Severe Scoliosis

Severe Scoliosis Definition

During diagnosis, the x-ray of the spine normally confirms curvature. When the Cobb Angle exceeds more than a 40-45 degree curve for adolescents and 50-55 degrees for adults, it is classified as severe and in such cases, the spine becomes highly deformed. The sideways curvature might include rotation causing the back to bulge to one side. In addition, the doctor will determine the severity by evaluating the degree of the Cobb Angle, spine, body, and the patient’s pain.

• Scoliosis is most often diagnosed in childhood or early adolescence. Scoliosis can develop in infancy or early childhood. However, the primary age of onset for scoliosis is 10-15 years old, occurring equally among both genders.
  In infants or children below the age of 4, it is referred to as Infantile Scoliosis. When discovered in children and adolescents, it is referred to as Pediatric Scoliosis. When found after puberty, it is referred to as Adult Scoliosis.
• When found after puberty, it is referred to as Adult Scoliosis.

For adolescents, this spinal problem usually affects the upper spine, mostly the thoracic or rib cage portion of the spine. In adults, it appears in the lumbar or lower back part of the spine. Moreover, most cases of spinal curvature seem mild and usually do not progress. When doctors can not ID a cause, they will call it Idiopathic Scoliosis. However, this spinal problem may link to other conditions like Cerebral Palsy and Muscular Dystrophy, injuries or infections that affect the spine to include congenital spinal abnormalities.

Scoliosis is usually confirmed through a variety of diagnostic methods:

Physical Examination

A standard exam that is sometimes used by pediatricians and in grade school screenings is called the Adam’s Forward Bend Test. During this test, the patient leans forward with their feet together and bends 90 degrees at the waist. From this angle, doctors can identify any asymmetry of the trunk or abnormal spinal curvatures. This simple initial screening test can identify potential problems but cannot determine the exact type or severity of the deformity. For an accurate and positive diagnosis, radiographic tests are required.

Imaging Techniques

• X-ray: Application of radiation to produce a film or picture of a part of the body. This can show the structure of the vertebrae and the outline of the joints. X-rays of the spine are obtained to search for other potential causes of pain, such as infections, fractures, or deformities.
• Computed Tomography Scan (CT or CAT Scan): A diagnostic image created after a computer reads x-rays. This can show the shape and size of the spinal canal, its contents, and the structures around it. CT scans are very good at visualizing bony structures.
• Magnetic Resonance Imaging (MRI): A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology. MRIs can show the spinal cord, nerve roots, and surrounding areas, as well as enlargement, degeneration, and deformities.

The curve is measured by the Cobb Method and is diagnosed in terms of severity by the number of degrees. A positive diagnosis of scoliosis is made based on a coronal curvature measured on a posterior-anterior radiograph of greater than 10 degrees. In general, a curve is considered significant if it is greater than 25 to 30 degrees. Curves exceeding 45 to 50 degrees are considered severe and often require more aggressive treatment.

Scoliosis Types

The Cobb Angle helps determine the severity of scoliosis, and measuring can occur via X-ray images. The higher the Cobb Angle, the more severe the scoliosis. Understanding these classifications is vital for both diagnosis and treatment approaches, aiding orthopedic surgeons in making informed decisions about patient care.

Mild Scoliosis

Mild scoliosis exists when the Cobb Angle is more than 10° but less than 25°. Most of the time, treatment does not involve surgery, and doctors will monitor the patient for signs of progression. It usually does not require any major treatment aside from regular checkups. In children and adolescents, braces or casting appear effective in making quick adjustments to their growing bones.

Moderate Scoliosis

The Cobb Angle in moderate scoliosis is between 25° and 40°. This may result from the progression of a mild curve that was poorly managed. Bracing and supportive treatment may help in this stage for children and adolescents depending on the situation and the specialist. Finally, spinal alignment can still definitely continue with growing bones.

Bracing for Moderate Scoliosis

Bracing is particularly effective in patients who have not reached skeletal maturity. If the child is still growing and their curve is between 25 degrees and 40 degrees, doctors may recommend a brace to prevent the curve from progressing. Recent improvements in brace design mean that newer models fit under the arm rather than around the neck, providing greater comfort and compliance.

There are several different types of braces available. While experts may disagree on which type is most effective, large studies indicate that braces, when used with full compliance, successfully stop curve progression in about 80 percent of children with scoliosis.

For optimal effectiveness, doctors should check the brace regularly to ensure a proper fit. The patient may need to wear the brace 16 to 23 hours every day until growth stops. Regular monitoring and adjustments are crucial to maintain its effectiveness and to accommodate the child’s growth.

By understanding the stages of scoliosis and the effectiveness of bracing, parents and caregivers can make informed decisions about the best course of action for their child’s spinal health.

Severe Scoliosis

This occurs when the Cobb Angle is greater than 40°–45° for adolescents and 50°–55° for adults. In this state, the spinal curvature is quite prominent alongside postural changes and other complications. Surgery is usually considered at this stage, especially for young people due to cosmetic reasons. The specialist uses this severity scale to determine the course of treatment to follow and how best to help each patient.

Bringing in the traditional severity scale—mild, moderate, and severe—plays a crucial role in the timing of diagnosis and the treatment of patients. This classification allows for informed decisions regarding patient care, whether it involves observation, bracing, or surgery. The degrees of curvature chart thereby aid healthcare professionals in determining the appropriate course of action for managing each case effectively.

Severe Scoliosis Symptoms

Most scoliosis diagnoses originate from multiple causes that get found after a thorough body exam. Obvious symptoms in adolescents between the ages of 10 and 18 include:

• Uneven shoulders
• Off-center head position
• Uneven legs
• Unilateral scapular prominence
• One hip higher than the other
• One side of the rib cage jutting forward

Other symptoms include:

• Lower back pain in older adults

infants with scoliosis symptoms include:

• One side of the chest bulging
• Lying with a body curve on one side
• Shortness of breath or chest pain in severe cases

Symptoms Across Different Degrees of Severity

Moderate Curvatures

Patients with moderate curvatures often manifest symptoms such as uneven shoulders and rib cage prominence. In addition to these visual signs, they may experience noticeable lower back pain and discomfort, significantly impacting their daily activities. Reduced lung function is a common concern, affecting respiratory capacity and overall well-being.

Small Curves

Small curves might present with asymmetries in the shoulders, waist, or rib cage. These asymmetries can lead to back pain and discomfort, particularly after extended periods of sitting or standing.

Large Curves

Large spinal curves, characterized by a spine curvature above 40 degrees, can have more serious implications. These include impacts on spinal cord and lung function. For cases exceeding 50 degrees, surgical intervention is often recommended. Recognizing these situations involves observing noticeable spinal deformities and uneven shoulders, with rib cage distortion indicating the severity of the condition.

Severe Curves

Symptoms of severe curves can significantly impact the overall physical well-being of individuals. This highlights the need for comprehensive approaches to treatment. In many cases, spinal fusion surgery is recommended as a traditional treatment method. Additionally, neuromuscular cases can lead to progressive spinal curves, underscoring the necessity for early diagnosis and intervention.

By understanding the symptoms across different severities, medical professionals can better tailor their diagnosis and treatment plans to each case.

Lower Back Pain in Severe Scoliosis

Lower back pain can occur in adults due to degeneration and other conditions like osteoporosis and arthritis. However, lower back pain occurs with a spinal curve. In adults, spinal degeneration can lead to side-to-side curvature of the spine, called Adult Onset/Adult Degenerative Scoliosis. It involves wear and tear of spinal discs and spinal joints resulting in a shifting and curving of the vertebrae. Adult spinal curve patients often possess spinal stenosis, a condition where the spinal canal narrows. This leads to a compression of the nerves present in that area of the spine. This compression alongside pressure on the spinal discs, the facet joints, and pain in the muscles typically causes lower back pain. Since Scoliosis affects the spine, it can cause tight muscles, fatigue, and lower back pain. The pain becomes intense and will cause problems in daily activities.

When comparing adult cases to adolescent cases, it’s important to note that adults are often associated with degenerative changes in the spine. This can result in back pain, stiffness, and difficulties with breathing. Unlike adolescents, treatment approaches for adults may differ, and in severe cases, spinal fusion surgery is considered. To manage the progression of adult cases, regular monitoring is essential. Understanding these differences across age groups is crucial for tailored diagnosis and treatment disciplines.

Because scoliosis by itself does not cause back pain, other causes need identification before determining the treatment approach. The best way to approach lower back pain caused by spine problems is to manage the spine problems properly. Depending on the type of lower back pain, there are several treatment options available.

Treatment

When there is a confirmed diagnosis of scoliosis, doctors must address several issues to determine treatment options:

• Spinal maturity: Is the patient’s spine still growing and changing?
• Degree and extent of curvature: How severe is the curve and how does it affect the patient’s lifestyle?
• Location of curve: According to some experts, thoracic curves are more likely to progress than curves in other regions of the spine.
• Possibility of curve progression: Patients with large curves prior to their adolescent growth spurts are more likely to experience curve progression.

After these variables are assessed, doctors may recommend the following treatment options:

Observation

In many children with scoliosis, the spinal curve is mild enough to not require treatment. However, if the doctor is worried that the curve may be increasing, they may wish to examine the child every four to six months throughout adolescence.

Therapy

• Hydrotherapy
• Massages
• Stomach and Back Strengthening Exercises
• Supporting Braces

Bracing

Braces are only effective in patients who have not reached skeletal maturity. If the child is still growing and their curve is between 25 degrees and 40 degrees, a brace may be recommended to prevent the curve from progressing. There have been improvements in brace design, and newer models fit under the arm rather than around the neck. While experts may disagree on 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, the brace should be checked regularly to ensure a proper fit and may need to be worn 16 to 23 hours every day until growth stops.

Medication

Some OTC (Over-The-Counter) medications like Tylenol and Advil can help with the pain. If the pain doesn’t get relieved, patients should notify their doctor, who can prescribe stronger pain medication.

Physical Therapy

Physical therapy helps increase flexibility and loosen the affected muscles while reducing pain. Although it does not provide a cure, it assists in managing symptoms. However, finding physical therapists specializing in scoliosis is crucial, as therapists without adequate experience can do more harm than good.

Spinal Injections

These injections deliver steroids around the nerves and joints of the spine to reduce pain, particularly in cases of acute and severe pain.

Surgery

As mentioned above, surgery is often recommended for severe cases of scoliosis. In children, the primary goals of surgery are to stop the curve from progressing during adulthood and to diminish spinal deformity. Most experts recommend surgery when the spinal curve is greater than 40 degrees and there are signs of progression. Surgery can be performed using an anterior approach (through the front) or a posterior approach (through the back) depending on the specific case.

Understanding Decompressive Laminectomy in Scoliosis Treatment

Decompressive laminectomy is a surgical procedure primarily recommended for patients who suffer from both scoliosis and spinal stenosis. Scoliosis causes a sideways curvature of the spine, while spinal stenosis involves the narrowing of spaces within the spine, which can put pressure on the nerves that travel through the spine. This surgery aims to alleviate this pressure and associated symptoms.

The Surgical Procedure Explained:

In a decompressive laminectomy, surgeons remove the laminae, which are the back parts of the vertebrae forming the roof over the spinal canal. Removing these structures provides additional space for the nerves, thus relieving pressure and pain.

When is it Recommended?

This procedure is particularly recommended for scoliosis patients who:

• Experience significant spinal nerve compression due to spinal stenosis
• Continue to suffer from persistent pain or neurological symptoms despite other treatments
• Have noticeable instability in the spine sections affected by scoliosis and stenosis

In addition to the laminectomy, surgeons may also perform spinal fusion, sometimes using spinal instrumentation. This is to ensure the stability of the spine post-surgery, especially in areas where the structure has become unstable due to curvature and degeneration.

Decompressive laminectomy offers a viable solution for those affected by the simultaneous occurrence of scoliosis and spinal stenosis, aiming to improve both spinal function and quality of life.

Understanding Posterior and Anterior Approaches in Scoliosis Surgery

When addressing scoliosis surgery, two primary methods prevail the posterior approach and the anterior approach. Both techniques are tailored to correct spinal curvature, but they differ fundamentally in their execution and outcomes.

Posterior Approach: The Standard Technique

The posterior approach is commonly used for treating adolescent idiopathic scoliosis. This surgical procedure is conducted with the patient lying face down. Here, surgeons access the spine through the back, making it easier to install metal rods and bone grafts necessary for straightening and fusing the spine. The essential steps involve:

• Aligning the spine using rigid rods.
• Performing spinal fusion by placing bone grafts across the curved sections to promote solid linkage between the vertebrae. This method helps maintain the spine in a straight position as the graft fuses, offering stability and long-term correction of the deformity.

Anterior Approach: Minimally Invasive Possibilities

The anterior approach requires the patient to lie on their side. Surgeons make incisions on the side of the body, sometimes removing a rib and temporarily deflating a lung to gain better access to the spine. This approach often utilizes Video-assisted Thoracoscopic Surgery (VAT), which enhances the surgeon’s visibility of the area with minimal invasiveness. Benefits of this technique include:

• Improved accuracy in deformity correction due to enhanced visualization.
• Fewer spine segments need fusion.
• Potentially quicker rehabilitation and faster patient mobilization.

However, despite its advantages, the anterior approach may require patients to wear braces for several months post-operation and carries a slightly increased risk of complications, though VAT has reduced these risks significantly.”

In addition to the anterior approach, minimally invasive surgery (MIS) techniques, utilizing advanced fluoroscopy and endoscopy, further refine the precision and reduce the impact of surgical interventions. These methods improve the accuracy of incisions and hardware placement, significantly minimizing tissue trauma, which is crucial for enhancing patient recovery and reducing hospital stays. It is, however, important to recognize that not all scoliosis cases can be addressed through MIS. The choice of surgical method is influenced by a variety of factors, including the severity and location of the spinal curvature, patient health status, and specific anatomical considerations.

How Can Minimally Invasive Surgery (MIS) Be Used to Treat Scoliosis?

Minimally invasive surgery (MIS) offers a revolutionary approach to treating scoliosis by utilizing smaller incisions compared to traditional surgical methods. Through the adoption of advanced technologies like fluoroscopy and endoscopy, surgeons can perform precise incisions and accurately place hardware, significantly reducing tissue damage.

Key Advantages of MIS for Scoliosis:

• Smaller Incisions: By using smaller cuts, the patient experiences less pain and a quicker recovery time.
• Advanced Imaging: Fluoroscopy provides real-time X-ray imaging during the operation, ensuring that incisions and hardware placement are accurate.
• Endoscopy: With camera technology, surgeons can visualize the surgical area in great detail, making the process more efficient and effective.

Considerations:

It’s crucial to note that not every scoliosis case can be addressed using MIS. The suitability of this method depends on factors like the severity of the curvature, the patient’s overall health, and specific anatomical considerations. A thorough evaluation by a medical professional will determine the most appropriate surgical approach for each individual.

The integration of MIS in treating scoliosis brings forth a paradigm where surgical efficacy is maximized while minimizing physical trauma, making it a preferable option in suitable cases. Yet, the necessity for careful patient selection and the potential limitations in applicability underscore the need for a comprehensive evaluation by specialized surgical teams. This approach ensures that each patient receives the most appropriate and safe surgical intervention for their specific condition.

Key Differences

The choice between the posterior and anterior approach depends on specific patient needs and the nature of the spinal deformity. The posterior approach is robust, involving extensive instrumentation and fusion, typically ensuring strong, long-lasting spinal correction. Meanwhile, the anterior approach stands out for its less invasive nature and potentially faster recovery, albeit with its distinct considerations, such as post-surgical bracing and a slightly higher morbidity rate, which modern techniques like VAT are helping to mitigate.

However, it’s crucial to understand that while many scoliosis patients experience significant benefits from these surgical interventions, there is no guarantee of stopping curve progression or completely alleviating symptoms in every case. The benefits of surgery must always be carefully weighed against its potential risks. Each patient’s condition and response to surgery can vary, making it important to consider these factors in consultation with healthcare professionals.

When deciding on scoliosis surgery, doctors will determine several critical factors to include the following:

Spinal Maturity:

• Is the patient’s spine still growing and changing? This is crucial because a still-growing spine might require different timing or approaches to surgery.

Degree and Extent of Curvature:

• How severe is the curve, and how does it affect the patient’s lifestyle? More severe curves that impact daily activities might necessitate more urgent intervention.

Location of Curve:

• According to some experts, thoracic curves are more likely to progress than curves in other regions of the spine. This information helps in predicting the future trajectory of the condition.

Possibility of Curve Progression:

• Patients with large curves prior to their adolescent growth spurts are more likely to experience curve progression. Understanding this risk helps in planning the timing and type of surgical intervention.

By carefully evaluating these factors alongside the specific surgical approaches, healthcare professionals can tailor the treatment plan to the individual needs of each patient, aiming for the best possible outcomes. This comprehensive assessment ensures that every decision made is in the best interest of the patient’s long-term health and quality of life.

In conclusion, both the posterior and anterior approaches to scoliosis surgery offer effective solutions, each with its own set of advantages and considerations. The posterior method is more traditional and comprehensive, while the anterior provides a novel, less invasive option. Deciding on the best approach requires a thorough understanding of the potential outcomes and a careful assessment of the risks involved.