Cleveland_Clinic_Host: Welcome to our Online Health Chat with Douglas Orr, MD. Dr. Orr specializes in spinal surgery at the Cleveland Clinic Center for Spine Health and has a joint appointment in the Department of Orthopaedic Surgery. He is certified by the American Board of Orthopaedic Surgery and by the Royal College of Physicians and Surgeons of Canada. Dr. Orr has surgical expertise in the cervical, thoracic and lumbar spinal areas, specializing in adult spinal surgery, including minimally invasive surgery, deformity surgery and spinal tumor surgery.
Dr. Orr received his medical degree from the University of Toronto Faculty of Medicine and served his surgical internship at The Wellesley Hospital at the University of Toronto, also completing his residency training in orthopaedic surgery at the University of Toronto. Dr. Orr received fellowships in orthopaedic spinal surgery from The Toronto Hospital and from the University of Wisconsin at Madison. Dr. Orr also received a fellowship in orthopaedic surgery from the Royal College of Surgeons of Canada. He was appointed to Cleveland Clinic in 2003.
Dr. Orr has authored and co-authored numerous articles on his specialty interests and has been an invited lecturer at orthopaedic conferences and symposia throughout the United States, Canada and in other countries.
Welcome Dr. Orr and thank you for being here today to answer questions during our chat. First, would you briefly tell us what scoliosis is and then let's begin with some questions that have come in.
Speaker_-_Dr__Douglas_Orr: Scoliosis is an abnormal lateral curvature of the spine. It is most commonly found in children and teenagers who have not yet reached skeletal maturity, but is also frequently diagnosed in many adults. The causes and treatment of scoliosis is often much different for adult patients, especially when deciding which medical treatments are the best options in managing this spinal disorder.
Scoliosis in Adults
lauramc: Is it true that scoliosis cannot progress in adulthood?
Speaker_-_Dr__Douglas_Orr: No, this is not true. As the spine ages, the degenerative process can cause the curve to worsen. Typically, lumbar curves are more likely to progress. In general the curves progress about 1 degree per year if they are going to progress.
newtonm: Can scoliosis appear in an adult without any history of childhood curvature?
Speaker_-_Dr__Douglas_Orr: Yes there is a type of scoliosis called degenerative scoliosis that occurs later in life in people with no history of scoliosis.
newtonm: How does adult scoliosis differ from childhood scoliosis?
Speaker_-_Dr__Douglas_Orr: In adults scoliosis is more likely to be associated with pain in the back or legs than childhood. Adult curves tend to not be as progressive as childhood curves.
deppf: How old can a person be when this begins? My dad has lost significant height from osteoporosis and now appears to be sitting crooked. He is in his 60’s. Is this too old to do something?
Speaker_-_Dr__Douglas_Orr: There is no absolute cut-off after which surgery is not an option. A lot of it depends on overall health. There are 80 year olds who are healthier than many 60 year olds and there are 60 year olds that are physiologically 80. It all depends on the persons underlying health and the magnitude of the surgery that would be required to improve their symptoms. Osteoporosis in itself significantly increases the risk and may lessen the surgical options.
mannyp: My daughter has a very slight curvature to her spine (she is 13). Her doctor said that it was not enough to be concerned with and that she did not need any treatment at this time. Does she need to worry about this progressing as an adult?
Speaker_-_Dr__Douglas_Orr: The risk of progression depends on the size of the curve and her level of skeletal maturity. If she has a lot of growth left, then the risk of progression is higher. We can estimate how much growth remains by looking at the X-rays. As a general rule, once a girl starts having her periods, she will stop growing 12-18 months later.
ladams9200: My lumbar curve has progressed greatly over the past year. I didn't even know I had one until I developed sciatica after childbirth, then I went to Cleveland Clinic. Now it's at 25 degrees. How much worse will it get if it's progressed this much in a year? Any help would be appreciated.
Speaker_-_Dr__Douglas_Orr: A 25 degree curve is unlikely to get much worse. The risk of progression depends on what type of scoliosis you have.
lauramc: You mentioned that a curve of 30 degree or greater may progress during adulthood - what's the likelihood of progression of a 40 degree curve? Is there anything that we can do to try to prevent it? Thanks.
Speaker_-_Dr__Douglas_Orr: It depends on whether a 40 degree curve is in the thoracic (rib cage) spine or the lumbar spine.
If it is thoracic, the risk of progression after skeletal maturity doesn't really go up significantly unless the curve is over 50 degrees.
There is little that can be done to prevent progression other than not smoking and maintaining an ideal body weight.
rstuart: What happens when your diaphragm is pushed out of place by your spine due to scoliosis?
Speaker_-_Dr__Douglas_Orr: Because the rib cage also curves, the diaphragm changes shape due to scoliosis. The diaphragm is a very adaptable muscle and its function is not changed as a result.
Causes of Scoliosis
batterup: What causes spine curvatures?
Speaker_-_Dr__Douglas_Orr: There are many causes. Some are present at birth and are due to abnormalities in the formation of the vertebra (Congenital Scoliosis). Some are the result of abnormal growth patterns (Juvenile or Adolescent Scoliosis).This type of curve has a genetic predisposition. Some are due to asymmetric wear of the discs leading to a curve (degenerative scoliosis). There are also curve due to underlying neurologic problems (neurogenic scoliosis) and as the result of spine fracture that do not heal straight (post-traumatic scoliosis).
tooney: Can trauma that affects the spine end up causing scoliosis?
Speaker_-_Dr__Douglas_Orr: If the trauma was sufficient to cause the spine to fracture it can. The injury needs to be severe and is readily apparent when it happens. Delayed deformity months or years after a trauma is never the direct result of trauma.
Evaluation and Diagnosis
classact: As an adult, should I seek out a spine surgeon for evaluation? What should I ask?
Speaker_-_Dr__Douglas_Orr: If you were diagnosed with scoliosis as a child and your curve was greater than 30 degrees when you stopped growing you should see a spine specialist every 3 to 5 years to ensure it is not progressing. Otherwise the indication to see a spine surgeon is pain or loss of function that has not responded to non-operative care.
Treatment Options for Scoliosis
newtonm: How is scoliosis treated in an adult?
Speaker_-_Dr__Douglas_Orr: The type of treatment varies widely depending on the symptoms. Many adults with degenerative scoliosis have little or no symptoms and require no treatment. Non-operative treatment may include physical therapy, medications or nerve root blocks. There are a wide variety of surgical options depending on the symptoms, the severity of the deformity bone quality and general overall health.
Managing the Pain of Scoliosis
ladams9200: Hello Dr. Orr! I have had a previous spinal fusion surgery with 2 Harrington rods fused down to L4. I then had a small second surgery. Now, 13 years later, I am curving between the L4-S1 region and it is causing me a lot of pain to the point I'm developing insomnia also. The surgery suggested is not realistic for me this time in my life and was wondering if there was anything you would suggest helping this progressive curve and pain, other than living on pain meds of course. My insurance doesn't cover PT very well so that's not feasible right now either. Anything I could do at home? Why do you think this happens after having previous surgeries? I thought I would be completely fixed but that's not the case.
Speaker_-_Dr__Douglas_Orr: Fusions for scoliosis immobilize the vertebrae that are fused, but you continue to move through the other discs and these discs may wear out more rapidly as a result. A fusion to L4 with Harrington rods has approximately an 85% chance of leading to problems like you have. If surgery is not realistic for you at this time, there is little other than pain management that can be done.
ladams9200: Can sciatica reoccur more than once in life, brought on by the spine?
Speaker_-_Dr__Douglas_Orr: Yes. It is uncommon but approximately 10% of people who have sciatica due to a disc problem will have a recurrence of the sciatica.
pellen: How good is chiropractic treatment on scoliosis?
Speaker_-_Dr__Douglas_Orr: Chiropractic treatment will not change the scoliosis, but may help with pain particularly acute episodes of pain ("throwing your back out"). Chiropractic treatment will not prevent progression of the curve.
bobandmary: Is massage effective to a person with scoliosis?
Speaker_-_Dr__Douglas_Orr: Massage may help control pain. If it makes you feel better, it is a good thing. If not - it is not.
rebeccacox: my son has a great deal of pain in his ankles and at times has some difficulty walking,is this because of the scoliosis causing him to walk awkward?
Speaker_-_Dr__Douglas_Orr: No - probably not. Ankle pain is most likely due to the ankles themselves.
kslabe: Is surgical intervention likely to benefit an adult scoliosis patient?
Speaker_-_Dr__Douglas_Orr: As I mentioned earlier in this chat, surgery may be a very good option in selected patients who have not been able to control their pain with appropriate non-operative care.
sharonde: My mother is 80 years old. She has very bad scoliosis and osteoarthritis in her back. Doctors want to do surgery for this problem because she has a terrible time walking. Do you think this is a good idea? She also fell and broke her hip in September, but recovery is very good. Thank you for your opinion.
Speaker_-_Dr__Douglas_Orr: Whether surgery is an option would depend on how bad the curve is and how bad the osteoporosis is. In some cases, there are less aggressive surgical options that can treat the symptoms without correcting the scoliosis.
lauramc: I have significantly limited mobility in turning my body and head (all directions). Would surgery help or would it further immobilize me? I have rotation, a lower 40 degree curve and an upper 26 degree one with a significant turn at the base of the neck (untreated).
Speaker_-_Dr__Douglas_Orr: If your mobility is limited due to pain, then treatment may improve your mobility. If the loss of mobility is due to structural changes in the spine, we cannot restore mobility as the treatment involves fusing the spine.
lauramc: Are there any surgical techniques today that do not immobilize the spine?
Speaker_-_Dr__Douglas_Orr: There are some newer and very experimental techniques to stabilize the spine but not fuse the spine. To date, the results of these techniques have not been particularly good.
pitpat: What determines if surgery is necessary for adult scoliosis?
Speaker_-_Dr__Douglas_Orr: Surgery becomes an option when non-operative treatments fail to adequately control the symptoms. We do not operate in adults on a preventative basis as we sometimes do for adolescent scoliosis.
punkd: What “angle” of scoliosis is required before a person is considered a candidate for surgery? Also, at what degree would it be considered a disability?
Speaker_-_Dr__Douglas_Orr: In adults, there is no "angle" at which surgery is required. The decision to have surgery is based on symptoms. There is no degree of scoliosis that constitutes a disability. Disability is again based on symptoms.
rebeccacox: X-rays are showing that my son (age 16) has mild left convex scoliosis of the lumbar spine, what does this mean and will he need surgery to fix it?
Speaker_-_Dr__Douglas_Orr: If the curve is mild (less than 30 degrees) the risk of the curve getting worse is low and he is unlikely to ever need surgery for it.
dallasr: My niece is 19 and a ballerina. She was diagnosed with mild scoliosis. What can she watch out for that would indicate the scoliosis is getting worse? Ballet is going to be her career.
Speaker_-_Dr__Douglas_Orr: The good news is that at age 19 she has stopped growing and if the curve is mild(less than 30 degrees) there is really no risk of progression. There is no reason for her to curtail her ballet career. Remember though that ballet is a very demanding profession and many dancers have intermittent back pain but rarely does it cause long term problems.
londonfog: Are Harrington rods and body casts still used? I remember those in the 1970’s with a friend of mine.
Speaker_-_Dr__Douglas_Orr: Harrington Rods have not been widely used since the early 80’s. We do use rod and hooks or screw but they are now much more sophisticated and versatile. Some surgeons do use braces after surgery though I have not done so in the past 8 years.
louis: Is there minimally invasive scoliosis surgery yet or is the surgery still open?
Speaker_-_Dr__Douglas_Orr: There are a number of minimally invasive options that can be used in selected cases but many patients do need a more traditional larger procedure.
NICKLEDE: Are there improved surgical techniques for correcting S-shaped for a 35 yr old female who has been previously told she is borderline for surgery and it was not recommended in the past?
Speaker_-_Dr__Douglas_Orr: Again the decision for surgery is not based on the size of the curve but on the severity of the symptoms.
Risks and Benefits of Surgical Intervention
pitpat: What complications can occur from surgery?
Speaker_-_Dr__Douglas_Orr: There are many possible complications. Some of them are common but minor and some are rare but serious. There is a small (1 in 3000) risk of paralysis with a major surgery.
pitpat: What are the risk / benefits of surgery?
Speaker_-_Dr__Douglas_Orr: This depends on what surgery we are doing, how extensive the surgery is and the general health of the patient. Smaller operations tend to have smaller short term risks though the smaller surgeries may increase the risk of longer term problems. Larger ones have larger risks. It is the balance of risk and benefit that determines what we do and in some cases the surgery carries to high a risk to be safely done.
hallens: Can the spinal curvature still worsen, even after a spinal fusion?
Speaker_-_Dr__Douglas_Orr: There are 3 possible ways a curve can worsen after a fusion. Most commonly, the curve progresses above or below the segments that are fused.
If a fusion does not heal, then the curve may progress.
The third is a rare form of progression in children that were fused for scoliosis before age 12. In these patients, the front of the vertebrae may continue to grow and worsen the curve due to a phenomenon called "Crankshafting." This does not occur commonly with modern fusion techniques.
leddie: What is kyphosis and can this appear in adults with bad posture?
Speaker_-_Dr__Douglas_Orr: Kyphosis is an exaggeration of the normal curve of the spine through the rib cage or thoracic vertebra. There are many causes of kyphosis. “Bad Posture” is usually a symptom of kyphosis and not the cause. In other words the kyphosis is the reason for the bad posture NOT the other way around.
Osteoporosis and Adult Scoliosis
lauramc: Is there any correlation between osteoporosis and scoliosis? Should scoliosis patients take extra measures to prevent osteoporosis? If so, do you have any suggestions?
Speaker_-_Dr__Douglas_Orr: If a patient with scoliosis develops osteoporosis their curve can get much worse and there may come a point where the bone quality is so bad, it becomes impossible to correct. It is vitally important that people with scoliosis be screened for osteoporosis and be treated aggressively if they have osteoporosis.
bent100: Can men also get scoliosis? Why does it always seem to be women that have it?
Speaker_-_Dr__Douglas_Orr: About 1:7 adolescents with scoliosis are male. It is much less common in males and we are not quite sure why. It is probably related to hormones during growth. Degenerative scoliosis occurs almost equally in males and females.
lauramc: What is the likelihood that a woman with scoliosis is likely to pass it on to her children? Is there any difference for a man? How likely are the biological nieces/nephews of a woman with scoliosis to inherit it? Is scoliosis more common in men v. women?
Speaker_-_Dr__Douglas_Orr: There is a 15% chance that any 1st degree female relative of someone with scoliosis will develop scoliosis.
There are families with a higher incidence and studies are ongoing looking at the genetic link. University of Utah has developed a genetic marker for the risk of scoliosis.
ladams9200: Sorry for so many questions but I am just completely overwhelmed with my reoccurrence of curving and don't know what to do. Since I do have such a severe case of scoliosis, what are the chances of my daughter getting it? I know it can be hereditary and I will never forgive myself if I pass this along to her, even though I know that's out of my hands. What can I do now (she's 19 months old) to maybe curb this from happening to her?
Speaker_-_Dr__Douglas_Orr: As stated earlier, there may be a chance of her developing scoliosis since you are a first degree relative. Since you are feeling overwhelmed, it would probably be best for you to be evaluated by a specialist in spinal deformity surgery to discuss your concerns.
rebeccacox: Is scoliosis genetic? My sons father has spondylosis.
Speaker_-_Dr__Douglas_Orr: Spondylosis is a fancy name for normal degenerative processes in the spine that may or may not become symptomatic.
connorb: Is there any way to prevent scoliosis from getting worse and avoiding surgery?
Speaker_-_Dr__Douglas_Orr: Stay active, keep your weight down, don’t smoke and prevent osteoporosis with appropriate diet, weight bearing exercise and sometimes medication.
Exercise and Scoliosis
execute: What types of exercises are beneficial for people with scoliosis?
Speaker_-_Dr__Douglas_Orr: Exercise is beneficial for any spine problems and there are 2 parts to it. One is a cardiovascular fitness program such as brisk walking, bicycling, swimming, and low impact aerobics. Second is a trunk strengthening exercise program that may be specifically designed for you by a therapist though Pilates and yoga are also quite good.
lauramc: Do you recommend stretching against the curve without stretching the other side? Could I be doing damage if where I stretch is not the center of the curve? I have a lower 40 degree curve and an upper 26 degree curve with rotation (untreated). Thank you for sharing your time.
Speaker_-_Dr__Douglas_Orr: You will not do damage with any type of stretching and in general, stretch towards the side that feels better.
lauramc: When you say to stretch against the painful side, do you mean only in the opposite direction of the pain while not stretching the other side at all? (PT suggested that I only stretch one side (opposite the curve) to compensate for the muscles supposedly being tighter on that side. Do you agree or should I stretch both sides equally? Thanks.
Speaker_-_Dr__Douglas_Orr: No - stretch in the direction that makes you feel better. For some people that is stretching into the curve and for some it is away from the curve.
michald: I wore a Milwaukee brace for 3 years in the 70's. My scoliosis did not get worse but it is still there. I seem to have a difficult time with exercise. My spine doesn't seem to work like everyone else's. Are there exercises designed particularly for people with scoliosis, or are there some exercises I should just avoid? I think it sometimes causes me not to do the exercise properly and I end up straining another part of my body.
Speaker_-_Dr__Douglas_Orr: There are no exercises that will cause damage to your spine or worsen your scoliosis. Exercises to strengthen your trunk muscles (commonly called core strengthening) are the most beneficial. Scoliosis does limit the mobility of the spine through the curve and patients with scoliosis may feel stiffer. Stretching exercises may improve but will not eliminate this.
Having a consultation with a physical therapist or athletic therapist may identify things that you are doing incorrectly that lead to your straining another part of your body.
Pregnancy and Other Myths Associated Scoliosis
2cats1dog: What are the risks involved in pregnancy with mild scoliosis?
Speaker_-_Dr__Douglas_Orr: In the past, it was felt that women with scoliosis would progress their curves during pregnancy. We now know that this is not true. There may be a transient increase in the curve due to hormonal influences but this corrects about 6 months after you stop breast feeding.
Another myth is that women with scoliosis have a higher incidence of caesarian sections.
Lastly, women with scoliosis have a slightly higher incidence of back pain during pregnancy, however remember 80% of women experience back pain during pregnancy.
lauramc: You mentioned that hormones can cause adult scoliosis to temporarily progress. Does hormone deficiency affect the curve? What about hormone supplementation via birth control?
Speaker_-_Dr__Douglas_Orr: Hormone deficiency does not affect the curve nor does hormone supplementation. Other than in pregnancy, hormone levels are not high enough to cause problems. Hormone deficiency is a cause of osteoporosis and that may affect the curve.
NICKLEDE: Are there any support groups for young adults (30+) with scoliosis in the NYC/NJ area? If so, how can one contact them?
Speaker_-_Dr__Douglas_Orr: Scoliosis.org is one web site that might be able to help find a support group.
Cleveland_Clinic_Host: We are getting ready to close for today. A large number of questions were received and we apologize if we did not get to your question. We will try to answer as many questions as possible in these last few minutes. If you have additional questions, please go to clevelandclinic.org/health/livepersonchat to chat online with a health educator.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Orr is now over. Thank you again Dr. Orr, for taking the time to answer our questions today.
Speaker_-_Dr__Douglas_Orr: It has been a pleasure. Thanks.
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