In Episode 35, host Heather Rotunda and Dr. Xavier discuss the four main types of scoliosis, what causes each one, and why no case of scoliosis fits neatly into a box.
Throughout the episode, you'll hear:
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Hello and welcome to episode 35 of Life Beyond the Curve. I'm your host, Heather Rotunda. Joining me today to discuss types of scoliosis is Dr. Xavier Counts in Louisville, Kentucky. Dr. Xavier earned his Doctor of Chiropractic from Logan College of Chiropractic in 2014 and opened Middletown Family Chiropractic with his wife, Dr. Elizabeth Counts. He's been CLEAR certified since 2020. Today, he cares for patients of all ages, and he's passionate about teaching families why acting early matters. I'm sure you'll enjoy this conversation with Dr. Counts as much as I did. Episode 35, here we go!
You're listening to Life Beyond the Curve, a podcast brought to you by CLEAR Scoliosis Institute. Each week we interview experts in the industry, answer your pressing questions, and empower you to take control of your scoliosis diagnosis and live life to its fullest. Enjoy the show.
Thank you for joining us, Dr. Xavier.
Hey, thank you for having me. It's a pleasure to be here. I try to never miss an opportunity to talk about scoliosis.
Love it. Today we're talking about scoliosis types. How many types are there, and what determines type?
I think most doctors would put scoliosis into four main categories. And I think idiopathic, neuromuscular, degenerative, and congenital would fill out most of those, but it's certainly a spectrum. I have cases that could fall into one or two categories, and they're all determined by what are the main factors causing them. And, well, I'm sure we'll dive into that here in a little bit, so I don't want to get ahead of ourselves. But of those four main types, idiopathic is definitely the most common. I think that's what most people think of when they think of scoliosis, but there's a lot of other different factors. And it's important to remember that, putting us into that category, no case of scoliosis fits into a box. But with those categories, we can come up with research that tells us how your case could evolve and what are things that we should be looking out for, not only now, but in the future.
Okay, great. Well, let's dive into a little more about each of those. What is idiopathic scoliosis?
If you look at the word idiopathic, I think a lot of people would say, "Oh, we don't know." And that's some of it, but it's not that we don't know, it's just that it's such a multifactorial problem. We know that there's genetic factors that are big drivers to those. We know it's the rate at which the vertebrae grow from one side to the other that can lead to that idiopathic scoliosis. So there's a theory about neural tension and muscular tension, about how much that can play into a role in the idiopathic type. And everything from hormones to nutrition to growth rates all impact idiopathic scoliosis. So it's not really that we don't know it, it's just that it's all-encompassing and it's multifactorial. So that would be idiopathic.
Okay, and you said that's the most common.
Yeah, by far and away it's the most common. Upwards of like 75 to 80% of cases are idiopathic. And then the other two make up roughly 10%. And then, yeah, the outlier to that is the degenerative cases of scoliosis, which I'm sure we'll get to.
Okay, so what is neuromuscular scoliosis, and do we know what causes that?
Yeah, neuromuscular is kind of a unique category. Usually it's secondary to some other type of diagnosis. Everything from cerebral palsy to muscular dystrophy — even autism spectrum disorders fall into this category as well, because they often come with low muscle tone, and that can be the reason why the scoliosis develops. But there's almost always some type of underlying condition, and it really depends on which gets caught first. In some cases it's the neuromuscular condition that's diagnosed first, and other times the scoliosis gets diagnosed first and we find out about the neuromuscular condition as the patient gets older or into adulthood. So yeah, neuromuscular, we do know what causes it, and it can be a multitude of different types of diagnoses and disorders.
Okay, so is it safe to say that not everyone with those neuromuscular disorders will have scoliosis, but everyone with neuromuscular scoliosis will have one of those?
Exactly. Yeah, almost always. And if we suspect that it might be a neuromuscular scoliosis, even if we don't have a diagnosis, it's my job, and the job of parents and family members of these patients, to make sure that we're getting to the bottom of it, because it does really help drive outcomes and drive results. So yes, absolutely. And like I said, either one can come first, but there's a lot of telltale signs we look for in x-rays that might tell us that a case could be involved in a neuromuscular diagnosis rather than an idiopathic type of scoliosis.
Okay, so what kind of things would you be looking for?
You're looking for curves that kind of don't match the norm. And I know that sounds weird, because I just spent time saying how scoliosis doesn't really fit into a box, but certainly we look for patterns. We know that the large majority of idiopathic scoliosis cases involve a right thoracic curve. So if we were to see a left thoracic curve, that would be something we'd want to dive into. Obviously, if the patient's having any type of neuromuscular symptoms, whether that be numbness and tingling, or muscle weakness, or a noticeable limp, we'd want to dive deeper into that. Usually by ordering an MRI, or referring out to a neurologist for a second opinion on the neuromuscular aspect of it. But yeah, don't let [unclear] keep you from getting treatment. [We'd] just definitely would want to know how to attack that case differently than idiopathic.
Great. So what is degenerative scoliosis, and do we know what causes that?
Yeah, it's definitely multifactorial, but de novo or degenerative scoliosis — the simple way to answer that question is just to say it's pressure and time. That's what causes it. Most of the time with de novo or degenerative scoliosis, the patient isn't diagnosed at a young age. It's something that they catch on to much later in life, over the age of 40, 50, 60. And I have patients that had no idea they had scoliosis until they got x-rayed at the age of 92 or 93. My oldest case of scoliosis is a 98-year-old who'd been dealing with it for years, and she's known about it, but she's technically classified as degenerative because we don't have any x-rays from when she was a teenager to diagnose it as an idiopathic type of scoliosis. So yeah, degenerative is exactly what it sounds like. It's a breakdown of the structural integrity of the spine, slowly over time, and everything from lifestyle to posture can affect it. So to answer your question about do we know what causes it, yes, it's pressure and time, but that's different from patient to patient, just depending on the type of life that they've lived.
Okay, so that patient that you just talked about, she's 98. She's learned about it, it's been official recently. But if you had x-rays from when she was, say, a teenager, it would be not degenerative, it would be idiopathic?
For adolescent idiopathic scoliosis, you have to be diagnosed from the age of 10 to 18 years old. If you get diagnosed past the age of 18, you can fall under the category of idiopathic, but most cases are going to fall under de novo or degenerative, especially if there's already signs that the bones have started to break down. And that's kind of the gray area between 18 years old and, let's just say, 40, 50, 60 years old; you might be diagnosed at the age of 50, but most of those cases, they kind of knew that they had scoliosis, but it was never severe enough to lead to a surgery or really severe interventions like a brace, or intensive therapy through scoliosis correction. So they might have known about it but never got an official diagnosis, and they might still fall under the de novo case. Really just depends on a couple of different factors.
Okay. So the last one that you mentioned; what is congenital scoliosis, and do we know what causes that?
Congenital — I want to be careful with the word congenital, because I think a lot of people hear that and they instantly think, "Oh, it's just my genetics." Well, that would fall under more of the category of the idiopathic that we've already talked about. Congenital refers to — we usually have some type of bony malformation that caused the scoliosis to happen. So yes, we definitely know what caused it. It's usually pretty clear on x-ray, but it's a spectrum as well. So we might have a really small bony malformation that led to a really small case of scoliosis, and then we might have some large bony malformations that lead to big cases, and anywhere and everywhere in between. So those bony malformations can be a malformation of the way that the sacrum forms, your tailbone, and that can lead to a tilt in the lower back, and eventually it starts curving back the other way, and that's how the scoliosis forms. Another example of that would be a wedged vertebra, where one side of the vertebra just never really grew. And that's something that happens congenitally, from birth, and that leads to scoliosis. I have a couple of unique patients who have several of their vertebrae fused together — bony fusions, not surgical fusions — and those fusions are so kind of asymmetrical that it led to a slight curve. And any one of those things can lead to scoliosis, and sometimes it's multiples of those things. Those happen embryologically, usually within the first nine weeks of life. So, you know, we don't find out about them until they get a little older, they start walking or crawling. And that's why congenital — I have cases of a two-year-old with congenital scoliosis, all the way up to much later in life, where they knew about it, but it didn't start causing the scoliosis until time allowed the spine to curve more dramatically. So yeah, definitely a known cause, and most always can be found with an x-ray or an MRI.
Okay. So we've talked about people on both ends of the age spectrum having scoliosis, but is it more common in one age range, or is it more common in men versus women?
[unclear] answer, because we just can look at the statistics that we have in research. And that's what I always like to say whenever I'm answering questions about how common things are. Research is really good on scoliosis. I think there's room for expansion on it, and there's no way that we can encompass the entirety of the population. So when we say common, it's definitely more common in females. Usually it's three to one, so for every one boy that has it, three female patients will have it. We tend to see de novo or degenerative scoliosis; it's ramping up quite a bit, and that's usually somewhere between like 35 to 38% of adults will develop or have some type of de novo or degenerative scoliosis. And a lot of that comes down to the fact that, you know, our spines are just meant to fight gravity, and gravity can win that battle. So we have to constantly be proactive and working to take care of our spines. And that's where scoliosis treatment comes in if you have a diagnosis, but even if you don't have a diagnosis of scoliosis, be proactive and make sure you're taking care of your spine. So yeah, three to one, male to female — female to male. And yeah, probably a little more common the older that we get, just because of the time and pressure.
Okay, that makes sense. So can all types of scoliosis that we've talked about today benefit from proactive treatment?
Yeah, I think that word proactive is really important. If you're finding out at a young age that you have scoliosis, now is the best time to start some type of treatment. And it doesn't always have to entail surgeries or braces, but knowing how your spine could progress if it goes untreated is a very important piece of information for you to have, as parents or patients, to make the decisions that are best for you. And the decisions are ultimately going to be dependent upon your goals. If your goal is to just maintain it and not let it get worse, that might lead us in one direction, or if your goal is to try to correct it, then it might lead us down another path. So knowing and being proactive about it is definitely the right response. I can't tell you how many times I hear patients later in life tell me, "Yeah, you know, I wish I would have done something about it when I found out about it," because they were diagnosed when they were 10, 11, 12, 13, and now they're 30, 40, 50 years old and they're having more chronic pain and symptoms arise from their scoliosis. And that's certainly not to say that everybody with scoliosis is going to have pain or symptoms from it, but you still want to work hard to make sure that you're being proactive. The more proactive you are now, the more you take scarier things out of the equation down the road. And a lot of adults end up having fusions later in life, not because their scoliosis was severe when they were a teenager — it just progressed so rapidly throughout the course of their lifetime, and their pain gets so severe that sometimes their only options are fusion surgeries. And it's my job, and our job at the CLEAR Institute, to try to help prevent those things, for sure.
Okay, so on that, if a patient comes to you who has had fusion surgery, are you still able to work with them?
Yeah, you know, honestly, I have patients who got fusion surgeries done back in the 1970s, and I have fusion surgeries that were done just within the past couple of years. And I always think there's plenty that can be done for cases like those, but a good evaluation is very important for that — to understand how that fusion was done, how it's reacted over time. But almost always there's things that we can do to help benefit the overall posture of the spine. To treat the areas both above and below the fusion is really important as well. I can't tell you how many times I see it where somebody has a fusion done just through their thoracic spine, [all] the way down by the tailbone, that last little portion of their lower back starts doing all sorts of weird twisting and tilting. And that's something that can be controlled with really good scoliosis care. So yeah, don't let fusion surgery scare you from getting treatment. Obviously, going to an expert who knows how to handle cases like that is really important, which is why you want to seek out a scoliosis clinician, not just any chiropractor or any doctor.
Okay, so you've mentioned a two-year-old patient and a 98-year-old patient. So no patient is ever too young or too old for treatment, correct?
Yes, exactly. And you know, as patients, you guys get to decide, [unclear], what your care can look like. But I think if you don't have the information, that's the place to start first. It's really hard to make those decisions, and it's really hard to make them on bad information. So if you're ever told your scoliosis can't be treated, or, "Hey, there's nothing you need to do about it right now", you know, if you do nothing about it, it's always going to slowly get worse. If you have that diagnosis of scoliosis, it's not just going to magically disappear on its own. And that's kind of a myth that I think needs to be busted. A lot of parents get told, "Yeah, we'll just watch it, kind of keep our fingers crossed and just hope it doesn't get worse. He or she might even grow out of it." And that sounds really good, but I've been doing this for a long time now, and I don't think I've ever seen somebody spontaneously grow out of their scoliosis or get better with age. It's got to be something that's being proactively worked on. So yeah, the sooner in life that you start, the better. But yes, [I] have a horde of patients in their 80s and 90s who, their main job is not to correct their scoliosis. Their job is to keep them functional and to keep them out of pain, and to get them up out of bed and moving the way that they want to move, so that they can enjoy the life that they want to — whether it's something as simple as gardening or playing golf, all the way up to, you know, helping people avoid surgeries and get off chronic pain medications. It's really important to seek care for it.
Okay, so what you just talked about, with it not just magically getting better; so if someone has been diagnosed with mild scoliosis, that does not indicate a lack of urgency?
No, it doesn't. I think urgency can be dependent upon the severity of the case. So, you know, if we get barely diagnosable 10, 11, 12 degrees of scoliosis, which is a small curve, as you can imagine, it doesn't mean we've got to get in tomorrow and start tomorrow, but there should be some type of plan that gets worked up in the relatively short term to help keep that curve [stable] and correct it, if that's a goal for you. Urgency comes from whatever your goals are. If your goals are correction, then yes, the more urgent we need to be about it. If your goal is maintenance, then less urgency, for sure. But yeah, it doesn't mean put it on the back burner, take an x-ray in a year and just keep your fingers crossed, for sure.
Okay. Do you have any final thoughts you'd like to share with the listeners today?
Maybe just to reiterate what we said at the beginning: no case of scoliosis fits in a box, but getting a good diagnosis and talking to a scoliosis clinician who really understands the differences between these types of cases, and the severity of these cases, can really help drive your decision. So if you're having a hard time, not sure where to turn to next, just go in and talk to somebody who's certified to treat and manage scoliosis, whether that's at the CLEAR Institute or starting somewhere. Chiropractic is a great place to start, because we have such a good understanding of the spine. But you don't need to wait, that's for sure, because time is always a factor.
Okay, so if someone listening has questions, can they call you and just say, "Hey, Dr. Xavier, I'm concerned about this, I don't understand this, can you help me out?"
Yeah, I think any of us who are at the CLEAR Institute, I think we all do almost all free consults, or some type of way to find out some more information before you even have to come into the office. So that can help make things easier. It can help take some anxiety out of the situation. [You] can reach out to me. I think if you wanted to, you could probably flash up my clinic information. I can give you my email, and I answer questions all the time through email or phone calls or Zoom consults. I go over x-rays with patients on telehealth, just to try to spread more education about the topic, because the more that we teach people about it, the quicker we can catch it, and that usually leads to much better outcomes.
Excellent. Thank you so much for joining us today, Dr. Xavier. We hope you'll join us again soon.
Yeah, thank you.
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