Contemporary Treatment of Scoliosis

The overall prevalence of scoliosis has not changed. It continues to be found in equal numbers of boys and girls, with adolescent idiopathic scoliosis accounting for about 85 percent of cases. However, curve progression is more common in girls. At The Cleveland Clinic, approximately 150 scoliosis operations are performed each year, 80 percent on girls.

As a rule, curvature of less than 25 degrees requires no treatment. Regular examinations are simply performed to monitor for progression.

In skeletally immature children, guidelines call for bracing to try to prevent further progression when the curvature progresses to 25 but not beyond 40 degrees. Bracing has no role in the skeletally mature patient.

Bracing is considered less onerous than in the past. In current favor is the Providence brace, which is worn for about 10 hours at night. Its bending action maintains flexibility and produces a temporary improvement of the curve. (“Temporary”must be emphasized, because the goal of bracing remains control or prevention of progression, not long-term improvement.) Early results with the Providence brace are nearly as good as those achieved with the Milwaukee and Boston braces, and compliance is clearly superior.

Compliance with bracing is a big issue. The majority of children needing bracing are girls aged 11 to 15, for whom wearing a large, cumbersome body brace during the day interferes with contemporary dress styles and can have an adverse psychosocial impact.We have found that most patients do not mind wearing the nighttime brace.

Curves between 40 and 50 degrees may fall into a gray zone of surgery versus conservative care. Often, an outward appearance of the curve typically affected by the degree of rotational deformity plays a role in surgical decision- making by the patient and their family. The more extensive the rotation, the more extensive the aesthetic impact. While scoliosis surgery is not done purely for cosmesis, this is the number one concern for many patients. Pain and progression issues 20 years hence are not concepts the typical teen grasps.

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At 50 degrees, however, surgery usually becomes a health necessity. Curves in this range will often continue to increase by one degree per year, even when the person is skeletally mature. High-magnitude curves can potentially impact lung and heart function, digestion and a host of other critical issues.

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Just 20 years ago, surgery for scoliosis often produced less-than-ideal results. The instrumentation used in the procedure was prone to failure, so casting or bracing was typically needed after surgery. Also, the techniques did not adequately address the 3-D component of this condition. Some patients developed secondary deformities, most notably a flat lumbar spine that can become quite problematic in the third decade and beyond.

Development of the Cotrel-Dubousset instrumentation solved some of these issues by allowing better restoration of 3- D alignment. However, the technique was still not optimal, as hooks attached under the spine could pull out under force. Several years ago pedicle screw fixation, which provides superior holding strength, became commonplace in the lumbar spine.

More recently, we have begun using screws throughout the thoracic spine as well, resulting in extremely secure fixation. Employing the technique throughout the spine produces the force necessary to achieve outstanding correction. While dysplastic joints and vertebral asymmetry may influence the degree of correction possible, results are uniformly superior to those obtained with earlier techniques.While we used to “promise” patients a 50 percent correction, we can now take a 60-degree curve and correct it to single digits. In some particularly flexible patients, we have obtained very nearly perfectly straight spines with this technique.