A Patient's Guide to Spinal Deformity/Scoliosis
The spine is a flexible, segmented column constructed of multiple bones and
joints (disks and facet joints) which are supported by various muscles and ligaments.
The entire system is delicately balanced in order to allow individuals to stand
upright with minimal energy exertion.
When viewed from the front, the spine is normally straight. However, when viewed
from this side, the spine demonstrates a series of curves. In the cervical (neck)
area, the spine curves gently towards the front. In the thoracic (chest) area
the spine has a backward curve. Again, in the low-back area (lumbar spine) the
curve is towards the front.
The overall result of these curves is that the head is balanced above the center
of the pelvis. In the ideal state, minimal energy expenditure is necessary to
maintain the head in this position when in relaxed, upright stance. The force
of body weight is fairly evenly distributed between the disc in the front and
the facet joints behind.
Occasionally, in certain individuals, this normal spinal alignment will be
disturbed. Individuals can develop an abnormal spinal alignment in either the
frontal plane (scoliosis), or the sagittal plane (kyphosis or lordosis).
In actual fact, no spinal deformity exists in only a single plane; all spinal
deformity is some combination of scoliosis, kyphosis or lordosis. Mild degrees
of spinal deformity are quite common and well tolerated. Occasionally in certain
individuals, spinal deformity can become large and require medical or surgical
Scoliosis is a lateral bending of the spine. There are many causes of scoliosis,
but the most common type is termed "idiopathic". This means that the actual
cause is unknown. A great deal of research is currently underway to try to determine
the cause of idiopathic scoliosis. Scoliosis can begin to develop in early childhood
or even in adulthood, but the most common time to develop a spinal curvature
is during the adolescent growth spurt.
The thoracic spine is the most common site of scoliosis. Thoracic scoliosis
is generally associated with deformity of the rib cage as well as the spine
itself. The curvature becomes clinically apparent because of the rib cage asymmetry
that develops. There may be elevation of one shoulder as well. Other manifestations
of scoliosis include an apparent leg length discrepancy. In most cases, scoliosis
is not associated with any pain.
During growth, scoliosis can progress fairly rapidly. During adolescence, curves
may increase in magnitude up to one or two degrees per month. Bracing has been
shown to be an effective method to control curve growth. Bracing cannot permanently
correct the curve. Bracing is only effective in relatively immature patients
and in curves below 40 degrees. Above this size, braces are relatively ineffective
in controlling curve growth.
Certain types of scoliosis are also not amendable to brace treatment such as
when there is frank thoracic lordosis. Many patients present for evaluation
when they are already too close to skeletal maturity for brace use to be effective.
Bracing cannot prevent adult curves from progressing although a brace may be
prescribed for pain control in the adult.
Although fitness and exercise can be generally recommended for spinal health,
there is no series of exercises that has been demonstrated to be consistently
effective in preventing the progression of a scoliotic curve. Likewise, electrical
muscle stimulation is not effective in stopping the progression of scoliosis.
Surgery for scoliosis is generally recommended in the adolescents with large
curves who have significant growth remaining. The larger the curve at the end
of growth, the more likely it is to progress in adulthood. Surgery for scoliosis
involves correction of the curve and fusion of some portion of the spine. The
correction is obtained through the insertion of internal fixation (rods). The
rods are connected to the spine by a series of hooks, screws and wires. This
internal fixation maintains the correction until a solid fusion is obtained.
Generally, some form of bone graft material is used to help promote fusion.
There are many different spinal fusion and instrumentation techniques that
can be used for the correction of scoliosis. Fusion can be accomplished either
anteriorly (through removal of disks) or posteriorly. The fusion technique and
the amount of the spine that requires instrumentation is specific to each individual
case and can only be determined through clinical examination and careful analysis
of X-rays and other imaging studies.
Adult scoliosis is somewhat different from the adolescent variety. Many patients
may have some residual curvature from childhood, which was not sufficient to
require treatment but which progresses after the end of growth. However, it
is possible for curves to begin in adulthood.
Many factors may contribute to the development of scoliosis in adults. Curves
tend to be much more slowly progressive (generally in the range of one or two
degrees each year). Curve progression may be associated with the disc degeneration
and spinal arthritis. Pain may be related to nerve root impingement from spinal
stenosis or the degenerative spinal arthritis itself.
The alteration in the mechanics of the spine brought about by the spinal deformity
can also be a source of pain in and of itself. In many cases, the pain related
to adult scoliosis can be managed without surgery. Medication, exercise, physical
therapy, bracing, smoking cessation end weight loss are all common methods used
to help control back pain related to scoliosis.
Surgical treatment of scoliosis in adults is reserved for patients with intractable
severe pain, which is refractory to a prolonged period of non-surgical treatment
or for patients who demonstrate significant curve progression following skeletal
maturity. The surgical treatment of adult scoliosis is similar to adolescents
in the sense that internal fixation and fusion are generally required. However,
adults often require more extensive surgery than children.
Their curves are more often rigid and are more difficult to correct. Significantly
degenerated segments need to be incorporated into the fusion construct. Also,
adults do not fuse their spines as readily and require more extensive techniques
to ensure that a solid fusion is obtained. Adult scoliosis is more likely to
be associated with kyphosis and require anterior column reconstruction in order
to fully address the spinal deformity in three dimensions.
Surgery for scoliosis can be extensive and the risk of complications exists.
Complications can include anesthetic complications, bleeding, infection, loss
of correction, failure to obtain a solid fusion, instrumentation loosening or
breakage as well as neurologic complications. Other complications exist is well.
Each patient should have a thorough discussion with their doctor prior to surgery
so that they understand the potential complications that can occur with this
type of surgery before they agree to proceed with surgery.
The length of hospitalization and recovery vary depending upon the magnitude
of the surgical procedure. Adolescents generally are in the hospital for less
than one week and are ready to return to school about six weeks following surgery.
Adults take longer to recover. Using modern instrumentation techniques, postoperative
bracing is rarely required.
Returning to full activities is prohibited until a solid fusion is seen on
X-ray. This may take several months but once the fusion is mature, most patients
can return to all their normal activities, without limitations. Surgery for
scoliosis, in general, is highly successful. The majority of patients experience
significant relief of pain and improve cosmetic appearance. The benefits of
this surgery are substantial.
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