Adolescent Scoliosis Correction
Scoliosis is an abnormal curvature of the spine that affects approximately seven million people in the United States. For patients with adolescent idiopathic scoliosis (AIS), the parent or the patient are usually the first to notice the scoliosis but sometimes it is not discovered until a school screening or a doctor's visit. Most patients with AIS do not have many symptoms, but larger curves may cause outwardly noticeable deformity (such as a rib hump) or pain. In severe cases the curve may even begin affecting the lungs or heart function.
Scoliosis is a condition where the spine curves abnormally to the right or left side [Figure 1]. Scoliosis is "three dimensional" when the spine curves from side to side as well as twisting. As the spine rotates this may cause clinical changes in the appearance of the patient's back and may also lead to painful degeneration of the spine or alter organ function [Figure 2].
Figure 2: For patients with scoliosis, the spine develops a curvature as seen in the drawing on the right.
Figure 2: A photograph of a patient with scoliosis taken from behind. The curvature is seen between the shoulder blades (thoracic spine).
Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis and typically affects children starting around the age of 10 years old. The term adolescent means that a patient is not yet skeletally mature, meaning that they are still growing. The term idiopathic means "occurring without known cause." Idiopathic scoliosis is a genetic disorder. At present the precise cause is not yet known, however; Dr. Good and the team at the Virginia Spine Institute are part of ongoing research to determine the genetic causes of scoliosis and other spinal diseases. This research has also already led to the use of genetic testing for some patients with scoliosis to help understand their risk of their curvature increasing and help guide treatment options.
Symptoms of scoliosis may include back pain, leg length discrepancy, uneven hips, or abnormal gait. The patient may notice one shoulder being higher than the other, a prominent shoulder blade, or visual curvature of the spine from one side to the other. Some patients with AIS first notice that their clothes no longer fit correctly.
NON-OPERATIVE TREATMENT OPTIONS:
Medical assessment of a patient with scoliosis includes medical history, physical, and neurologic examination as well as diagnostic testing. Family history is important to evaluate for some medical conditions that may be causing scoliosis. The experts at the Virginia Spine Institute will perform a physical examination which includes a visualization of the spine. Also, a scoliometer (level) is used to measure the asymmetry of the patient's spine when they bend forward. x-rays are taken of the entire spine to evaluate the curvature and, using a Cobb angle measurement, to measure the curvature in terms of a number of degrees.
Most patients with adolescent idiopathic scoliosis do not require formal treatment and most patients have small curves that do not cause any specific symptoms. For patients with small curves (10◦ to 20◦), no formal treatment is required [Figure 3]. For these patients, observation of the curve over time is needed to determine if the curve is worsening while the patient grows. For these patients genetic testing may be used to help predict the risk of curve progression in the future.
Figure 3: X-ray of a teenager with mild scoliosis. This patient had no symptoms from the scoliosis and she was observed until she finished growing. She did not require any further treatment and has no limitations on her activities.
For patients with larger curves (20◦ to 40◦) brace treatment is sometimes used to try to prevent the curve from getting worse during the remainder of the patient's growth. Bracing treatment cannot correct a scoliosis, however, the goal of the brace is to prevent further progression of the curve during the patient's growth spurt. For patients who need a brace, a light weight thoracolumbosacral (TLSO) brace or Boston brace is most commonly used. This is a light weight brace that is custom molded to the patient's body. This brace can be worn under clothes and allows patients to participate in most sports and activities [Figure 4].
Figure 4: A TLSO brace is a lightweight plastic brace that is molded to fit a person with scoliosis. The goal of a brace is to keep the curve from getting bigger during the growing years.
RISK FACTORS FOR PROGRESSION OF A CURVE:
There are a number of factors that may be related to the risk for AIS progression. These include the patient’s age (younger age means higher chance of curve progression), pattern of the scoliosis curve present (type or shape of curve), and gender (girls are much more likely to have scoliosis curves that progress to the point that treatment is required).
It has become widely accepted that genetic factors play a significant role in the development of adolescent idiopathic scoliosis. At present, the general consensus is that there are a number of different genes that are involved in the development of a scoliosis curve.
Recent breakthroughs have allowed researchers to develop a specific form of genetic testing to be used for young patients with idiopathic scoliosis to help predict the patient's risk of curve progression. This is a simple test that is performed by analyzing the patient's saliva which can be collected during a routine office visit. The test allows scoliosis specialists to better predict an individual's risk for developing a progressive scoliosis. The physicians at the Virginia Spine Institute are proud to be involved in the research effort by enrolling patients in ongoing genetic studies and to offer this breakthrough genetic testing to our patients as a part of their scoliosis evaluation.
OPERATIVE TREATMENT OPTIONS:
Surgery for adolescent idiopathic scoliosis is usually necessary for patients whose curve is larger than 40° to 45°. The goal of scoliosis correction surgery is to correct the spinal curvature and prevent the curve from getting bigger during the rest of the patient's life. For patients with larger scoliosis curves or significant growth remaining, surgery is the best option in order to prevent further progression of the curvature [Figure 5].
Figure 5: This is a 13 year old girl with progressive double major scoliosis in her thoracic and lumbar spine. X-rays over time showed that her curves were getting bigger. At the time of surgery, she had a 39° curve in the thoracic spine and a 50° curve in the lumbar spine. Dr. Good performed a posterior spine fusion using pedicle screws. The fixation was strong enough that no brace was needed and she got out of bed the first day after surgery. X-rays taken two years after surgery show correction of her scoliosis and excellent spinal alignment. The patient is participating in full activities without pain.
A number of surgical advances have been made to allow for greater correction of scoliosis curvature and improved spinal stability after surgery. These advances allow most patients to begin walking immediately after surgery and resume activities over the following months. Most patients do not require bracing after adolescent scoliosis correction surgery. The decision to undergo scoliosis correction surgery should only be made after a careful evaluation and discussion between the patient, the family, and the surgeon.
OPERATIVE TREATMENTS FOR AIS CURVATURE:
For most patients with scoliosis curvature, scoliosis correction is performed with a posterior spine fusion with instrumentation. Posterior surgery means that the incision is made in the back of the spine. During this procedure spinal implants including rods and screws are attached to the spine and used to correct the spinal curvature. The implants hold the spine in the new position as they fuse or mend. The spine ultimately heals in this new position [Figure 6].
Figure 6: This is a 15 year old girl with progressive thoracolumbar scoliosis. X-rays over time showed that her curve was getting bigger and she began leaning toward her left side. At the time of surgery, she had a 52° curve at the junction between the lower thoracic and upper lumbar spine. Dr. Good performed a posterior spine fusion using pedicle screws. X-rays take post-operatively show correction of her curve and posture.
During this operation bone graft from the patient's spine and in some cases bone morphogenetic protein are used to enhance the fusion and maximize the chance that the spine will fuse correctly. Performing the surgery in this fashion allows the surgeon to avoid taking bone graft from the hip or iliac crest. Iliac crest bone graft harvest is commonly used by some surgeons, however, this has been shown to increase the patient's pain and lengthen surgical recovery time.
For patients with scoliosis, the spinal specialists at the Virginia Spine Institute work to fuse the smallest number of vertebrae possible. This helps to maximize the remaining motion in the spine. The decision of how many vertebrae to fuse is based on the patient's' x-rays and clinical appearance. This final decision is discussed at length with the patient and their family prior to the surgical procedure. The expert team at the Virginia Spine Institute is always committed to performing procedures that post the least amount of risk and are the least invasive for each patient.