient is examined while leaning forward. The physician may palpate the spine along the vertebrae to determine alignment. Kyphosis is detected with the presence of a forward tilt of the head and neck and/or a sway back or increased lordosis in the middle back. The individual is examined standing and lying down, since the back curves of kyphosis typically do not fully reverse when lying down. Walking is observed to detect any abnormality in gait. Tenderness may be present with kyphosis but not with scoliosis. The pectoral muscles of the arms and ham string in each leg are examined for tightness, which is often present with kyphotic back curves. Strength is evaluated and reflexes are checked to determine if there is any nervous system involvement (neurological deficits). X rays may be ordered to evaluate degree of curvature and maturity of the skeletal structure; x rays may also reveal signs of abnormalities in the spine that have been present since birth (congenital). Pulmonary tests are done to determine if breathing is affected.

A medical history helps the physician understand the individual's present state of health as well as health history , especially childhood illnesses and injuries and whether or not any back curves were noted in childhood or young adulthood. Scoliosis is known to run in families so it is also important to know if any relatives have been diagnosed with curvature of the spine or idiopathic scoliosis.

Treatment

Treatment of back curves is always related to the cause and progressiveness of the deformity. Back curves of scoliosis that are less than 20 degrees and kyphotic back curves less than 40 degrees are likely to be treated for pain alone, sometimes using anti-inflammatory drugs. Individuals with postural kyphosis or slouching are advised to exercise to gain abdominal strength and to stretch hamstrings. Pain management may also include transcutaneous electrical nerve stimulation (TENS). Braces or back supports (body jacket) may be used for more severe curves or to slow progression of the curvature in both scoliosis and kyphosis. Exercise is recommended to help maintain strength, mobility, flexibility of the spine, and muscle functioning. Surgery or other invasive procedures are not usually performed for scoliosis or kyphosis. When surgery is performed, it is usually to correct balance, stabilize the spine or reduce the degree of deformity if the curve is greater than 50 degrees. The patient's age and general health along with careful evaluation of risk versus benefits determine mobility or comfort that can be achieved.

Therapy

Physical and occupational therapy are often helpful for individuals with back curves, not only to help train the individual in performing the physical activities of daily life, but also to help maintain the highest comfort level possible. Restorative yoga involves gentle or more vigorous stretching and back extension and is less physically demanding than other forms of exercise. Done regularly, yoga can improve tolerance of activity and help maintain mobility.

Prognosis

The prognosis for individuals with scoliosis or kyphosis is very good, even with progressive forms, if no complications develop. Postural kyphosis is not associated with other health problems or complications. In other forms of back curves, complications may develop as degenerative changes occur in the spine. Cardiac and urinary tract conditions may develop in individuals with congenital scoliosis. Congestive heart failure sometimes develops in older individuals with advanced idiopathic scoliosis. The largest curves may entrap nerves and compromise nervous system function. Lung function may also be compromised. The greatest risk of complications is associated with surgery, including injury to blood vessels or nerves, or degenerative changes near the surgical site.

KEY TERMS

Compression fracture —Breakage of spinal vertebrae through illness or injury, usually resulting in loss of height.

Congenital —Any specific abnormality or illness that is present at birth.

Gait —The unique rhythm, stride and pace of walking characteristic of an individual.

Idiopathic —A condition or disease that has occurred without a known cause.

Kyphos —A bump that forms on the back.

Kyphosis —Presence of a concave rounded bump on the back or curvature of the back, also called hump back or hunchback. Some kyphosis of the thoracic spine and sacral area is normal. Abnormal backward curves of kyphosis can be posture-related only or exaggeration of the thoracic curve.

Lordosis —Normal convex curve of the spine or an abnormal convex curve, usually of the lumbar spine.

Scoliosis —An abnormal side-to-side or lateral curvature of the spine.

Vertebrae —The bones, also called discs, that make up the spine or backbone.

Caregiver concerns

Loss of mobility and balance as a result of back curves, and changes in vision with postural changes may result in falls . Care givers must be alert to restricted movement and limitations of the patient, be available to assist as needed, and maintain a living area free of obstruction. Helpful aids such as foot stools, reaching devices, cushions for comfort, and other aids recommended by the physician may make daily life easier and more comfortable for the patient. Pain may be constant for some patients and pain medications should be managed or administered by the care giver to avoid overdosing or dependence. Anxiety or depression should be reported to the physician.

Resources

Canale, S. Terry. “Adult Idiopathic Scoliosis.” Campbell's Operative Orthopaedics. 10th ed. Philadelphia: Mosby, 2003.

Silver, Julie K., and Walter R. Frontera. “Scoliosis and Kyphosis.” Essentials of Physical Medicine and Rehabilitation. 1st ed. Henley and Belfus Inc., 2002.

OTHER

“Kyphosis (Roundback) of the Spine.” Your Orthopedic Connection. American Association of Orthopaedic Surgeons. September 2007 [cited April 3, 2008]. http://orthoinfo.aaos.org/topic.cfm?topic=A00423.

ORGANIZATIONS

American Academy of Orthopedic Surgeons, 6300 N. River Road, Rosemont, IL, 60018, (847) 823-7186, orthoinfo@aaos.org, www.aaos.org.

National Scoliosis Foundation, 5 Cabot Place, Stoughton, MA, 02072, (617) 341-6333, (800) NSF-MYBACK, (617) 341-8333, NSF@scoliosis.org, www.scoliosis.org.

L. Lee Culvert