For 14-year-old Abby Kienzle, it was a brace that saved her from having to go under the knife. Four years earlier, the Malvern teen was diagnosed with an “S”-shaped curve of the lumbar and thoracic spine, along with a rotated hip. “I noticed that Abby’s shoulders were off. She looked crooked to me,” says her mom, Cindy.
Remember in grade school when you had to bend at the waist for the doctor? Today’s screening for adolescent scoliosis remains the same, but treatment for patients like Abby has come a long way.
According to the National Scoliosis Foundation (NSF), six million Americans—or 2 to 3 percent of the population—have a curvature of the spine. Most experience no pain or other intrusive symptoms. For those who do, today’s treatment options are varied, ranging from simple monitoring of the curvature to surgery.
When normal, the spine is a long, straight bone that runs from the neck to the sacrum (lower back). Because it acts as a shock absorber for the body, any deviation in its alignment can cause pain and improper internal organ function. The Scoliosis Research Society (SRS) defines scoliosis as a curvature of the spine 10 degrees or greater. The most common curvatures appear as the letters S or C on the back.
The degree of curvature can vary greatly. In fact, most people don’t have a perfectly straight spine. But when the curvature is severe, it can cause pain, an uneven gait and internal problems with the heart, lungs or breathing system. The course of treatment will depend on what type of scoliosis is present, whether or not the patient has reached skeletal maturity, the degree of curvature and the appearance or level of deformity. While scoliosis is typically associated with children, adults can also have the condition. The causes and treatments may differ. As such, there are orthopedic surgeons who work strictly with children or adults.
The Kienzles’ pediatrician sent Abby to Shriners Hospital for Children in Philadelphia, where she was fitted for a brace to help prevent her 17-degree curve from getting worse. Abby has the most common form of scoliosis—idiopathic, meaning “of unknown origin.” It can show up in infants, juveniles (ages 3-9) and adolescents (ages 10-18.) The latter group accounts for 80 percent of all idiopathic cases. Although infantile cases are more prevalent in boys, the more progressive cases are seen in girls.
Unless the curvature is severe, orthopedic surgeons will usually wait until the child reaches full skeletal growth before advising surgery. Observation is often repeated every three to six months. In some cases, patients will wear a brace to help stunt the curvature growth.
Today’s braces are comfortably designed and can be easily removed for athletic activity. Abby’s hardly resembles the bulky, chin-high braces of 20 years ago. It’s plastic, with padding on the inside and straps along the sides. Bracing and other forms of orthotic therapy are most effective with children who haven’t yet reached maximum skeletal growth and who have spinal deformities or curvatures of 25 to 40 degrees. For patients who don’t respond to brace therapy or whose curvatures threaten to increase, surgery may be warranted.
Two other types of adolescent scoliosis, congenital and neuromuscular, almost always require surgery. The former is the result of abnormal spine formation—vertebral malformations that occur early on in embryonic gestation, usually a few weeks after conception. Early surgical intervention is suggested, even before the child’s second birthday, as this can help prevent future procedures. Typically, CT and MRI scans are performed to rule out other physiological reasons for the deformity.
Neuromuscular scoliosis is seen in children with spinal cord injuries and diseases such as spina bifida, cerebral palsy and muscular dystrophy. Patients with this condition have difficulty sitting and are immobile, or have severely compromised walking. Early surgical intervention is the best treatment option.
When surgery is called for, spinal instrumentation and fusion are the most commonly used procedures. This involves grafting bone taken from the patient’s hip or pelvic area. The added bone is fused to the spine with screws and pins to stabilize it and prevent further abnormalities. Technological advances such as the thoracoscope (a long, thin, tube-like instrument with a light at the tip) allow for more careful monitoring of the spine, smaller incisions and a more pleasing cosmetic outcome. And a new 3D technique with multiplanar technology allows for multi-level views, easier spinal correction and a more reliable fusion.
Dr. Amer Samdani is on the cutting edge of progressive scoliosis treatments. A pediatric spine surgeon at Shriners, Samdani strives to avoid surgery if the patient’s curvature is less than 50 percent, or if the curvature isn’t likely to worsen or pose a threat to the patient’s gastrointestinal track or pulmonary system.
“As far back as 15 to 20 years, scoliosis treatment focused on casting and spine fusion,” he says. “Now there are many new procedures.”
Among the most recent treatments, Shriners was instrumental in developing stapling and is one of the few hospitals to implement the vertical expandable prosthetic titanium rib (VEPTR). “These both allow for intervention of severe scoliosis without fusion of the spine,” says Samdani.
VEPTR involves surgically attaching a titanium rib to the back chest area to help expand the rib cage, increase thoracic volume and straighten the growing spine. Stapling was developed 20 years ago as a method of correcting bowlegs and knock-knees but was initially ineffective for scoliosis because the staples kept dislodging in the chest cavity. But recent technological improvements have corrected that glitch.
Surgery is even less likely in adult patients, who usually respond well to non-invasive treatments such as moist heat, physical therapy, medication and pain management. While pain isn’t typically present in adolescent scoliosis, it is the main reason adults opt for surgery. Bracing isn’t effective for older patients because the spine is done growing—and they don’t help with the pain.
Dr. Todd Albert, vice chairman of Jefferson University Medical College’s department of orthopedics, works exclusively with adult patients. He mainly treats those who have uncorrected adolescent curvatures that continue to grow, or those with degenerative disc conditions. And he doesn’t recommend that adults rush into surgery. He suggests getting a couple of opinions from doctors who specialize in spinal surgery and are scholarship trained. Non-invasive treatments are always ideal, but surgical options have vastly improved over the years and continue to do so.
As for Abby, her curve is now at just 12 percent, and she’ll likely avoid surgery. All that’s left is monitoring the curve, getting X-rays every six months and changing her brace yearly. In fifth grade, Abby wore the brace 24 hours a day for a year, removing it only to shower or play sports. By sixth grade, she’d stopped wearing it to school. Now she wears it only at night. In fact, it’s hard for her to sleep without the brace. “It’s completely unnoticeable when Abby is wearing a sweatshirt or big T-shirt,” says her mom.
But the brace is one security blanket Abby will be happy to do without.
While most schools screen for the condition, there are some telltale signs to look for.
1. A leaning to one side.
2. A hump on one side when bent over.
3. Uneven hips or shoulders.
4. A protruding shoulder blade.
5. Clothes fitting unevenly.
6. Legs two different lengths.
7. An uneven gait or limp.
Adult signs might involve any of the above, as well as numbness and tingling (due to nerve compression) and back or leg pain.
Risk: All surgeries involve the risk of bleeding, infection and post-surgical discomfort, but scoliosis surgery is relatively safe.
Recovery: Physical therapy may be required after surgery to build muscle strength and increase range of motion.
The exam will involve a family history, visual evaluation, forward bends, walking, height measurement and X-rays.
According to the Scoliosis Research Society, “there is no scientifically documented role for exercises, manipulation or electrical stimulation in the management of scoliosis.” “Chiropractors can be helpful for acute back pain, not chronic,” says Jefferson University Medical College’s Dr. Todd Albert. “They have no efficacy in scoliosis.” Still, alternative treatments such as acupuncture or massage may help manage pain. For more information on scoliosis, visit scoliosis.org and iscoliosis.com.