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Orthopaedics
Scoliosis


A healthy spine supports the body, protects the spinal cord, allows flexibility and movement, and provides points of attachment for muscles and ligaments. The spine has three normal curves that form a natural "S" shape of the vertebral column. There are 33 total vertebrae that form five regions of a spinal column: seven cervical, 12 thoracic, five lumbar, five fused vertebrae (sacrum), and four smaller fused vertebrae (coccyx). The "S" shape occurs as a child develops into an upright position. During growth and development, the cervical and lumbar vertebrae form a posterior curved-in appearance, while developing thoracic vertebrae form a posterior curved-out appearance.

When the spine develops in an abnormal lateral position, the curve is termed scoliosis. True scoliosis is diagnosed when the lateral curve is greater than 10 degrees. Four types are identified:

Idiopathic Scoliosis
This the most common type and occurs in children between 3 and 10 (Juvenile Idiopathic Scoliosis) and older children and teens between 11 and 18 (Adolescent Idiopathic Scoliosis). Adolescent scoliosis represents 80 percent of cases. Curves are found with equal frequency in boys and girls, though girls have higher risk for curve worsening than boys. Worsening of the curve occurs around puberty, when growth rates are the fastest. Lung and heart function are not disturbed until thoracic curves exceed 70 degrees. This finding typically occurs later in life among patients with untreated idiopathic infantile, juvenile or adolescent scoliosis.

Congenital Scoliosis (infantile idiopathic)
This is less commonly occurs and presents before 3 years of age, affecting males more than female. If the curve is less than 25 degrees, surgery is not needed. If the curve is greater than 25 degrees and progressive, surgery is usually needed.

Neuromuscular Scoliosis
This can occur with any condition that affects the central nervous system. Neuromuscular curves tend to progress rapidly and involve the majority of vertebrae. This type of scoliosis is usually resistant to bracing. Larger curves that develop need surgical correction. Cerebral palsy, muscular dystrophies, and muscular atrophy are neurological conditions that are associated with neuromuscular scoliosis.

Degenerative Scoliosis
This can occur with aging. As our once-spongy disc between the vertebrae become dense, then each vertebrae compresses, and ligaments lose elasticity. The result is curvature of the spine.

Treatment

Options for treatment of scoliosis include observation, bracing and surgery.

Observation
This is recommended when scoliosis curves measure greater than 10 degrees but less than 30 degrees. Monitoring for curve progression may occur every four to six months until a patient has reached skeletal maturity (for girls, this is around 14 years; for boys, around 16 years).

Bracing
This is recommended when scoliosis curves measure 30 degrees or greater in a young patient who has yet to reach skeletal maturity. The primary goal of bracing is to stop curve progression. The pediatric orthopaedic surgeon recommends bracing for 22 to 23 hours per day. However, initially brace time is less until a comfort level is achieved and then increased incrementally to 23 hours per day.

Three common types of braces

  • Cervical thoracolumbosacral orthosis (CTLSO or Milwaukee brace). This brace is used for mid-thoracic curves and higher. The brace has a molded pelvic portion, metallic upright supports, pressure pads along the thoracic vertebra, a throat mold and base of skull portion. Because of the high visibility of the brace, patient compliance is an issue.
  • Thoracolumbosacral orthosis (TLSO or Boston brace). This brace is used to manage lower thoracic and lumbar curves. The brace has prefabricated pelvic and thoracolumbar modules with custom lateral pressure pads. The brace is less visible when worn, and patients are more likely to comply.
  • Bending thoracolumbosacral orthosis (TLSO or Charleston brace). This brace provides a bending force against the curve and is designed to be worn during the night. Patient compliance is good.

Surgery
Surgery for idiopathic scoliosis is recommended for curves greater than 45 degrees.

Because scoliosis is a three-dimensional deformity, surgical correction is aimed at correcting the entire condition. Currently, the most common surgical procedure is a posterior spinal fusion with instrumentation and bone grafting. Fusion of the spine stops further progression of the curve while reducing the deformity. The instrumentation used provides multiple points of fixation thereby lessening the need for post operative casting or bracing.

Post-operative hospital care generally lasts five days. Return to routine daily activity occurs progressively, though early walking is common. Post-operative home care is managed for each patient, with pain medication and activity guidelines. Clinic follow-up begins six weeks after surgery and continues as needed.

Spinal fusion surgery can result in complications. The highest risk, neurological deficits (loss of motor and sensory function), can be minimized by the use of intraoperative neuromonitoring. Electrodes painlessly attached to the patient allow the surgeon to watch moment-to-moment changes within the nervous system while working to align the spine. When a signal is received through the electrodes, adjustments can be made before problems occur. Less-common surgical risks include wound infection (1%), pseudoarthroses or non-healing of the fused bone (1-2%), and hardware failure or prominence (10-15%).

The natural progression of scoliosis depends on the curve size and skeletal maturity. Curves greater than 25 degrees may worsen in a skeletally immature patient. Thoracic curves greater than 50 degrees and lumbar curves greater than 30 degrees may worsen after skeletal maturity at one degree each year. Thoracic curves greater than 75 degrees can cause lung problems.

Scoliosis can be a serious orthopaedic problem but can be successfully managed by observation, monitoring, bracing, and surgical intervention when necessary. Proper selection of a fellowship-trained pediatric orthopaedic surgeon can ensure thorough management during growth and development of the pediatric spine.

Our department offers pediatric-trained orthopaedic surgeons for mid-Missouri patients and families. We invite you to contact us and call our clinics for an appointment.

Additional resources
American Academy of Orthopaedic Surgeons 
FamilyDoctor.org
KidsHealth.org 
Scoliosis Assocation
Scoliosis Research Society
Stryker: A Guide to Minimally Invasive Spine Surgery 
National Institutes of Health 
National Scoliosis Foundation 
 




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