Spinal Deformities

The spine, or backbone, is made up of small bones (vertebrae) stacked — along with discs — one on top of another. When viewed from the side, a healthy spine has gentle curves to it, which help the spine absorb stress from body movement.

When viewed from behind, the spine should run straight down the middle of the back.

However, certain spine conditions that affect children during their early or late childhood years — and sometimes even before birth — curve the spine more than normal or deform it. The spine also may be rotated or twisted, pulling the ribs along with it to form a multidimensional curve that may impair breathing.

The orthopaedic spinal team at Children's Hospital of Philadelphia (CHOP) offers comprehensive evaluation and treatment for children with all forms of scoliosis and kyphosis. Our surgical team performs 3,000+ orthopaedic surgeries a year, including more than 250 surgeries specifically on children with spinal deformities related to scoliosis. These include:

• Congenital scoliosis
• Early-onset scoliosis
• Idiopathic scoliosis
• Kyphosis, including Scheuermann disease and postural kyphosis
• Neuromuscular scoliosis

There are a number of health problems that may cause the spine to curve more than normal or to be misaligned.

Congenital (acquired before birth) deformities of the spine occur when bones or vertebrae do not develop properly during pregnancy.

Some spinal deformities are due to injury or repeated trauma such as sports injuries, and some are caused by disease like malignant spinal tumors or benign spinal tumors.

Other spinal deformities, like idiopathic scoliosis, have no known cause and are not associated with an underlying disease.

Clinicians at Children's Hospital of Philadelphia are actively researching a range of spinal deformities. Orthopaedic doctors regularly collaborate with The Center for Applied Genomics at CHOP, one of the world's largest genetics research programs and the only center at a pediatric hospital to have large-scale access to state-of-the-art throughput genotyping technology.

Recent research at CHOP to identify a gene mutation as a potential cause of idiopathic scoliosis won a Hibbs Award from the Scoliosis Research Society, an international organization dedicated to the education, research and treatment of spinal deformities.

With research, orthopaedic leaders at CHOP hope to be able to predict spine conditions and treat them before many of the symptoms begin.

Depending on the age of the child and the severity of the condition, spinal deformities can cause a variety of symptoms, including:

• Uneven shoulder heights
• Head is not centered with the rest of the body
• Uneven waistline
• Tilted pelvis
• Breathing difficulties
• Walking difficulties
• Hunched back (kyphosis)
• Back pain

Because many of the symptoms of specific spine conditions overlap, accurate diagnosis and careful monitoring are essential to planning the most successful course of treatment for your child.

The Division of Orthopaedics at Children's Hospital of Philadelphia (CHOP) provides complete care — diagnosis, surgical or nonsurgical treatment, and follow-up care — for children with a wide range of spinal deformities.

We offer a full spectrum of diagnostic testing, work closely with a dedicated, multidisciplinary team, and have access to the expertise and full resources of CHOP in every pediatric subspecialty. CHOP is ranked No. 1 in the nation for orthopaedic care, according to U.S. News & World Report.

Your child will be diagnosed for a spine curvature disorder by a pediatric orthopaedist who will conduct a thorough medical examination and family history, observing the curve of your child's spine during the physical exam.

The physician will also use imaging tests to look more closely at the spine to see if there are any problems with the bones of the spine and to measure what degree of curve is present.

Early detection of spinal deformities is important for successful diagnosis, treatment and outcomes. Diagnostic tests may include:

• X-rays, the primary diagnostic tool for scoliosis to show abnormal spinal bones and the precise angles of curvature.
• EOS imaging, an imaging technology that creates 3-dimensional models from two planar images. Unlike a CT scan, EOS images are taken while the child is in an upright or standing position, enabling improved diagnosis due to weight-bearing positioning.
• Magnetic resonance imaging (MRI), which uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body. An MRI does not expose your child to radiation.  
• Computed tomography (CT) scan, which uses a combination of X-rays and computer technology to produce cross-sectional images (“slices”) of the body.
• Bone scan or DEXA scan, which determines the health and strength of bones. CHOP's analysis of these scans is unique in that our clinicians compare your child's scan to normative data we have compiled from other children, not the standard adult values.
• Positron emission tomography (PET) scan, in which a small amount of radioactive sugar is injected into a vein and a scanner makes detailed, computerized pictures of areas in the body where disease may occur. PET scans are particularly useful tools when doctors suspect your child has a benign tumor or malignant tumor.
• Ultrasound, which uses ultrasonic waves to image internal body structures and muscles. An ultrasound does not expose your child to radiation. 
• Pulmonary function tests, which measure how well the lungs take in and release air and how well they move gases, such as oxygen, from the atmosphere into the body’s circulation.
• Blood tests.

Every spine condition is different, so treatment is determined on a case-by-case basis. In planning your child's individual treatment, our team of specialists will consider the severity of the curve, where it occurs in the spine, and your child's age and stage of growth.

Nonsurgical interventions

If your child's condition is not severe, the clinical team may suggest monitoring your child with regular observation, X-rays and lab tests. 

Back braces, halo vests and other bracing devices are often the first line of defense against a child's worsening spinal curves. By immobilizing the child's spine, the hope is that the spinal curve will not get progressively worse and that any associated pain will be controlled. If bracing is successful, it may delay — or in some cases avoid — the need for spine surgery in some children.

At CHOP, our orthopaedic physicians work closely with the National Orthotics and Prosthetics Company (NOPCO) to fit patients with custom-designed halo vests and other braces. Because NOPCO has a local office at CHOP, these braces can be measured, created and fitted in a short period of time. In the past six years, more than 100 patients at CHOP have received halos as part of their treatment.

Bracing is the most common treatment for all forms of scoliosis and spinal deformities at CHOP. Doctors may prescribe a brace for your child as treatment or as a medical aid leading up to or immediately after spine surgery. It is important that your child uses the brace as directed, which includes details about how many hours per day the child should wear it and what activities your child is permitted to do without the brace.

If your child's spine condition is interfering with neurologic (nerve) function, causing persistent pain or breathing difficulties, or is due to an infection or a tumor, corrective spine surgery is usually required.

Surgical interventions

Our pediatric orthopaedic surgeons are pioneers in the use of innovative surgery that accommodates your child’s growing and maturing body. Two of the most common surgical treatments for scoliosis are growing rods (for children who are still growing) and spinal fusion (for children who have reached skeletal maturity).

Spinal fusion

After your child has stopped growing, spinal fusion surgery may be recommended to permanently stabilize the spine.

During the spinal fusion operation, the bones in the back are joined together with bone taken from the hip bone or pelvis. Metal rods are placed alongside of the spine to hold the bones in a straight position while the bone graft heals. The extra bone from the hip or pelvis helps knit the bones together.

Each patient is evaluated individually and treatment suggested based on your child’s long-term health needs.

Growing rods

For young children with scoliosis, spinal surgery to implant growing rods offers a dual benefit: correcting the spinal curve and allowing continued growth of the spine.

Growing rod surgery is done through the back of the spine. In most cases, the curve in the child's back is spanned by one or two rods under the skin to avoid damaging the growth tissue of the spine. The rods are attached to the spine at two spots — above and below the curve.

Every six months, the child returns to the Hospital to have the rods expanded or "lengthened" to keep up with the child's growth and continue straightening the spine. In some cases, the growing rods may need to be replaced if the child's growth continues beyond the maximum expansion level of the initial rods.

VEPTR

If your child is still growing and the spinal curve is affecting your child’s rib and lung development, he or she may also be diagnosed with thoracic insufficiency syndrome. That means the lungs are not getting enough air and “growth sparing” techniques are appropriate.

An innovative surgical device called vertical expanding prosthetic titanium ribs (VEPTR) was invented and pioneered by one of CHOP’s leading pediatric orthopaedic surgeons. The VEPTR stabilizes the curved spine, allowing the child’s ribs, spine and lungs to expand and grow.

Like growing rods, the VEPTR is surgically adjusted as the child ages and reaches full maturity. To learn more, see the Wyss/Campbell Center for Thoracic Insufficiency Syndrome.

Safety and collaboration

If your child has other health issues — such as heart, lung or kidney problems — our orthopaedic team will work closely with cardiac, pulmonary, nephrology and other specialists to determine the order in which medical issues should be addressed.

We treat your child as a whole person — not just his or her condition. By working in multidisciplinary groups of medical and clinical experts, we can produce the best possible outcomes for your child.

Safety is a top priority at all times at Children’s Hospital of Philadelphia. Read about the measures our experts are taking to optimize safety in surgery.

If back bracing is required, your child will be re-evaluated every six months until your child's condition is stable. If bracing is recommended as a treatment leading up to spinal surgery, your child will be evaluated regularly before and after surgery until your child's condition is stable. After the spine is stabilized, annual visits to an orthopaedic healthcare provider are recommended.

If your child received growing rods or VEPTR surgery, an additional procedure — spinal fusion — may be necessary when your child has finished growing.

Regular checkups to monitor your child's back are recommended as your child grows to ensure that the spinal condition does not worsen.

Psychosocial issues

Spinal deformities can be emotionally difficult and threaten a child's self-image, causing anxiety and depression. At CHOP, we help children not only appear and function normally, but also provide emotional support during treatment.

Our team will help set realistic goals with you and your child and revise them as needed. We offer a wealth of support services for you and your child at the Hospital and throughout the CHOP Care Network. We can also help you find resources closer to your home.

We recognize your child's pediatrician or referring physician as an important part of the care team and provide regular updates to him or her about your child's progress.

Patients who've received treatment for spinal deformities can achieve positive outcomes and live happy, productive lives.

Our pediatric clinical professionals will follow your child until young adulthood, between 18 and 21, and help to transition to adult orthopaedic care, if needed.