Scoliosis Treatment in Turkey

Spinal curvature, known as “scoliosis,” is a condition most often diagnosed during adolescence. Scoliosis, which develops as the vertebrae curve to the right or left for various reasons—or twist around their own axis—can begin at an early age and seriously affect a person’s life if left untreated.

What is scoliosis?

Scoliosis is the oldest known spinal deformity, with an incidence ranging from 0.2% to 6%. It can develop due to various causes such as trauma and congenital growth disorders, and in 80% of scoliosis cases the cause is unknown. Typically, at the beginning of the growth period, parents notice findings such as shoulder asymmetry in the child, a bulge in part of the back, and hips that are not level.

Scoliosis is a sideways tilt of the spine of 10 degrees. In a normal, healthy spine, when viewed from behind, the vertebrae run straight from top to bottom in the neck, thoracic (back), and lumbar (waist) regions. In scoliosis, the vertebrae shift to the right or left and also rotate around their axis. For this reason, it is defined as a three-dimensional deformity.

Because of scoliosis, shifts occur in the hips, rib cage, and shoulder blades, in addition to posture and cosmetic disturbances. In adolescents, this abnormal loading on the developing spine leads to vertebral deformities.

The prevalence of scoliosis ranges from 0.2% to 6%. It is more frequent and more progressive in girls. It is observed in 1.5% of schoolchildren, and it is estimated that at least 150,000 children in Turkey have scoliosis.

This disorder, which is common in preschool boys, is 3–5 times more common in adolescent girls, depending on growth rate. Scoliosis, which usually does not cause prominent complaints early on, is often detected by school screenings or incidentally on X-rays taken for other reasons. Poor body appearance is one of the main reasons families consult a doctor. The first striking signs are asymmetry of the shoulders, shoulder blades, breast level, and waist folds. This may be accompanied by low back and back pain. With increasing curve magnitude, breathing difficulty may also occur.

What are the symptoms of scoliosis?

Scoliosis may show no symptoms in the early period. Even when symptoms appear, action is often not taken because complaints are minimal. For this reason, it is detected either in school screenings or incidentally on X-rays taken for any reason. The first finding that typically brings a family to the doctor is cosmetic asymmetry. The earliest observation in idiopathic scoliosis is that one shoulder is higher than the other. Asymmetry of the shoulders, breast level, waist or trunk folds are the first notable visual disturbances. Forty percent of cases have back and low-back pain. Curves over 50 degrees can cause breathing problems.

Scoliosis degrees

The natural course of scoliosis does not always remain the same. The spinal curve may progress, remain stable, or rarely improve. On two or more consecutive examinations, progression is defined as an increase of ≥5 degrees for curves over 20 degrees, and an increase of 10 degrees for curves under 20 degrees. Double curves, thoracic curves, female sex, larger curve magnitude at diagnosis, and curves diagnosed under age ten tend to progress. For curves under 30 degrees, the progression rate is very low. Scoliosis degrees are listed as follows:

Chronological classification

• Infancy: 0–2 years
• Juvenile: 3–9 years
• Adolescence: 10–17 years
• Adulthood: 18 years and older

By location

Anatomically, scoliosis can be classified as cervical, cervicothoracic, thoracic, thoracolumbar, and lumbar.

Angular classification

Imaging methods are used to quantify angular scoliosis. After imaging, spinal curvature is diagnosed by angle; this is especially useful in deciding on the need for surgery.

• Angles under 10°: termed “spinal asymmetry” and have no health impact. A curve must exceed 10° to be considered scoliosis requiring management. Low-grade curves do not pose a future scoliosis risk. The key is to determine whether the curve is progressing.
• Angles 20–40°: more common in adolescence. Considered moderate scoliosis; exercises, physiotherapy, and bracing are often very effective.
• Angles ≥40°: curves of 40° have largely completed growth and progression. Thoracic curves over 45–50° generally indicate surgery; for lumbar curves, 40° may be a threshold.

Causes of scoliosis

In 80% of patients, the cause of curvature cannot be identified. Structural causes include congenital vertebral anomalies; neuromuscular diseases (cerebral palsy, syringomyelia, poliomyelitis, myopathies); spinal tumors; trauma; spinal infections; and metabolic diseases. Postural disorders and leg length discrepancy are also causes. In brief:

• Congenital scoliosis due to vertebral malformations
• Infantile/juvenile scoliosis starting in early childhood
• Neuromuscular scoliosis from conditions like muscular dystrophy
• Connective tissue disorders (e.g., Marfan, Ehlers–Danlos)
• Scoliosis due to polio, inflammatory diseases, trauma
• Scoliosis from leg length inequality or hip/knee joint problems

How is scoliosis diagnosed?

Scoliosis can be diagnosed by examining the child. Asymmetry of the midline can be seen when viewing the bare back. When the child bends forward, lateral curvature and rib prominence on the opposite side become evident—this is called a rib hump. This may be harder to notice in some “balanced scoliosis” cases.

X-rays are obtained first to confirm spinal curvature, determine its magnitude and location, and see if there are associated bony anomalies. Scoliosis should be monitored with X-rays every six months. Other imaging (bone scan, CT, MRI) may be used for patients with neurologic findings or those planned for surgery.

Diagnosis is easily confirmed with plain radiography when scoliosis is suspected. MRI is rarely required. Because radiologic tests are used frequently in diagnosis and follow-up, the ovaries and breasts should be shielded with lead when imaging children.

Scoliosis curves are defined as primary and secondary. The apex (peak) is where the curve is most angled—i.e., the vertebra most rotated and farthest from the midline. Scoliosis is also named by the spinal level of the apex: cervical (neck), lumbar (low back), thoracic (mid-back). Sometimes multiple regions are involved; for example, when both thoracic and lumbar regions are affected, it is termed thoracolumbar scoliosis. It is most common in the thoracic region.

The shape and degree are determined on radiographs. The most commonly used measure is the Cobb angle. Treatment is guided by Cobb angle and growth stage. The Cobb angle is measured using lines along the upper endplate of the top vertebra of the curve and the lower endplate of the bottom vertebra; perpendiculars to these lines define the angle between the axes of those vertebrae.

Treatment of scoliosis

Scoliosis rarely regresses spontaneously. Early in growth, it is not possible to predict the course. Some recent studies show that children with certain genetic traits may progress. Important monitoring criteria guide treatment decisions. In some situations, progression is frequent and treatment success rates are lower, such as:

• High curve magnitude at first diagnosis
• Double curves (thoracic and lumbar)
• Neuromuscular scoliosis
• Severe muscle contracture and tightness

Treatment in Turkey is determined by the risk of curve progression. Accepted methods:

• Observation and regular follow-up
• Bracing (orthoses)
• Scoliosis-specific exercises and rehabilitation
• Surgery

If the Cobb angle is under 15° in children who have not yet started their growth spurt, specialized follow-up is usually recommended. For Cobb angles of 15–20°, scoliosis exercises and tailored rehabilitation should continue. Intensive rehabilitation programs are recommended for children with Cobb angles over 25°.

When early signs of puberty appear (hair growth, voice change, rapid height increase, breast development or onset of menstruation in girls), extra caution is needed and treatment is essential. Because curve velocity and risks are higher, progression risk—not just Cobb angle—should guide the plan. Children at high risk of progression should definitely use braces in addition to physiotherapy and rehabilitation. Bracing should continue 16–23 hours per day depending on growth status and curve magnitude until growth completion.

Surgical treatment may be applied if the Cobb angle exceeds 50° in individuals at high risk of progression where bracing fails. In scoliosis surgery, the spine is straightened centrally using rods and screws; these implants sometimes remain permanently. It should also be known that surgery can lead to late complications.

Role and effectiveness of bracing

Bracing is the most debated topic in scoliosis. Experts with different concepts hold varying opinions on its efficacy. A key reason is that properly designed, monitored, and curve-type-specific bracing is not uniformly known or applied in every country. Another reason is the resistance of growing children to wearing braces.

Technology has advanced greatly: braces can now be designed and fabricated with computer assistance, minimizing errors seen with classical techniques and achieving very successful results.

Braces used in scoliosis are called TLSO (Thoraco-Lumbo-Sacral Orthosis). They come in various types and models. Choosing and applying the correct brace model requires distinct expertise. The specialist must select the model, ensure timely additional corrections, and adjust pads during frequent follow-ups. Crucially, the team must also include experienced technicians who fabricate the brace correctly. In other words, scoliosis treatment requires teamwork: physician, technician, physiotherapist, family, and child must work together, monitoring every phase.

Scoliosis exercises

Scoliosis may be halted with exercise programs. These are highly effective especially for children ≥7 years with curves >15°. Good results are also seen in patients with curves >40°.

In addition to techniques like Bobath, Vojta, and Katharina Schroth, classic stretching and strengthening can be included. Considering the psychological factors in rehabilitation, intensive exercise programs have major benefits for adolescents. Group dynamics help teens connect with peers who share similar challenges.

Physiotherapy and rehabilitation applications

Rehabilitation programs with or without bracing are applied depending on timing in children with Cobb 20–30°. Those with 30–40° and adults with pain also benefit.

Several physiotherapy approaches are prominent: Vojta therapy, acupuncture, and the widely studied Schroth method. Details should be thoroughly explained to children and families, with clear guidance on required cooperation. Some programs are intensive; others run 3–4 sessions per week.

Intensive Rehabilitation for Spinal Deformity (SIR/YSR)

This customized, intensive program—arranged according to curve direction and individual factors—provides three-dimensional treatment based on proprioception and movement. The goal is to correct asymmetry and achieve appropriate posture in daily activities.

Patients referred from various locations join a 4–6 week program, 4 hours per day. For group sessions, patients with similar curve directions, magnitudes, and ages are grouped together; individual programs are used when needed. Core elements include breathing exercises; learning and maintaining correct posture via self-stimulating cues; curve correction with various balance and movement exercises; restoring normal balance and mobility; plus adjuncts such as orthotic concepts, stretching programs, massage, and swimming.

These programs are delivered by physiotherapists certified in the Katharina Schroth method. The aim is to educate patients about their condition, prevent curve progression, and maintain proper posture.

Scoliosis surgery in Turkey

Surgery is used for advanced cases or where the curve continues to increase despite exercises and bracing—or is expected to progress. In other words, if the Cobb angle increases despite conservative methods and exceeds 50°, surgery may be necessary. The decision should consider not only radiographic angle but also the patient’s psychological, social, and cultural context. Scoliosis during adolescence usually does not reach a level that damages the heart and lungs. Essentially, two surgical approaches are used: posterior and anterior. The posterior approach uses the back of the spine.

The goals of surgery are early monitoring of all patients, stopping progression, resolving cosmetic issues, and eliminating pain and neurological problems if present. When necessary, early interventions and simpler procedures may restore the spine. The most important point is performing the right surgery at the right time and protecting the spinal cord while correcting spinal and bony structure. With intraoperative imaging and neuro-monitoring tools that prevent injury to the cord and nerves, success rates are now very high. Treatment requires long-term follow-up and sustained communication between the care team and family.

Spinal mobility decreases after scoliosis surgery. In the anterior approach, the rib cage is accessed via the armpit area. Its drawback is that a postoperative brace is required; advantages include better preservation of spinal mobility and more aesthetic scarring (hidden under the arm).

Postoperative considerations and risks

As with any surgery, scoliosis operations carry certain risks—about 5% overall. If no complications occur, the patient can be discharged within 14 days. Undesirable outcomes may include:

• Infection, controllable with antibiotics
• Post-bleeding respiratory distress, relieved by draining accumulated blood
• Screw loosening or implant failure, requiring a second surgery
• Neurological deficit in <1% of cases (usually reversible)