Scoliosis and Kyphosis in Children: Signs and Surgery Timing

Scoliosis and kyphosis in children are best corrected early. A hemivertebra, a half-formed vertebra present from birth, found in a four-year-old can be corrected in an operation of two to three hours. The same hemivertebra left until the mid-teens can demand an operation of 16 hours, with more than two litres of blood loss and the removal of one and a half vertebrae around the spinal cord.

Spinal deformity is the part of spine surgery where, for Dr. Puneet Girdhar, head of spine surgery at BLK-Max Super Speciality Hospital in New Delhi, timing decides almost everything. He estimates that 80 per cent of his deformity patients come late. This article covers how scoliosis and kyphosis are classified, the signs that any doctor can pick up at the bedside, the thresholds for observation, bracing and surgery, and the cases that show what late presentation costs.

Types of scoliosis and kyphosis in children

Scoliosis is a sideways curvature of the spine; kyphosis is a forward curvature that produces a hump on the back. The two often occur together. Dr. Girdhar groups scoliosis into three types, each with its own cause and pattern.

Idiopathic scoliosis appears close to or before puberty and has no identifiable cause. It affects girls far more often than boys, and the imbalance between the sexes widens as curves become larger.

Congenital scoliosis results from a birth defect of the vertebrae. Typically one vertebra forms only on one side, a half vertebra known as a hemivertebra. As the child grows, the asymmetric vertebra tilts the whole spine to one side, and the curve worsens with growth.

Neuromuscular scoliosis occurs in children with conditions such as cerebral palsy or spinal muscular atrophy. The back muscles lack proper innervation, the child cannot maintain sitting balance, and the spine collapses into a characteristic long C-shaped curve because the muscles on one side have failed.

Warning signs of scoliosis in a child

The warning signs of scoliosis are visible on the bare back: uneven shoulders, a rib hump, an uneven waist and a body that leans to one side. When a parent or a child raises a concern about the back, Dr. Girdhar asks doctors to examine the bare back with the child standing and looking straight ahead. The full list of signs:

• Uneven shoulders. The shoulders should be level. One higher than the other means something is wrong.
• A head not centred over the pelvis. If the head sits off to one side, the spine is leaning like the Tower of Pisa.
• A prominent hip on one side, or a limp.
• A rib hump. A rib cage more prominent on one side at the back indicates a thoracic curve.
• An uneven waist, with loss of trunk balance.
• Lean of the whole body to one side, a sign that the spine is shifting off the sacrum.
• Skin changes over the spine. Dimples, hairy patches and colour changes may point to spina bifida, a tethered cord, or a syndrome in which the spine is one of several affected systems.

Any of these signs warrants imaging and, where a curve is confirmed, an opinion from a spinal deformity surgeon.

When scoliosis needs observation, bracing or surgery

The decision rests on two variables, the size of the curve and how much growth remains: a curve under 25 degrees in a growing child is observed, and Dr. Girdhar considers surgery necessary once a curve reaches 40 to 45 degrees near skeletal maturity.

Small curves in growing children. A curve of less than 25 degrees in a child who is not yet skeletally mature is observed. Monitoring through growth shows whether the curve is stable or progressing.

Bracing. Dr. Girdhar describes the studies on bracing as controversial, and notes that parents and children are psychologically reassured by taking this further step. The evidence, however, now includes a randomised controlled trial. The Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST), published in 2013, found that bracing significantly reduced the progression of high-risk curves to the surgical threshold in adolescents with idiopathic scoliosis, and that the benefit rose with the number of hours the brace was worn.

Surgery. Once a curve reaches 40 to 45 degrees in a child close to skeletal maturity, Dr. Girdhar considers surgery necessary. In his words, nothing will save these curves from worsening.

Growth rods for early-onset scoliosis

Growth rods control a severe curve in a young child while letting the spine keep growing, with a final fusion deferred until 13 to 15 years of age. Some children present with severe deformity long before they have finished growing. Dr. Girdhar described a syndromic child of about six with a 70-degree scoliosis and a 70-degree kyphosis. Children with syndromes may be 10 or 12 years old but look four or five, which compounds the problem. A definitive fusion at six would stop the growth of the spine.

The solution is a growth rod. The rod controls the curve while allowing the spine to lengthen and the child's height to increase, correcting the deformity and guiding growth at the same time. This growth modulation continues until the child is 13 to 15 years old, when a final fusion is performed.

Hemivertebra surgery: why to refer at four or five

The hemivertebra is where Dr. Girdhar's message is most urgent. Whenever a hemivertebra is reported on an X-ray or seen on one, the child should be referred for correction as soon as he or she turns four or five. At that age the operation is small: the hemivertebra is removed, and a short correction and fusion is performed. The surgery takes two to three hours, and from the next day the spine grows normally.

Why children arrive late

He identifies three reasons. Families may not know where to go. Awareness is limited among the public, the community and doctors, so children are not referred at the right time. And there are superstitions and false beliefs, in particular that a small child's curve will correct itself with growth. For a congenital curve such as a hemivertebra, that belief has no scientific basis.

What late presentation looks like

One girl came to him at 16 with a neglected hemivertebra. By then she had a very advanced kyphotic hump, bad scoliosis and marked shoulder imbalance. The adjacent vertebrae had deformed in response, and the whole spine was out of alignment in every plane.

The operation took 16 hours. Dr. Girdhar performed an extended vertebral column resection (VCR), removing an entire vertebra and half of the next, inserted a cage, placed long-segment fixation from above to below the deformity, and decompressed three levels. Ultrasonic osteotomes made the bone cuts. Blood loss exceeded two litres and was managed by the intensive care team. On the first post-operative day, with her central and arterial lines still in place, she was stood up in the intensive care unit with good correction of her shoulder balance and the deformity, and with no weakness, numbness or nerve damage in her legs.

Had she been referred at four or five, the same disease would have needed a two-to-three-hour operation.

Vertebral column resection for kyphosis after spinal tuberculosis

Tuberculosis of the spine in early childhood can leave a deformity that keeps growing long after the infection is cured. Dr. Girdhar described a girl from West Africa who had spinal tuberculosis as a small child. The infection destroyed a vertebra in the thoracic spine, and she healed on anti-tubercular treatment. But with a vertebra missing, the spine continued to grow in the wrong direction. By the time she reached him, the spine had bent through 90 degrees, a curve that showed as a hump on the back.

The hump was not only cosmetic. The spinal cord was being stretched over the internal angle of the deformity, the gibbus. She developed weakness in both legs (paraparesis), along with urinary frequency, urgency and difficulty with bladder control, and she had become dependent on a wheelchair.

The operation

The treatment was a vertebral column resection (VCR): decompression of the spinal cord, removal of the gibbus and of the entire vertebra pressing on the cord from the front, insertion of a mesh cage, and correction of the deformity, followed by physiotherapy. Dr. Girdhar counts this among the most difficult operations in spinal surgery. It typically takes 8 to 10 hours and sometimes 12.

She improved markedly in the first three months. At one year she walked independently without any walking aid and had good urinary control.

Where VCR should be done

Dr. Girdhar is emphatic that vertebral column resection belongs at an advanced centre. A unit that performs two or three spinal operations a month, or four or five decompressions, should not undertake it. It needs a dedicated centre with high volume, the technology for complex procedures, and a team and ecosystem to support the patient through the operation and afterwards.

Revision scoliosis surgery and complex corrections

Revision deformity surgery works through a scarred field, and here the neuromonitoring signals are the central concern. Planning screw placement in a previously operated spine is where robotics offers its clearest advantage, as the article on robotic and navigated spine surgery explains.

A failed earlier operation

One child had previously undergone a lumbar fixation elsewhere, for reasons Dr. Girdhar could not determine. The curve lay above the fixation and continued to worsen, reaching 100 degrees by the time of his correction. The revision through the scarred field took 10 hours. He reduced the curve from 100 degrees to around 20 to 25, with balanced shoulders and an appearance close to normal.

Corrections of this kind require complex asymmetric pedicle subtraction osteotomies, which can add three to four hours to an operation. Throughout, the neuromonitoring signals are the central concern, particularly in revision surgery. Dr. Girdhar's principle is that an operation to correct the shape of the back is worth doing only if the patient's neurological function is preserved.

The cervicothoracic junction

Deformity close to the neck, at the junction of the cervical and thoracic spine, combined scoliosis and kyphosis in another patient. He performed a vertebral column resection at this level in eight hours. The correction looks small on an X-ray, but it required ultrasonic osteotomes, removal of the entire vertebral body and lamina, decompression and stabilisation, all while maintaining neurological integrity.

Simpler curves

Not every case is at this extreme. Thoracolumbar scoliosis can be corrected fully, and children look normal within a few months. An acute kyphotic hump can be completely corrected.

The surgeon's first duty

Across every deformity case, Dr. Girdhar returns to one principle: whatever the operation, the spinal cord and nerves must be protected. That is the duty of a spine surgeon. Modern technology, accumulated experience, surgical skill and a supporting ecosystem are what allow the most complex corrections to end with a patient standing the next day, neurologically intact. For the referring doctor, the most effective intervention is simpler: recognise the signs early, and refer a child with a hemivertebra or a progressing curve before the window for a small operation closes. The tools that make these corrections safe, including neuromonitoring and ultrasonic bone cutting, are described in the complete guide to advances in spinal surgery.