IDIOPATHIC SCOLIOSIS

Questions and Answers

Idiopathic Scoliosis is Classified By The Age At Which It Occurs, Falling Into One Of Four Categories:

• Infantile – Also known as early-onset scoliosis. Develops in children, mostly boys, under the age of 3.
• Juvenile – More common in girls, this kind of scoliosis occurs between the ages of 3 and 10.
• Adolescent – This type of scoliosis makes up the majority of cases. It’s most common in girls between the ages of 11 and 17. Adolescent idiopathic scoliosis refers to children and is the most common — representing nearly 90 percent of cases.
• Adult – This type refers to adults 18 years and older.

The curvature of idiopathic scoliosis (Infantile, Juvenile, and Adolescent) varies from person to person, with mild curves being more common than severe curves. In children and adolescents who are still growing, the curve can get worse rapidly during a growth spurt. While this type of scoliosis can develop in younger children, it most often begins during puberty for both boys and girls.  However, girls usually develop severe curves that require medical care.

What Are the Risks and Benefits of Scoliosis Surgery?

When determining whether scoliosis surgery is the right option, it’s essential to weigh both the benefits and the risks. Here’s a detailed look at both aspects:

Benefits of Scoliosis Surgery

• Improved Alignment: Surgery can significantly straighten the spine, enhancing overall posture and physical appearance.
• Pain Relief: For many patients, corrective surgery relieves chronic pain associated with severe spinal curves.
• Prevention of Curve Progression: Surgery can halt the progression of scoliosis, preventing further curvature and associated complications.
• Enhanced Functionality: Correcting spinal deformities can improve lung and heart function in cases where severe curves compress these organs.
• Increased Quality of Life: Many patients experience improved mobility and a better quality of life post-surgery.

Risks of Scoliosis Surgery

• Potential for Complications: As with any major surgery, risks include infection, blood loss, and complications from anesthesia.
• Incomplete Correction: There’s no guarantee that surgery will fully correct the spinal curve or alleviate symptoms for every patient.
• Pain and Recovery: Post-surgery recovery can become lengthy and painful, requiring significant time away from daily activities and work.
• Hardware Issues: In some cases, the rods or screws used to correct the spine may become loose or break, necessitating further surgery.
• Nerve Damage: There’s a small risk of nerve damage, which could lead to issues with mobility, sensation, or even paralysis in severe cases.

Conclusion

When considering scoliosis surgery, it’s crucial to consult with a healthcare professional to fully understand both the potential benefits and risks. While many patients benefit significantly from the surgery, others may experience complications or only partial relief. Careful assessment and a personalized approach are key to making the best decision for each individual’s needs.

Likelihood of Progression

Once scoliosis is diagnosed, concern may arise whether the curves will continue to grow bigger. Doctors cannot determine if a curve will continue to grow, but the following is known:

• Curves in the thoracic spine are more likely to progress than lumbar curves.
• The likelihood of growing bigger depends on the size of the curve. Larger curves are more likely to get bigger.
• If the curves start at a young age or before a girl begins her period, they are more likely to progress.
• The higher the child’s Risser sign number at diagnosis, the less chance of progression. The Risser sign also measures skeletal maturity and is based on a 0 to 5 scale with 5 being full skeletal maturity.

Idiopathic Scoliosis Symptoms

In children and adolescents, small curves often go unnoticed until they hit a growth spurt during puberty and there are more obvious signs, such as:

• Tilted, uneven shoulders, with one shoulder blade protruding more than the other
• The prominence of the ribs on one side
• Uneven waistline
• One hip higher than the other
• Back pain
• Difficulty breathing

Adult Idiopathic Scoliosis

Adult idiopathic scoliosis refers to the continuation of the disease from childhood. Scoliosis may have started during your teenage years and gone unnoticed, not progressing until you reached adulthood. This form of scoliosis can affect both the thoracic and lumbar portions of the spine.

In adults, the symptoms are often more severe and may include:

• Spinal stenosis, an abnormal narrowing of the spinal canal that can cause back pain that’s worse when standing or walking.
• Nerves can sometimes become compressed and may cause radiating pain in the mid to lower back, as well as numbness, tingling, or weakness in the legs.
• Due to changes in the shape and size of the thorax, idiopathic scoliosis may affect pulmonary function. Recent reports on pulmonary function testing in patients with mild to moderate idiopathic scoliosis showed diminished pulmonary function. In severe cases (generally in curves more than 90 degrees), scoliosis can result in diminished lung function. This impact on lung function demonstrates the importance of regular monitoring and early intervention for individuals diagnosed with idiopathic scoliosis, regardless of the severity of their condition.

Diagnosing Idiopathic Scoliosis

Idiopathic scoliosis gets diagnosed through a combination of physical examinations and specialized X-ray images. During the physical examination, one of our doctors at the Southwest Scoliosis and Spine Institute, Richard Hostin, MD, Devesh Ramnath, MD, Ishaq Syed, MD, Shyam Kishan, MD, and Kathryn Wiesman, MD, will examine the curvature of the spine, looking closely at the degree of rotation in the spine. They will also note any secondary changes in other parts of the body.

X-ray images are important to pinpoint the shape and location of the curves, as well as for measuring the degree of the curvature for classification. Southwest Scoliosis and Spine Institute utilizes the revolutionary EOS 2D/3D X-ray imaging system, which allows us to quickly take full-body images of patients in standing or seated positions in just a few seconds while delivering the lowest possible dose of radiation.

What Factors Determine the Treatment Options For Scoliosis

When diagnosing scoliosis, several critical factors come into play that influence the treatment path. These factors focus on the patient’s physical development, the specifics of the spinal curve, and the risk of curve progression.

Spinal Maturity

The growth stage of the patient’s spine is crucial. If the spine is still growing and changing, doctors will implement different treatment options.

Degree and Extent of Curvature

The severity of the spinal curve plays a significant role. A mild curve might only require regular monitoring, while a severe curve that impacts the patient’s daily life may necessitate more intensive interventions.

Location of the Curve

The position of the curve within the spine can affect the treatment decision. For instance, curves in the thoracic region (the upper back) are often more prone to progression than those located in other parts of the spine.

Risk of Curve Progression

The likelihood of the curve worsening is a key factor. Patients with substantial curves before entering their adolescent growth spurt are at a higher risk of progression, which could warrant proactive treatment measures.

By thoroughly evaluating these factors, healthcare providers can tailor a treatment plan that best suits the individual needs of the scoliosis patient, aiming to maintain or improve their quality of life. In many cases, doctors treat idiopathic scoliosis through a combination of watching and bracing. However, in cases where the patient’s curve progresses to the point that it causes pain or difficulty breathing, the doctor may recommend surgery as the best option.

Observation

Your doctor will typically recommend watching a patient whose curves are not severe. Using our advanced in-house imaging system, doctors can get X-ray images of the spine every 4 to 6 months to determine if the curve continues to grow or not, while the patient receives an extremely low dose of radiation. This low-dose imaging system protects children from the effects of radiation.

Scoliosis brace

In (primarily adolescent) patients whose curve progresses past 20-25 degrees, doctors often prescribe a back brace until the patient reaches full skeletal maturity. Though bracing cannot correct the curvature, in many cases, it can stop it from getting bigger. For this reason, bracing should begin early in detection and be worn as prescribed. Braces are most effective in patients who have not reached skeletal maturity. If the child’s curve is between 25 and 40 degrees, doctors will recommend a brace to prevent further progression.

There have been improvements in brace design, with newer models fitting under the arm rather than around the neck. While there is some disagreement among experts about which type of brace is most effective, large studies indicate that braces, when used with full compliance, successfully stop curve progression in about 80% of children with scoliosis. For optimal effectiveness, doctors should check the brace regularly to ensure a proper fit, and it may need to be worn for 16 to 23 hours every day until growth stops.

Understanding the Different Types of Braces for Scoliosis

When it comes to scoliosis treatment, braces play a crucial role, particularly for patients who haven’t reached skeletal maturity. To effectively manage scoliosis, several types of braces are available, each with its unique benefits. Here’s a breakdown:

Thoracolumbosacral Orthosis (TLSO)

• Description: This is a common brace that wraps around the torso, providing stabilization to the spine.
• Usage: Typically recommended for scoliosis curves between 25 and 40 degrees.
• Advantages: Modern TLSO braces are designed to be less invasive, fitting comfortably under the arm without encircling the neck.

Cervico-Thoracic-Lumbo-Sacral Orthosis (CTLSO)

• Description: Extending from the neck down to the hips, the CTLSO offers comprehensive support.
• Usage: Often used for higher spinal curves that extend into the cervical region.
• Advantages: Ensures maximal correction for complex or high-level spinal curves.

Charleston Bending Brace

• Description: A nighttime brace that bends the spine against the curvature during sleep.
• Usage: Designed for single, C-shaped curves in the lower back.
• Advantages: Enhances compliance by only needing to be worn at night, allowing freedom during the day.

Milwaukee Brace

• Description: One of the earliest types of scoliosis braces, comprising a full torso brace extending up to the neck.
• Usage: Best for high thoracic or cervical curves.
• Advantages: Offers significant correction for severe curves, although less commonly used today due to advancements in other braces.

Rigo-Chêneau Brace

• Description: A custom-made brace that uses a three-dimensional correction approach.
• Usage: Suitable for various curve patterns, including complex and multiple curves.
• Advantages: Provides tailored support, distributing pressure precisely where needed.

Key Points for Effective Use

Wearing a brace effectively can halt curve progression in about 80% of children with scoliosis when used correctly. For maximum impact:

• Regular Check-ups: Ensure the brace fits properly at all times.
• Daily Wear: Depending on the type, braces may need to be worn for 16 to 23 hours daily until growth stops.

By understanding the various brace options and adhering to usage guidelines, scoliosis patients can significantly improve their outcomes while maintaining active and engaging lives.

When is Bracing Recommended for Scoliosis?

Bracing is typically recommended for scoliosis patients who haven’t yet reached skeletal maturity. In other words, children and adolescents are still growing.

For bracing to be considered, the curve of the spine usually falls between 25 and 40 degrees. At this angle, there’s a significant risk of the curve worsening, and a brace can help manage this risk.

Key Factors for Bracing:

• Growth Stage: The child must still be in their growth phase.
• Curve Degree: It should be between 25 and 40 degrees.

Modern Brace Design

Recent advancements in brace design have made them more comfortable and less visible. Unlike older models, newer braces fit under the arm instead of around the neck.

Types of Braces

There are various types of braces available, and while experts may differ on which is most effective, research shows that compliance is crucial. When worn as prescribed, braces successfully halt curve progression in about 80% of cases.

Compliance and Monitoring

For optimal results, the brace should be consistently checked for proper fit. Children may need to wear the brace for 16 to 23 hours daily until they stop growing. Regular adjustments ensure the brace remains effective throughout the growth period.

In summary, bracing is recommended for growing children with a spinal curve between 25 and 40 degrees. With modern designs and proper compliance, bracing effectively prevents further curvature in the majority of cases.

What Are the Surgical Approaches for Scoliosis?

When it comes to surgical interventions for scoliosis, understanding the various approaches is crucial. These methods aim to correct spinal curvature, alleviate pain, and improve the patient’s quality of life. Here are the primary surgical options:

Posterior Approach

Posterior spinal fusion is one of the most common surgeries for scoliosis, particularly in adolescents with idiopathic scoliosis. This procedure is performed through the back (posterior) while the patient lies on their stomach. Key components of this surgery include:

• Spinal Fusion: Involves adding a bone graft to the curved area to create a solid union between vertebrae.
• Instrumentation: Rigid rods are attached to the spine to keep it straight while the fusion takes effect.

This approach is beneficial due to its established effectiveness and the relatively short recovery time, with most patients resuming their regular activities within months.

Anterior Approach

For some cases, particularly where better deformity correction is required or fewer vertebral segments need to be fused, an anterior approach might be preferred. Here, the surgeon accesses the spine from the patient’s side. This method incorporates:

• Video-Assisted Thoracoscopic Surgery (VATS): Enhances visualization and is less invasive than fully open procedures.
• Incisions and Rib Removal: Necessary to gain access to the spine, during which a rib might be removed, and the lung deflated temporarily.

While the anterior approach can lead to quicker rehabilitation and better spine mobilization, it may require postoperative bracing and has a higher risk of complications compared to the posterior approach.

Decompressive Laminectomy

This procedure focuses on relieving pressure on spinal nerves by removing the laminae (the back part of the vertebrae). Often combined with spinal fusion, this approach is beneficial for patients who experience both scoliosis and spinal stenosis. Instruments like screws and rods stabilize the spine post-surgery.

Minimally Invasive Surgery (MIS)

Minimally Invasive Surgery (MIS) techniques are employed when suitable, as they offer the advantage of smaller incisions and less tissue trauma. Advanced imaging technologies, such as fluoroscopy (live X-ray) and endoscopy (camera technology), help ensure the precise placement of surgical instruments. While MIS is less invasive, it’s important to note that not all scoliosis cases are suitable for this approach.

Conclusion: Each surgical method has its unique benefits and potential risks. The choice of approach depends on various factors, including the patient’s age, the severity and location of the curve, and any additional health concerns. Consulting with a specialist can guide the decision-making process to ensure the optimal surgical plan is selected.

What are the Goals of Scoliosis Surgery in Children?

Scoliosis surgery in children primarily aims to achieve two crucial objectives:

• Prevent Curve Progression: The surgery seeks to halt the advancement of the spinal curvature as the child grows into adulthood. This helps avert potential complications that worsening scoliosis can bring later in life.
• Reduce Spinal Deformity: Another critical goal is to lessen the degree of spinal deformity. Correcting the curvature as much as possible is key to improving posture, appearance, and overall spinal function.

Most medical experts agree that surgery is generally recommended when the spinal curve exceeds 40 degrees and shows signs of worsening. This measure ensures that the intervention is necessary and can provide the most benefit.

When is Surgery Recommended for Scoliosis in Children?

When a child is diagnosed with scoliosis, determining the right treatment involves assessing various factors:

• Spinal Maturity: Is the child’s spine still growing?
• Degree and Extent of Curvature: How severe is the curve, and how does it impact the child’s everyday life?
• Location of the Curve: For instance, thoracic curves are typically more prone to progression compared to curves in other areas of the spine.
• Curve Progression Likelihood: Children with significant curves before their adolescent growth spurts are at higher risk for worsening conditions.

Treatment Options

Following these assessments, the appropriate treatment options are:

• Observation: For minor curves that are unlikely to progress significantly.
• Bracing: Often recommended for growing children as a way to prevent further curvature.
• Surgery: Reserved for more severe cases.

Surgery Recommendations

Surgery is generally advised when:

• The spinal curve exceeds 40 degrees.
• There are clear signs of curve progression.

Surgical Goals and Approaches

The primary objectives of scoliosis surgery in children are:

• Halt Curve Progression: Prevent the curve from worsening into adulthood.
• Reduce Spinal Deformity: Improve the spine’s appearance and function.

Surgical procedures can differ based on the specifics of the case and may involve:

• Anterior Approach: Surgery is conducted from the front of the body.
• Posterior Approach: Surgery is performed from the back of the body.

The choice of surgical method depends on various clinical factors and the individual needs of the child. By addressing these conditions, healthcare providers can recommend the optimal surgical strategy to ensure the best outcomes for young scoliosis patients.

Surgical Treatment for Adolescent Idiopathic Scoliosis

When scoliosis curves in adolescents progress beyond 50 degrees, surgery often becomes essential. This is typically the case whether or not prior bracing has been attempted.

Common Surgical Procedures

Among the various surgical options, posterior spinal fusion with instrumentation is the most prevalent. In this surgery, an orthopedic surgeon makes an incision along the back and “fuses” the affected vertebrae into a single, solid bone.

The Fusion Process

To achieve this fusion:

• Bone Chips: The surgeon uses bone chips to aid the fusion.
• Autografts: These are taken from another part of the patient’s body.
• Allografts: These are donated bone chips sourced from a bone bank.

Securing the Spine

Hooks, screws, and rods are utilized to hold the spine in the correct alignment while it heals. After fusion, these implants remain in the body; removing them would generally necessitate another surgery, which is usually not required.

Minimally Invasive Options

For some patients, minimally invasive spine surgery may be an option. This technique involves smaller incisions and quicker recovery times, but is only suitable for specific cases.

In Summary

Surgical treatment of adolescent idiopathic scoliosis typically involves posterior spinal fusion using a combination of bone grafts, screws, and rods to stabilize and align the spine. The overarching goal is to halt the progression of the curve and improve the patient’s quality of life.

What is Minimally Invasive Surgery (MIS) for Scoliosis?

Minimally Invasive Surgery (MIS) for scoliosis involves operating through smaller incisions compared to traditional open surgery. This technique utilizes advanced tools like fluoroscopy, which provides real-time X-ray imaging, and endoscopy, using a camera to guide the surgeon. These technologies help enhance precision in making incisions and placing hardware, thereby reducing damage to surrounding tissues.

Benefits of MIS for Scoliosis:

• Reduced Tissue Trauma: Smaller incisions lead to less tissue damage.
• Improved Accuracy: Advanced imaging and camera technology facilitate precise surgical maneuvers.
• Faster Recovery: Less invasive procedures typically result in quicker recovery times.

Factors Influencing the Decision for MIS:

While MIS offers several advantages, it is not suitable for all scoliosis cases. The decision hinges on various factors, including:

• Severity of the curvature
• Patient’s overall health
• Specific anatomical considerations

In summary, minimally invasive surgery for scoliosis is a sophisticated option aimed at minimizing tissue damage and speeding up recovery, but its applicability depends on individual case specifics.

Risks Associated with Scoliosis Surgery in Older Adults

Undergoing scoliosis surgery in older adults brings a unique set of risks and challenges. Here’s a comprehensive overview of key considerations:

Factors Contributing to Increased Risks

• Advanced Age: As patients age, their bodies generally become less resilient, making surgery and recovery more complicated. Older bones and tissues heal more slowly, increasing the likelihood of complications.
• Smoking: Smokers face an elevated risk during surgery due to diminished lung function and poorer blood circulation. These issues can lead to slower wound healing and a greater risk of infection.
• Excess Weight: Being overweight puts additional stress on the spine and complicates both the surgery itself and the recovery process. It can also increase the likelihood of comorbid conditions, such as diabetes or cardiovascular disease, which further complicate surgical outcomes.
• Coexisting Medical Conditions: Conditions such as diabetes, hypertension, and heart disease can exacerbate surgical risks. These conditions may require careful management before, during, and after surgery, prolonging the recovery period.

Extended Recovery Time

• Longer Hospital Stays: Older adults might need to stay in the hospital for a longer period post-surgery, increasing the risk of hospital-acquired infections.
• Rehabilitation Challenges: Physical therapy is crucial after scoliosis surgery, but older adults may face difficulties due to pre-existing mobility issues or decreased muscle strength.

Increased Complication Rates

Studies indicate that complications, such as infection, blood clots, and respiratory problems, are more common in older scoliosis surgery patients. Here’s why:

• Infections: The reduced immune response in older adults makes them more susceptible to postoperative infections.
• Blood Clots: Older adults are at higher risk for developing deep vein thrombosis (DVT) during immobilization post-surgery.
• Respiratory Complications: Reduced lung capacity can lead to pneumonia or other respiratory issues following surgery.

Recommendations for Mitigating Risks

• Preoperative Assessments: Comprehensive health evaluations before surgery can help identify and address potential risks.
• Smoking Cessation Programs: Quitting smoking well in advance of the surgery can significantly improve outcomes.
• Weight Management: Achieving a healthier weight can reduce surgical risks and improve recovery.
• Optimized Medical Management: Managing coexisting medical conditions under the guidance of healthcare providers can mitigate complications.

In summary, scoliosis surgery in older adults carries several risks due to factors like advanced age, smoking, excess weight, and pre-existing medical conditions. Understanding these risks helps in making informed decisions and taking appropriate preoperative and postoperative measures to improve outcomes.

Understanding the Long-Term Outlook for Kids and Teens with Idiopathic Scoliosis

Idiopathic scoliosis, while a significant medical consideration, is not considered life-threatening. Generally, children and teenagers with this condition can anticipate leading normal and vibrant lives.

Factors Influencing the Prognosis

• Nature and Severity: The extent of the spinal curvature plays a critical role in shaping the future outlook. Mild cases often have minimal impact, while more pronounced curves may require intervention to prevent complications.
• Age: The age at which scoliosis is diagnosed can significantly affect the outcome. Younger children have a longer period of growth, which can influence how the condition progresses.
• Timely Diagnosis and Treatment: Catching scoliosis early is key. Early detection allows for a range of treatments that can mitigate potential long-term effects, enhancing the overall quality of life.

Treatment and Lifestyle

• Therapeutic Approaches: Treatment may involve bracing or, in more challenging cases, surgical procedures like spinal fusion. The goal is to manage the curvature and prevent progression.
• Active Living: Most patients can engage in regular activities and sports, which are crucial for maintaining both physical and mental health.

Conclusion

In essence, with the right combination of early diagnosis, appropriate treatment, and active living, kids and teens with idiopathic scoliosis can enjoy fulfilling futures. The focus remains on minimizing the impact of scoliosis to ensure a healthy, active lifestyle.

Understanding the Differences Between Adult and Childhood Scoliosis

Scoliosis in adults significantly differs from scoliosis in children, primarily due to the underlying causes and treatment objectives related to skeletal maturity.

Causes and Types of Adult Scoliosis

Unlike children, adults with scoliosis can be classified into three main categories:

• Adults Treated in Adolescence: These individuals had scoliosis as children and underwent surgical treatment.
• Untreated in Adolescence: Some adults did not receive treatment when they were younger, resulting in unaddressed progression.
• Degenerative Scoliosis: A specific type known as degenerative scoliosis appears later in life, often in the lumbar spine, and is associated with aging.

Progression Rates

A notable difference lies in the progression of the condition:

• In adults, scoliosis progression occurs in approximately 40% of cases over two decades.
• Among these, 10% of adults face significant progression, while the remaining 30% exhibit mild, gradual progression, averaging less than one degree annually.

Degenerative Scoliosis and Age

• Degenerative scoliosis is prevalent among older adults, particularly those aged 65 and above. This form of scoliosis frequently coincides with spinal stenosis—a condition where the spinal canal narrows, leading to nerve compression.

Symptoms and Pain

• Adults with degenerative scoliosis often experience a gradual onset of back pain linked with physical activity. Conversely, in children, scoliosis may be more noticeable visually with less immediate discomfort.

Treatment Approaches

• Children: The primary focus is correcting spinal curvature to prevent further deformation as they grow.
• Adults:  Treatment aims to manage pain and maintain the quality of life. Surgery is generally considered only when conservative methods, such as physical therapy and pain management, fail to provide relief, unlike in children, where surgical intervention might be more common and necessary.

By understanding these differences, it becomes clear that adult scoliosis requires a distinct approach, considering the natural aging process and its impact on the spine, while also accounting for the previous treatments or lack thereof during adolescence.

Why Choose the Southwest Scoliosis and Spine Institute?

The following are just a few of the many reasons why patients might choose us.

• Expertise in the spine: The team of specialists at Southwest Scoliosis and Spine Institute is comprised of spine experts.  They specialize in the diagnosis and treatment of spinal conditions, ensuring the best possible care for their patients.
• Cutting-edge technology: Our practice uses the latest technology and techniques to diagnose and treat a wide range of conditions.  In addition, we use minimally invasive procedures that reduce pain and promote faster recovery.
• Comprehensive care: Our practice offers a full range of services, from diagnostic imaging and physical therapy to surgery.  We ensure that patients receive complete, seamless care for their spinal conditions.
• Dedicated facilities: Southwest Scoliosis and Spine Institute is dedicated to providing patients with a safe and comfortable environment.

Finally, surgeries to correct idiopathic scoliosis are complex and multi-step procedures.  Our Southwest Scoliosis and Spine Institute surgeons, with offices in  Dallas, Plano, and Frisco, Texas, are specially trained and have years of experience performing these types of spine surgeries. We have seen over 100,000 patients and have performed over 16,000 operations.  If you or your loved one is experiencing back pain, we strongly urge you to call us for an appointment, and we will see you in less than 24 hours.

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American Association of Neurological Surgeons: Scoliosis