The Spine and Scoliosis

Making the Right Choices in the Treatment of Idiopathic Scoliosis: A Patient's Guide

The Spine and Scoliosis
The spine has an important role. The spine supports our erect posture, stabilizes our limbs relative to our trunks, supports our abdominal and thoracic regions, and protects our neural elements. The spine is in balance when the head is aligned with the pelvis. Scoliosis is a condition in which the spine is curved in the coronal or frontal plane. The coronal plane is the view from the crown (corona) of the head down. The frontal plane is the view of the body from the front. Scoliosis encompasses curves of 10 degrees and greater.

Scoliosis may be caused by:

• abnormalities in the vertebra at birth.
• neuromuscular disorders, such as cerebral palsy, myelomeningocele, or paraplegia.
• connective tissue abnormalities, such as osteogenesis imperfecta, Marfan's syndrome, or Ehlers - Danlos syndrome.
• other injuries to the developing spine.

In the adolescent, the most common cause of spinal deformity is idiopathic which means unknown. While the cause of adolescent idiopathic scoliosis remains unknown, we are currently researching possible causes that may include genetic predisposition, vestibulobasilar or central nervous system causes, or growth pattern asymmetries. It appears most likely that adolescent idiopathic scoliosis is the result of multiple factors including genetic and environmental influences.

By age 16, the prevalence of Adolescent Idiopathic Scoliosis in:

• curves >10° affects 2-3%
• curves >20° affects 0.3-0.5%
  

That means, approximately 3 to 5 people in every large high school are affected. Screening for scoliosis is an attempt to identify the disorder at an early stage, but screening varies across communities. Often, family or friends first detect scoliosis in an adolescent by noticing an asymmetry in the shoulders, rib cage, waist, or pelvis. Screening is useful if early identification permits treatment that may halt the progression of the deformity. While scoliosis screening programs remain an entrenched policy in many school systems, there is little evidence that screening contributes to improving management or reducing surgical rates for scoliosis. Though, a physician should routinely screen siblings of a patient with scoliosis.

Thomas G. Lowe, M.D.



Dr. Berven has provided the reader with an overview of scoliosis developing in the skeletally immature adolescent. The important fact to remember is that only a small fraction of adolescent patients who develop a curvature of the spine will ever require treatment other than periodic observation during the growth period. It is however important, once scoliosis has been diagnosed or is suspected, to be seen by an orthopaedic surgeon, who specializes in spinal problems in children to determine the severity of the deformity by an examination and x-rays and what, if any, treatment is indicated.

Most of the time he/she will recommend periodic follow-up examination during the growth period until growth is complete. Exercises alone have never proven helpful in the treatment of scoliosis. A small number of patients (<0.5%) will require the use of a back brace combined with an exercise program during growth, however the brace, if needed can be removed for daily athletic activities and exercise. Braces are now available which are cosmetically acceptable and easy to wear. Braces often will control curves <40º but a few will increase and require surgery. An even smaller number (<0.25%) with curves greater than 40º- 45º may require surgical correction of their scoliosis. When surgery is necessary, the use of a brace is rarely needed and present surgical techniques are usually very successful.

As Dr. Berven suggested, always discuss treatment options with your orthopaedist so that you thoroughly understand his/her recommendations and seek other opinions if he/she is unable to explain recommendations.

Baron S. Lonner, MD



Dr. Berven provides an excellent review of the management of adolescent idiopathic scoliosis that emphasizes the importance of informed decision-making by the patient, family, and surgeon. New treatment options in AIS include the possibility of modulating or controlling growth of the spine by causing differential growth on one side of the spine more than the other to allow for gradual correction of the scoliosis with growth. This approach, utilizing "staples" or flexible tethers placed by minimally invasive techniques would be utilized in patients who continue to grow and in whom bracing has failed. Flexibility of the spine is preserved by theses techniques. This is currently an experimental area.

Results of surgery in the adolescent patient have been predictable and quite good. Goals of surgery include correction of deformity, preservation of pulmonary (lung) function, avoidance of long-term pain as a consequence of untreated curvature, and preservation of as many motion segments of the spine as possible. Studies assessing outcomes of surgery in patients have shown high rates of satisfaction and improvements in self image, pain, and even function.

Dr. Berven should be congratulated on his approach to patient care based on informed decision-making and inclusion of the patient and family in the process of devising a treatment plan.

• Surgical Management of Scoliosis
• Deformity and Scoliosis
• Patient and Family Participation in Scoliosis Treatment
• An In Depth Review of Scoliosis: Treatment of Adolescent Idiopathic Scoliosis
• Bracing for Adolescent Idiopathic Scoliosis
• Scheuermann's Kyphosis: Non-Operative and Surgical Treatment