Adolescent Idiopathic Scoliosis, Brace Treatment and Spine Surgery

Is surgery the right treatment choice for children and teens with scoliosis?

Peer Reviewed

Spine surgery can be a beneficial treatment for scoliosis when used in properly selected children or teenagers with adolescent idiopathic scoliosis (AIS), such as patients with large curves (greater than 50-degrees) that are likely to worsen even after reaching adulthood, according to scoliosis experts who participated in a recent Scoliosis Research Society Webinar on adolescent idiopathic scoliosis.

AIS is the most common type of scoliosis. It is defined as a sideward curvature of the spine greater than 10-degrees, it begins at age 10 years or later, and has no known cause, explained Kevin Neal, MD, Orthopedic Surgeon at Nemours Children’s Specialty Care Hospital and Chief of Pediatric Orthopedic Surgery at Wolfson’s Children’s Hospital in Jacksonville, Florida.

Furthermore, adolescent idiopathic scoliosis is believed to be genetic (runs in families), Dr Neal said.

adolescent girl in hospital bed with her mother and doctor at her sideSpine surgery can be a beneficial treatment for AIS when recommended in properly selected children.
Why do some scoliosis curves get larger?
“Smaller curves in older patients have a low risk of worsening, and larger curves in younger patients have a much higher risk of worsening,” said Dr. Neal. Patients with small curves (less than 40-degrees) typically are not more likely to have back pain or an increased risk of injury compared to the general population, he said.

When children or teens have curves greater than 50-degrees, “we are fairly sure that the curves will progress slowly over time,” Dr. Neal said. “I would generally recommend surgery for curves at this level [size] because most patients don’t want the curve to progress [increase in size].”

Curves between 40- and 50-degrees are somewhat of a grey area, Dr. Neal said. “We generally ask patients how they feel about their back” and whether they can live with the curve, Dr. Neal noted.

When may bracing treatment be recommended?
To help stop curves from getting larger, spinal bracing appears to be the most effective treatment for moderate scoliosis (ie, curves 20-degrees to 45-degrees) in children who are still growing, and who are willing to wear a brace, Dr Neal said. Willingness to wear a brace is important because the longer the brace is worn, the more effective it is.

“There are various types of braces, and there is no one brace that is most effective,” Dr. Neal said. “My advice is that it's best to take your doctor’s advice on the best brace for your scoliosis.”
Cheneau bracesThe Cheneau brace is made of thermoplastic with Velcro closings to secure the brace in position. This type of brace may help provide three-dimensional correction of scoliosis.When and why might bracing not be a recommended scoliosis treatment option?
“Bracing is not as effective in very young patients who have so much growth to come that it will overcome the brace,” Dr. Neal said. Bracing still may be used for younger patients to help delay surgery rather than to prevent the curve from worsening. Thus, bracing is typically used in older children who have fewer years of growth remaining to alter the spine, Dr. Neal explained.

In addition, bracing is not used for curves that are high up in the back or for large curves.

When is surgery recommended for scoliosis?
Surgery may be for patients with a cosmetically unacceptable spinal curve, or the curve is likely to progress after a child stops growing, such as those that are larger than 45- to 50-degrees, said Mark C. Lee, MD. Dr. Lee is Associate Professor of Pediatric Orthopaedics at the University of Connecticut at Connecticut Children’s Medical Center in Hartford.

“The first goal of surgery is to correct the deformity and make the curve better,” Dr. Lee said. “The second is arthrodesis (fusion), and the third is safety.”

“The spine is essentially a bunch of building blocks connected by very small joints,” Dr. Lee said. “The idea of fusion is to eliminate these small joints and connect these building blocks one after the other. The surgery is successful, if you go back and look at the spine 3 years after surgery and remove all the instrumentation (eg, rods and screws) and the surgeon sees one big layer or block of bone that goes from the top of the instrumentation to the bottom. This fusion is what will have a lasting effect and prevent the curve from getting worse in the future.”

Advances in Spine Surgery to Treat Scoliosis
Recent advances in surgery for scoliosis include improved implant design, innovations in infection control, blood loss management, and real-time neuro-monitoring to protect the spinal cord and nervous system, explained Dr. Lee.

The overall rate of neurological complications (injury to the spinal cord or nerves) during scoliosis surgery is approximately 0.5% and the infection rate is 1%. Approximately 5% of children and teens who undergo scoliosis surgery will need another surgery on their spine in the future.

Overview of Scoliosis Surgery
Ryan Goodwin, MD, Section Head of Orthopaedic Surgery at the Cleveland Clinic, discussed the following steps used during surgery to treat adolescent idiopathic scoliosis:

  1. The levels of the spine to be operated on are identified and reconfirmed during surgery. The surgeon may access the spine from the front and/or back of the patient’s body. There are different approaches and methods surgeons use depending on the surgical goals and plan.
  2. Scoliosis may cause one or more levels of the spine to become stiff. To release stiff levels the surgeon may remove one or more discs and perform osteotomy(ies). During an osteotomy, spinal bone is cut and removed in order to realign the spine.
  3. Different types of spinal instrumentation (eg, rods, screws) are implanted to stabilize the realignment of the spine.
  4. Bone graft is packed into and around the instrumentation to stimulate fusion (bone growth) and bone healing.
  5. The surgical incision is closed and dressed.

After surgery, good pain control is essential to allow the patient to get out of bed and move around, Dr. Goodwin said. The hospital stay is typically 3 days.

Can teens who are still growing undergo scoliosis surgery?
“Children and teens who are still growing can have scoliosis surgery, but it depends on magnitudes [curve size],” Dr. Lee said. If a child has a lot of growth to come, the curve can come back. “For teenagers who are age 12 or 13, we try to wait until the major growth cycle is done,” Dr. Lee explained.

Fusing the spine does not mean the teen will stop growing, Dr. Lee added. While the fused section of the spine will not grow longer, other areas of the spine will grow, as will the arms, legs, and other parts of the body.

What to expect after surgical treatment?
Most children and teens can expect to resume normal daily activities a few days after leaving the hospital, Dr. Neal said. “I work with my patients to be off medications 1 to 2 weeks after surgery and to return to school 2 to 3 weeks after surgery,” Dr. Neal explained.

“I generally limit rough activities (eg, sports, carrying a heavy book bag) for at least a few months after surgery,” Dr. Neal said. “For really rough activities—collision sports like tackle football, ice hockey or riding roller coasters—I suggest waiting 6 months after surgery, but all surgeons have differing recommendations.”

“Parents often ask about physical therapy after scoliosis surgery,” Dr. Lee noted. While physical therapy is needed after many orthopaedic surgeries, teenagers who undergo scoliosis surgery almost never need this treatment, Dr. Lee said.

Dr. Goodwin added that limiting activities that impact the spine, such as running and jumping is most important after surgery to allow the bony fusion to heal properly.

Disclosures
Ryan Goodwin, MD, is a consultant with Stryker Spine (Consultant).
Mark Lee, MD, disclosed no relevant financial relationships.
Kevin Neal, MD, disclosed relationships with OrthoPediatrics (Royalties), Medtronic (Unpaid Consultant).

Updated on: 12/07/17
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Isador H. Lieberman, MD, MBA, FRCSC
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