Online Health Chat with Dr. Thomas Kuivila
March 3, 2010
Cleveland_Clinic_Host: Scoliosis, or curvature of the spine, usually affects children 10 to 16. Signs include leaning to one side, having uneven shoulders, one shoulder blade that sticks out, an uneven waist or a raised hip. Pediatric orthopaedic specialists evaluate the curvature to determine treatment. Slight curves may never progress and are observed. A night-time back brace can keep moderate curves from progressing. Surgery is needed for severe scoliosis to ensure healthy growth and organ function
Thomas Kuivila, MD, is a staff physician in the Center for Pediatric Orthopaedics. He currently heads the Section of Pediatric and Adolescent Spinal Disorders in the Orthopaedic and Rheumatologic Institute and is the Residency Director in the Department of Orthopaedic Surgery.
Dr. Kuivila’s specialty interests include congenital and developmental spinal disorders to include scoliosis, kyphosis and spondylosis and lithesis. He is also an expert in pediatric orthopaedic trauma. His research interests include bioabsorbable fixation and minimally invasive scoliosis surgery.
Dr. Kuivila completed his orthopaedic surgery residency at Cleveland Clinic and then went on to complete his pediatric orthopaedic surgery fellowship at Brown University in Providence, Rhode Island
To make an appointment with Thomas Kuivila, MD or any of the other specialists in our Orthopaedic and Rheumatologic Institute at Cleveland Clinic, please call 866.275.7496. You can also visit us online at www.clevelandclinic.org/ortho
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Thomas Kuivila. We are thrilled to have Dr. Kuivila here today for this chat. Let’s begin with the questions.
Overview of Scoliosis: Then and Now
lanisha1: How is pediatric scoliosis treated differently today than it was 20 years ago?
Speaker_-_Dr__Thomas_Kuivila: Advances in many areas make scoliosis surgery safer and more effective than in the past.
The first is the instrumentation used (rods, etc.). Today we use what is referred to as segmental fixation. We attach to many levels of the spine compared to the Harrington model where only 2 hooks were used.
The first thing this does is give us a better correction of the curve and helps restore 3 dimensional alignment. It also allows us to forgo postoperative bracing or casting.
Another big change from the past is the use of bone grafts. Whereas we once took bone from the pelvis, we now use almost exclusively bone bank bone and synthetic bone substitutes.
We also employ intra-operative blood salvage strategies which can eliminate the need for blood transfusions.
What is Scoliosis?
cottong: If scoliosis is not diagnosed as a kid, during regular check-ups but is later diagnosed in someone's 20's, would this be a new condition that just developed or just something that was either misdiagnosed or just plain never diagnosed?
Speaker_-_Dr__Thomas_Kuivila: Most scoliosis occurs between the ages of 10 and 14. If discovered in the 20's, it most likely was mild and not picked up.
playing: When a boy gets scoliosis, is it usually more or less severe than when a girl gets it? Do they generally get the same kind or in one more prevalent than another, depending upon the sex?
Speaker_-_Dr__Thomas_Kuivila: Low grade scoliosis has equal prevalence boy: girl. Girls are many times more likely to progress in the curvature than a boy. A major curve in a boy is really no different than a major curve in a girl however.
clarisp: Are there any “side effects” to having scoliosis? What other problems can it cause?
Speaker_-_Dr__Thomas_Kuivila: The majority of scoliosis causes no symptoms, and results in no activity limitations. Even after surgery, most people return to all but the most brutal of sports.
When scoliosis progresses beyond 60 degrees, there can be long term problems with regard to heart and lung function.
2many: Is scoliosis ever caused through an injury?
Speaker_-_Dr__Thomas_Kuivila: Yes. A spinal cord injury in a growing child will often cause scoliosis.
channelsurfer: Can scoliosis be caused by poor nutrition as an infant or child? Is scoliosis more prominent in Third World countries?
Speaker_-_Dr__Thomas_Kuivila: No. While nutrition is important, the incidence of scoliosis among malnourished children is no different.
porto2: For a person who has had surgery as a young adult, what problems will she experience as she gets older, particularly in her senior years when she also has to contend with arthritis, osteoporosis, back problems, etc.?
Speaker_-_Dr__Thomas_Kuivila: She may have no problems whatsoever related to the scoliosis. Fusions which leave half of the lumbar spine in tact are no more likely to cause back pain than in any other person.
202strings: If vertebrae are fused in a young adult, how does this affect future growth? What about instrumentation without fusion as an option?
Speaker_-_Dr__Thomas_Kuivila: The age of the patient at the time of surgery will determine how growth will be affected. Surgery after the age of 13, for girls and 15, for boys, rarely results in significant height loss. As a matter of fact, straightening a curve usually results in height gain.
Instrumentation without fusion has a higher infection rate than instrumentation with fusion. It is however an excellent option for a young child with a rapidly progressing curve.
tulips: How can you correct rib hump, due to scoliosis?
Speaker_-_Dr__Thomas_Kuivila: Because scoliosis is a 3 dimensional deformity with spinal rotation, the ribs rotate with the spine, causing a rib prominence on the convex (outer) side of the curve and rib depression on the other side of the curve.
Modern instrumentation often permits significant rib hump improvement in the course of correcting the spinal deformity.
Significant rib humps which cannot be fully corrected at the time of surgery may be candidates for a procedure known as a thoracoplasty after the patient is well healed from their spine surgery.
ladida: What is a crankshaft phenomenon?
Speaker_-_Dr__Thomas_Kuivila: Crankshaft phenomenon is when the spine grows in the front, after it has been fused surgically in the back, resulting in an increased rotational deformity.
Correction of severe crankshafted spines might require additional surgery.
mark: Can a scoliosis acquired at age 12 cause low back pain later in life, say in the 70's? If so, solutions?
Speaker_-_Dr__Thomas_Kuivila: Yes, it certainly can. This may be due to progression of the curve and it may also be due to muscle imbalance in the back, where one side has to work harder than the other. Most low back pain from a curve is treated non-operatively with physical therapy and medication.
jamon: Can a person have paralysis due to their scoliosis?
Speaker_-_Dr__Thomas_Kuivila: Paralysis due to scoliosis is rare and nerve injury due to scoliosis surgery is also very rare. Modern surgical techniques and intra-operative spinal cord monitoring are to be thanked for the safety of the procedure.
Types of Scoliosis
jjwhite: What exactly does mild levoconvex lumbar scoliosis mean?
Speaker_-_Dr__Thomas_Kuivila: 'Levo' means left. The majority of infantile curves are levoscoliosis. Levoconvex lumbar means there is a curve in the spine which goes to the left.
marys: What does it mean when you have rotary thoracolumbar dextroscoliosis with an extra spinal synovial cyst and low lying cerebellar tonsils extending below the level of the foramen magnum, among many others?
Speaker_-_Dr__Thomas_Kuivila: First, scoliosis is a 3 dimensional deformity. While we think of it typically as a lateral bend, there is always significant rotation of the spine as well.
A dextrorotary thoracolumbar scoliosis is a curve centered at the junction of the thoracic and lumbar spine which rotates to the right (dextro = right.)
A synovial cyst is an outpouching of joint fluid from one of the facet joints at the back of the spine. It frequently is associated with some facet arthritis.
The low lying cerebellum can be cause for concern. One should ensure that this is not due to what is called a tethered spinal cord. A MRI will determine if a tethered cord is present.
grandma: What is the worst form of scoliosis? Which is the hardest to treat?
Speaker_-_Dr__Thomas_Kuivila: Kyphoscoliosis is a challenging form of scoliosis to treat. Kyphoscoliosis is a curvature and forward lean, sometimes seen commonly in neurofibromatosis.
Scoliosis management is also challenging when there are bony abnormalities which have been present since birth, or when a patient has underlying brittle bone disease.
jojo: Will wearing a brace complete straighten my daughter's spine? Will she have activity limitations after she no longer needs the brace? Also, is it possible to have the spine "recurve" later in life?
Speaker_-_Dr__Thomas_Kuivila: Bracing prevents progression of curves about 85% of the time. A brace will not cause the spine to be permanently straightened. If a brace is worn until skeletal maturity, the majority of curves do not progress further when the brace is discontinued.
There should be no activity limitations for a braced or post-braced patient.
halburton: How often does a brace fail to help correct the curvature? If the brace fails, is surgery then the only option?
Speaker_-_Dr__Thomas_Kuivila: Brace failure is about 15%. Failure implies progression of the curve beyond 45-50 degrees. Currently surgery is the only option to treat curves which have failed the bracing protocol.
how2: When my niece has her surgery, will her correction be 100% or will she still have some curvature? I’m sorry but I don’t know the exact amount of her curvature, only that it is fairly bad.
Speaker_-_Dr__Thomas_Kuivila: It is rare to correct a curve completely. The spine typically has undergone some bony changes and therefore 100% correction is not typical. The goal of the surgery is to achieve as much correction as is safely possible and to end up with a well balanced spine which looks better in appearance.
beth: What are some of the biggest complications of scoliosis surgery?
Speaker_-_Dr__Thomas_Kuivila: Fortunately, serious complications are rare. We are always concerned with infection, therefore preoperative antibiotics are given; neurologic issues such as tingling, numbness and weakness are similarly rare; rod breakage or screw pulls out are uncommon as well.
There is always blood loss in the surgery and some patients occasionally require a transfusion.
The goal of the surgery is to fuse the spine and again, in rare instances, a portion of the spine may not fuse necessitating addition of more bone grafting.
Surgery for Scoliosis
lanisha1: How severe is the scoliosis curve before surgery is recommended?
Speaker_-_Dr__Thomas_Kuivila: Surgery is indicated for most curves over 50 degrees in both adults and adolescents. A curve may be fixed when as low as 40 degrees in certain situations - provided the patient's health is good. There is no upper limit of curvature for considering surgery.
playon89: What type of hardware is used for a spinal fusion?
Speaker_-_Dr__Thomas_Kuivila: Most implants are stainless steel, though occasionally a titanium implant is used. The current state of the art for scoliosis employs the use of pedicle screws for attachment of the rods to the spine.
In certain cases hooks and cables or wires are used as well.
grownup: Can you talk about the laser surgery? What are the advances and disadvantages? Who is a good candidate?
Speaker_-_Dr__Thomas_Kuivila: Lasers are not used in scoliosis surgery.
january: Is there one type of surgery that is better than another or does it depend on the condition of the patient or the preference of the doctor?
Speaker_-_Dr__Thomas_Kuivila: It depends primarily on the curve type and location.
Scoliosis and Exercise
HHT019: What are the best exercises for a person with scoliosis and do they really help at all?
Speaker_-_Dr__Thomas_Kuivila: Whether exercises, stretching, or manipulation will actually change the course of scoliosis is controversial.
However, I always advise patients that maintaining good flexibility, including the back and legs, good core strength and good aerobic fitness are generally good for the back.
Scoliosis Research and Genetics
scarychick: Is scoliosis hereditary?
Speaker_-_Dr__Thomas_Kuivila: Yes. The majority of scoliosis is genetic in nature. At least 8 different genes have been identified which are responsible for scoliosis.
A new test available at Cleveland Clinic helps to predict whether a curve will progress based on which and how many of these genes one carries. This test obtains your genetic material from your saliva and is therefore an easy and painless test.
jackO: What type of research is being done into the treatment of scoliosis?
Speaker_-_Dr__Thomas_Kuivila: A great deal of work is being done with respect to the genes that are responsible for scoliosis. This may someday significantly influence our treatment. We continue to research and fine tune surgical techniques to make scoliosis surgery safer and more effective.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Thomas Kuivila is now over. Thank you for joining us and thank you again Dr. Kuivila for taking the time to answer our questions about pediatric scoliosis.
Speaker_-_Dr__Thomas_Kuivila: Scoliosis often requires no treatment but should be evaluated and if treatment is required it is better tolerated and safer than a decade ago. Pediatric orthopaedic surgeons manage scoliosis and kyphosis in individuals up to age 25. After age 25, the spin typically responds more like that of an adult and therefore a consultation with an adult spine surgeon is more appropriate.
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