Online Health Chat with Ryan Goodwin, MD and R. Douglas Orr, MD
September 25, 2013
Scoliosis is an abnormal sideways curvature and rotation of the spine—the backbone of your body. Although most common in young teenagers, scoliosis affects children as well as adults. Scoliosis affects about two to three percent of children and teens, and up to 30 percent of adults worldwide. Scoliosis may be detected in infancy, childhood, adolescence or adulthood. While this condition affects both males and females, females are 10 times more likely than males to need corrective surgery for scoliosis.
Your spine is made up of 33 vertebrae (bones), and stretches from your head to your tailbone. Your spine houses your spinal cord, a collection of nerves and cells that connect with your brain, to form the central nervous system. When the spine curves due to diseases such as scoliosis, functional and cosmetic issues arise. These symptoms can be painful, but are rarely dangerous.
In most cases, the cause behind scoliosis is unknown but it’s thought to be a combination of factors including abnormal development of the bones, soft ligaments or weak muscles. Abnormalities with the inner ear and balance functions may either cause or be the result of scoliosis. The resulting curvature of the spine affects all of the muscles in the back, as well as the alignment of the hip. Scoliosis treatment methods depend on your age, how much more you are likely to grow, the degree and pattern of your spine's curve, the extent of pain, functional limitation and cosmetic appearance of the spine. Bracing may be used to temporarily halt the worsening of the curve during a growth spurt.
Deformities of the spine approaching or greater than 45 degrees can cause pain, functional impairment or severe cosmetic deformity. For this extent of curvature, your doctor may recommend spine stabilization surgery. Scoliosis tends to worsen as children approach puberty. The recommendation for surgery and its timing in children, adolescents and adults is dependent on your decision with your surgeon. The goal of stabilization surgery is to straighten and hold the spine straight in the safest fashion possible. This surgery involves fusing the vertebrae together with the help of bone grafts, and uses metallic implants to hold everything together until the fusion matures.
About the Speakers
Ryan Goodwin, MD, is director of the Center for Pediatric and Adolescent Orthopaedics and Assistant Professor at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. He is a board-certified orthopaedic surgeon in the Department of Orthopaedic Surgery at Cleveland Clinic. His primary interests include scoliosis and spine deformity, pediatric and adolescent hip disorders, pediatric trauma and clubfoot.
Dr. Goodwin completed his fellowship in pediatric orthopaedic surgery at Children’s Hospital San Diego/University of California at San Diego. He completed his residency training in orthopaedic surgery at and internship at Cleveland Clinic. Dr. Goodwin completed medical school at Case Western Reserve University in Cleveland. Dr. Goodwin currently sees patients at Cleveland Clinic main campus, Solon Family Health Center and Twinsburg Family Health & Surgery Center.
R. Douglas Orr, MD, is a staff physician in the Center for Spine Health and the Department of Orthopaedic Surgery at Cleveland Clinic. He is certified in orthopaedic surgery and general surgery by the Royal College of Physicians & Surgeons of Canada. Dr. Orr's specialty interests include kyphosis, scoliosis, spinal tumor, and adult spinal surgery, including minimally invasive surgery and deformity surgery. In addition, his research interests include outcomes in spinal surgery, spinal biomechanics and biomaterials.
Dr. Orr completed his fellowship in spine surgery at the University of Wisconsin Hospital and Clinic, in Madison, Wis. He also completed a fellowship in orthopaedic spinal surgery and a residency in orthopaedic surgery following graduation from medical school at University of Toronto Faculty of Medicine, in Toronto, Canada. Dr. Orr currently sees patients at the Center for Spine Health at Lutheran Hospital, in Cleveland, and Richard E. Jacobs Health Center, in Avon.
Let’s Chat About Scoliosis in Children and Adults
Moderator: Welcome to our chat ‘Scoliosis in Children and Adults’ with Cleveland Clinic pediatric scoliosis specialist Ryan Goodwin, MD and adult scoliosis specialist R. Douglas Orr, MD. We are very excited to have both physicians available to chat today! Let's begin with some background information about the topic and then continue with the questions.
Scoliosis Diagnosis: Causes, Symptoms and Progression
pilatesgirl: Do you have any ideas of what leads to scoliosis in children? How much is genetic, how much postural influence?
Ryan_Goodwin,_MD: We, as a medical community, still do not know the actual cause of scoliosis—hence the term 'idiopathic'. It is most likely caused by several factors, including genetics, subtle neuromuscular imbalance and some sort of asymmetrical growth. Postural influence has very little if anything at all to do with the development of scoliosis.
Rachelsmom: What would be considered an atypical curve pattern?
Ryan_Goodwin,_MD: The most common atypical curve pattern is a left thoracic curve. The vast majority of thoracic curves are to the right.
RobynGM: Has there been any association shown between hypermobility syndrome and scoliosis? I see that there is an association between Ehler-Danlos syndrome and scoliosis.
R._Douglas_Orr,_MD: There are many causes of hypermobility. Some are associated with an increased risk of scoliosis, but most are not.
KL3: Can scoliosis affect breathing with a 37-degree top curve? My 14-year-old daughter is five foot and four inches tall and 92 lbs. She runs cross country and dances. She reports shortness of breath towards the end of races, dancing, etc. She is otherwise healthy, with no medical history other than scoliosis.
R._Douglas_Orr,_MD: A 37 degree curve is too small to affect lung function. Curves really need to be in the 80 to 90 degree range to show demonstrable effects on lung function. A more likely cause of shortness of breath in this case is exercised-induced asthma. I would discuss this with her primary care physician.
sms: I was diagnosed with scoliosis at 15 years old. I am now 53 years old, and a mother of two. I have never had any issues or concerns about my curved spine until this past year. I started having some back pain in my left hip and tingling in my right shoulder. (I continue to get the tingling occasionally.) An orthopedic surgeon requested an MRI earlier this year that showed I have a 40 degree curvature. He said that I have some arthritis and he recommended six weeks of physical therapy. I continue to do my exercises and walk one to two miles daily. I am scheduled to be fitted with a brace next month, so that I can still do activities that I enjoy without ending up with major back pain. How bad is a 40 degree curvature? I look in the mirror and my back looks so crooked! Also, is it possible that my curvature could get worse in future years and eventually affect my internal organs? Sometimes I feel like my right hip is almost touching my rib cage.
R._Douglas_Orr,_MD: In an adult we are much less concerned about the absolute magnitude of the curve than the symptoms that it causes. In general a 40 degree curve is not considered to be a large curve and would not be an indication for surgery.
I do not feel that in adults braces should ever be used for the management of symptoms of scoliosis. Any brace that provides support to the spine will unload the muscles. Any muscle that is not working becomes weaker and eventually braces will always lead to increased back pain as the muscles become progressively weaker. A continued core-strengthening exercise program is a much better way to go. I would also strongly encourage you to continue your daily walking program. The more active someone is the less likely they are to have progressive symptoms.
Scoliosis will essentially never affect the internal organs. If a lumbar curve progresses significantly, it is possible that the rib cage may impinge on the pelvis. This can cause a typical pattern of pain with tenderness in the area. In some cases the curve stops progressing at this point as the rib cage acts as a brace.
Scoliosis would not be causing the tingling in your right shoulder since the nerves that go to the shoulder originate in the neck rather than in the portion of your spine where you have scoliosis.
Wildcat1: My scoliosis in the lower lumbar region is inflaming a nerve that travels to my hip and thigh. My doctor has provided epidural shots that help, but tells me major surgery to straighten all my vertebrae is recommended. What is causing this severe leg pain? Why don't we just concentrate on the nerve pain and fix the nerve?
R._Douglas_Orr,_MD: People with scoliosis develop the same types of degenerative changes that occur in people with straight spines. This can lead to pressure on nerve roots causing pain in the leg. If your spine is balanced, in some cases a more limited procedure to address only the symptomatic level can be effective and avoid the more major scoliosis operation. This idea is considered somewhat controversial, but growing evidence suggests that it is possible. I would talk to your surgeon about this possibility.
AliceRN: As a former child sufferer, I can tell you that I didn't slouch and lose my posture to be difficult—I simply got tired of holding myself up all day. My doctor gave me a brace to wear for one to two hours daily to just give me a break. Core exercises help, but they take a long time and require lots of hard work to take effect. With a 44-degree thoracic ‘S’ curve, how often would you recommend diagnostic examinations?
R._Douglas_Orr,_MD: In some patients with scoliosis, when their lumbar spine degenerates, they find that they are no longer able to stand up straight. This is not due to any weakness or problems with posture—this is due to gravity. We call this being in positive sagittal balance. Once someone is in positive sagittal balance, progression of the back part of the deformity is essentially inevitable. There is nothing short of further surgery that can treat that. Bracing in adults will eventually make the problem worse. Braces that provide support weaken the muscles. This makes standing upright more difficult and more painful. There is no documented indication for the use of a brace in an adult with scoliosis.
RobynGM: My 20-year-old daughter was diagnosed with scoliosis two years ago. She has an upper and lower curve, but has no pain or mobility issues. (She is very active with ballet and other types of dance.) At her age, should we expect her curvature to be stable and not progress further? Are there any nonsurgical methods to help prevent the curvature from getting worse?
R._Douglas_Orr,_MD: It is likely that her curve will remain stable at this point in time. If it progresses, it will progress at a very low rate of approximately one percent per year. There is very little that can be done to prevent progression if it is going to occur. However, there are things that will accelerate progression and increase the risk of needing surgery at a later stage. The first of these is cigarette smoking. Smoking accelerates the normal degenerative change that we all get with aging that is also accelerated in people with lumbar scoliosis. Smokers with scoliosis are at a much higher risk of progression as an adult. Excessive weight gain—greater than 40 pounds—is also associated with increased risk for symptomatic progression. What is also well established is that the more active a patient is, the less likely they are to develop problems in the future. I would strongly encourage your daughter to remain active throughout her adult life.
persh1: Will severe congenital scoliosis shorten my life?
R._Douglas_Orr,_MD: Scoliosis itself will not do so. In some cases, the chest wall and lungs do not develop normally and this can lead to lung problems that may affect your health. A lung specialist would be able to tell you if you have this type of problem.
Scoliosis from Polio
Sunpokebill: I was diagnosed with scoliosis when I was 16 years old. The reason was thought to be an early case of polio when I was five years old that caused a weakening of supporting muscles in the back area. I have coped with this for 45 years. I walk an average of 12 km per day. I have relatively little issue with the curvature, but find that my abdominal muscles do not tone up easily. I am also constantly sore on my right side as this is the side I bow out on. I assume that due to the curvature, which is not too bad, that there would be some compression or slight deformation of the abdominal cavity, especially as I get older. Would swimming be a more appropriate exercise than daily walking? My vertebrae seem to crack and snap a lot.
R._Douglas_Orr,_MD: Scoliosis due to polio tends to behave a little bit differently than idiopathic scoliosis. In general most people remain stable for many years as is evident in your case. It may be that the abdominal pain you are getting is that your rib cage is now impinging on your pelvis. Overall it sounds like your coping very well your scoliosis.
As to exercise the key is that you are exercising. If you enjoy your daily walks and the discomfort you have while walking is tolerable, then continue with walking since this is very good exercise. Some people do find that swimming allows you to be a little bit more active with less pain. The key is that you exercise on a daily basis. Snapping and cracking is very common even people without scoliosis. As long as it is not painful it is nothing to worry about.
Aortic Dissection and Scoliosis
AliceRN: Scoliosis is one of the signs of my connective tissue disorder. Since aortic dissection is also correlated, what is known about vertebrae tearing or causing abrasions of the aorta?
R._Douglas_Orr,_MD: Scoliosis occurs in connective tissue disorders such as Marfan syndrome and Ehler-Danlos syndrome. The aortic problems that occur in these diseases are due to problems in the connective tissue of the aorta itself. The vertebra will never cause tearing or abrasions of the aorta. Hardware placed in the vertebra to treat scoliosis very rarely can abrade the aorta.
Rachelsmom: Why would an MRI be needed for a child with scoliosis?
Ryan_Goodwin,_MD: Most children who have scoliosis do not require an MRI scan. Indications to order an MRI scan in a child with scoliosis include persistent pain, abnormal neurologic findings, presence of abnormal bone structure (congenital scoliosis), atypical curve pattern, and rapid progression of the curve. MRI scans are ordered in these cases to look for abnormalities of the neurologic structures (cysts of fluid in the spinal cord called a syrinx, brainstem abnormalities or tethered cord) that may represent a cause for the curvature or pain.
Physical Therapy and Exercise for Scoliosis
pilatesgirl: What is best exercise to help with scoliosis, to ease the muscular tensions?
R._Douglas_Orr,_MD: Any exercise program that strengthens the core muscles and builds flexibility is good and the presence of scoliosis. Given your screen name that you have used on your question I would assume that you do Pilates regularly. I think that Pilates and, particularly, Pilates combined with yoga is one of the best ways of managing scoliosis with exercise.
Rachelsmom: You mention that exercise is important for adults with scoliosis. Are there any particular exercises that children with scoliosis should do to strengthen core muscles?
Ryan_Goodwin,_MD: Any core strengthening exercise is good. Sit ups, crunches, yoga, and Pilates all contribute to core strength and general well-being. They do not affect curve magnitude though.
jburns: I am 44 years old. My left hip is higher than the other and my left leg is longer. I have pain in my hip and lower back. I am active, but feel like my trunk would be immobile if I didn't constantly stretch it. I stretch it throughout the day. I was told I had scoliosis and stenosis. What should I be doing?
R._Douglas_Orr,_MD: In some cases the scoliosis is due to the difference in leg lengths and can be corrected by putting a shoe lift in your shoes. Otherwise your ongoing program of stretching exercises and remaining as active as you can are probably the best ways of managing your symptoms.
GeorgeBMac: In idiopathic scoliosis—especially infantile—I understand that problems and deformities of the bones are ruled out. I would believe this means the deformity must be caused by what is left and what holds those vertebrae together and upright—soft tissue, such as muscle, tendons and ligaments. Yet—despite considerable anecdotal evidence that it can be effective—physical therapy that includes strength training and stretching those tissues is often ruled out in favor of things that tend to downgrade the quality of life such as bracing, casting and surgery. Is there any reason or justification for that?
Ryan_Goodwin,_MD: Early-onset scoliosis remains one of the most challenging problems we face in children's orthopaedics. Unfortunately, according to studies with a significant level of evidence, the only treatments that have been shown to change the natural history of these rapidly progressive curves are casts, braces and surgery. Physical therapy, which includes stretching and core strengthening, is helpful to promote general well-being and quality of life. Unfortunately, these modalities have not been shown to change the natural history of scoliosis and are passed over for more proven methods. Physical therapy can be used in these cases as well, and seem to be helpful in managing pain and promoting well-being. They do not seem helpful in treating curve progression.
GeorgeBMac: For idiopathic, infantile scoliosis, I keep hearing that core strengthening and stretching therapy have not been proven effective. However, this could simply mean that it has never been adequately studied. To your knowledge, has it ever been studied and has ever been proven to be ineffective?
Ryan_Goodwin,_MD: It has been studied but not at a high enough level of evidence. Most studies show that rapid curve progression is the endpoint. It would take a very large multicenter study with a large group of these patients to accomplish this. Unfortunately, this would be extremely difficult.
Rachelsmom: What are the different types of braces used to treat scoliosis? What are the advantages and disadvantages of each?
Ryan_Goodwin,_MD: There have been many types of braces that have been tried and studied. The Milwaukee brace is a large metal brace that includes the neck and was recommended for wear 23 hours per day. It is now largely historical because, quite frankly, no human wants to wear it. If you look up a picture of it you will understand why. In recent decades, the Boston brace and the Providence brace have become the 'gold standards'. These are custom-made plastic-and-foam underarm braces that can be worn underneath clothing. The Boston brace uses bony pressure points on the patient's ribs and pelvis to provide support and can be worn while upright. A 16- to 18-hour-per-day bracing schedule can be accomplished with this as patients can wear it to school. The Providence brace acts to 'unbend' the curve, and as such, is best worn while lying down. The main advantage is that this is a nighttime only brace, and is not recommended during daytime. Many patients prefer this as they do not have to wear it to school. Both have been shown effective in slowing progression of curves in cases of idiopathic scoliosis.
Rachelsmom: If a child requires bracing to treat scoliosis, at what age would the bracing start and how long does it typically last?
Ryan_Goodwin,_MD: The age at which brace treatment is initiated is variable, but in most cases of adolescent idiopathic scoliosis, it begins between the ages of 10 to 12 years old. Candidates for bracing need to have enough growth remaining and a curve between 25 and 40 degrees. It is important to remember that brace treatment can only slow the progression of the patient's curve—not correct it. The endpoint is either progression to surgery or skeletal maturity—beyond which bracing is no longer effective. Patients who are skeletally mature do not benefit from bracing.
cpa98: My daughter was diagnosed with scoliosis at the age of seven years old, and has been wearing a Boston Brace for almost one year (she was braced right away with an S curve of 28 and 32 degrees). What are her odds in eventually requiring back surgery at some point in her youth? Is there any hope that she would not need surgery, and that the brace would prevent the curve from getting any larger? Obviously, this has been a life-changing experience and hard on both of us.
Ryan_Goodwin,_MD: Based on her age, she has what we call juvenile idiopathic scoliosis. Children with this condition are more likely to require both nonsurgical (which you are already doing) and surgical intervention compared to those with the more common adolescent idiopathic scoliosis. One cannot exactly predict the odds of your child needing surgery for scoliosis, but they are certainly higher than someone who develops a curve in the adolescent years. Bracing is designed to slow or halt progression of the curve. Use of the Boston Brace has been shown to do this when compared to individuals who are not braced. There is always hope that a child will not require surgery. However, the reality is that a significant number of patients with early-onset scoliosis ultimately require surgical stabilization. The silver lining for those who do require it is that correction can be achieved.
KL3: Two of my kids have scoliosis. My 14-year-old daughter has a 37-degree top curve and is skeletally immature. My 11-year-old son has a 15-degree top curve. My daughter has been in a brace for one and one half years now, but my son doesn’t wear a brace. Are there any alternative treatments that have shown to be helpful? How will her last growth spurt impact the curve? Do you anticipate my son's curve to follow same path?
Ryan_Goodwin,_MD: Bracing and surgery are the only two treatments that have been shown to have an effect on the curve. Curves tend to progress most rapidly during the adolescent growth spurt. Once this slows, so should the rate of progression. Proper brace use should help in many cases as well—which it looks like you are doing. It is impossible to predict the clinical course of your son's curve. Remain vigilant and begin brace treatment if it is indicated. It is the best thing we know of as a medical community to delay or avoid surgery.
Other treatments, such as physical therapy, alternative soft braces, stretching, acupuncture and chiropractic care, have been shown to reduce pain in cases where it exists, but do not change the curve progression. The two types of braces with the best evidence of slowing curve progression are the Boston Brace and the Providence nighttime bending brace.
clrosc: My 17-year-son who is a high school wheelchair basketball player experienced a complete spinal cord injury at T12 in a car accident when he was eight years old. He was diagnosed with scoliosis at the age of 16 years old. He does wear a nighttime brace, but I'm not sure that it's helping slow the progression. Are there other options to bracing for someone who is in a manual wheelchair?
R._Douglas_Orr,_MD: If your son is now skeletally mature—meaning he is no longer growing—then there is no reason for him to continue to wear a brace at night. Braces are used to prevent curve progression due to growth. Scoliosis due to spinal cord injury tends to remain static after the end of growth. For a curve that is more than 50 to 60 degrees, there is a reasonably high risk—but not inevitability—of progression. At 40 degrees it is unlikely he will progress. Brace wear during the day will lead to increased muscle atrophy and potential for increased pain. Therefore, I would not recommend use of a brace during the day.
Treatment for Congenital Scoliosis with VACTERL Syndrome
dgahman: My 21-month-old son was born with VACTERL (vertebral, anal, cardiovascular, tracheo-esophageal fistula, renal and limb defects) syndrome. He has three bone abnormalities in his spine and has a 32 degree curve. He had a tethered cord that was corrected a year ago in July. That seemed to help with the forward curve. He is walking now, but leans to the right. I take him to Nationwide Children’s Hospital, in Columbus, every six months to continue to monitor his progress. What are some pediatric options for him? He is not wearing a brace, he receives physical therapy once a week. The doctors have told me not to stretch his neck as they feel it is the bone structure that causes him to lean his head sideways, but he can get to midline. I wonder if a brace would assist him either for his neck and/or back. He is an amazing little boy and is much tougher than his twin brother!
Ryan_Goodwin,_MD: What a fantastic story. I am glad he is doing so well. Patients with VACTERL syndrome typically have defined bony abnormalities of the vertebrae, which is called congenital scoliosis. Unfortunately, bracing has not been shown to be effective at changing the natural history of curve progression in patients with congenital scoliosis. There are some soft-sided braces and orthoses that can assist with positioning if needed. They may or may not be helpful for your son. I would consult with your treating physician or therapist for specifics on your son's case. I wish you the best of luck!
Chronic Back Pain Treatment
pa2four: Does Cleveland Clinic have new procedures to address donor site pain in chronic pain of the back?
R._Douglas_Orr,_MD: There are many reasons for donor site pain—some of which are treated bone and some of which are not. Depending on the incision used when taking bone for bone graft, this can damage small nerves leading to a painful neuroma. Occasionally, these neuromas can be removed with good relief of the donor site pain. This is a procedure that is widely available.
persh1: Why is it necessary to be awake during facet injections?
R._Douglas_Orr,_MD: It is safer to do so. If the needle is too close to the nerve, the person having the injection will feel pain. That way the person doing the injection will know not to inject anything in that position. If you were asleep, the injection could damage the nerve.
Purpose of Surgery for Adult Scoliosis
writer53: My daughter, who is now 26 years old, was diagnosed at the age of 10 years old with idiopathic scoliosis. She had about a 21-degree curvature which progressed to 26 degrees. Eventually she was prescribed a brace to wear at night. Over time her scoliosis progressed to 37 degrees at the age of 17 years old. A specialist in Houston said that it was pointless for her to wear the brace. He said that her curvature would probably stabilize now that she had finally reached her full adult height. He did not recommend surgery or rods since she was a dancer and needed her flexibility. She had yearly x-rays until she was about 22 years old. She has not had any further follow up since. She only experiences occasional, mild back pain. Her hips are definitely crooked with her right hip higher than her left hip. Should she be monitored and undergo yearly x-rays, or has she stabilized? Do you recommend rods for her back? Would this interfere with yoga and other exercises? Should she just leave it alone?
R._Douglas_Orr,_MD: Once someone is skeletally mature, curves—if they are going to progress—change at a rate of about 1 degree per year. The technique for measuring the magnitude of the curve is only accurate to about 5 degrees. Therefore, it does not make a lot of sense to get an annual x-ray to follow the curve. I would suggest a follow-up x-ray every three to five years unless symptoms change.
In adults we treat the symptoms of scoliosis—not its presence. The indication for surgery in an adult is pain that prevents her or him from doing their daily activities. In a healthy active woman like your daughter, there is no current indication for surgery.
Cervical Scoliosis Surgery
pa2four: Is there a treatment or surgery that can fix scoliosis as it affects the cervical area in an adult? What is the chance of having permanent pain due to the surgery when there was only a cosmetic problem with the scoliosis, but no pain before surgery? (My husband has chronic donor site pain from a spinal fusion 10 years ago. He wishes he'd never had surgery.)
R._Douglas_Orr,_MD: Many of the surgical techniques used in the thoracic and lumbar spines can also be used in the cervical spine. It would depend on the nature of the scoliosis. If there is no pain involved and the cosmetic appearance is acceptable, I would not recommend any surgery at all. Surgery is done to decrease pain and improve function. Occasionally, in the cervical spine for certain types of problems, we'll also do surgery to decompress the spinal cord. However, again, we do not perform this in somebody who has no symptoms.
RaRah: My teenage daughter was recently diagnosed with idiopathic scoliosis with a 53 degree curvature of the thoracic area. The orthopedic specialist is recommending a spinal fusion procedure within the next 12 months to correct the curvature, as she is still developing. Is spinal fusion the best procedure? What is a realistic length of recovery and what is the best postoperative therapy? What are the physical limitations or restrictions, if any?
Ryan_Goodwin,_MD: Spine fusion surgery is likely the best option for her. At 53 degrees there is a high likelihood that her curve will continue to progress throughout her adult life, which is the main reason scoliosis is treated. The timing is largely up to you and your daughter. If she is growing rapidly, she may be at risk for more rapid progression in the next 12 months. Otherwise, it could be done at a later convenient time. The length of recovery is highly variable between physician and center. It also depends on the extent of the curve and the levels that are involved or fused. A typical fusion for a right thoracic curve at our center would involve a four- to five- day hospital stay, and no sports or impact activities for six months. If all goes according to plan, I let patients return to full activities as tolerated—except for tackle football and true collision sports—at 6 months after surgery. Therapy is typically not required until that time as the goal is to obtain a solid fusion. I encourage patients to do a lot of normal walking, which is all that is necessary. I limit heavy lifting, bending and twisting until that time. Most patients feel up to returning to school after four weeks (if surgery is done during the school year) Of course, all surgeons have different recommendations and one should follow his or her guidelines.
Adult Scoliosis Surgery
persh1: I am a woman over 60 years old with congenital scoliosis. My surgeries include 11 fusions—both thoracic and lumbar. I also had hardware repair on a clamp placed at fusion surgery and three facet joint injections. Currently, my lower back is starting to affect my legs and walking is difficult. My surgeon is willing to perform another surgery if tests reveal a need. I am very hesitant to have another surgery. In your opinion are multiple spine surgeries safe for someone with my history and age? Except for my back I am in relatively good health.
R._Douglas_Orr,_MD: The decision to undergo surgery is always a balance between potential risk and benefit. Certainly in someone with multiple previous surgeries, the risks are somewhat higher. Surgery is, however, relatively routine at centers specializing in deformity surgery when symptoms warrant intervention and the patient is healthy enough to undergo the surgery. The key in this decision-making process is to have a surgeon who devotes a significant amount of his practice to revision deformity surgery.
JJ1234: I am a 55-year-old female. My last MRI shows moderate levoscoliosis (side-to-side scoliosis) centered about L2 and grade III isthmic spondylolisthesis of L5 in relation to S1. There is severe left foraminal stenosis at L5-S1. I am experiencing leg pain as a result. First, what is moderate scoliosis and does it get worse? Second, if a spinal fusion to address the spondylolisthesis is performed, will the scoliosis need to be fused as well? Also, is there any chance that minimally invasive surgery can be performed?
R._Douglas_Orr,_MD: There are a number of minimally invasive options that can be used to treat both the spondylolisthesis and, if necessary, the scoliosis. The treatment of scoliosis when associated with another spinal problem is somewhat controversial. There is, however, a growing body of evidence that suggests treating the primary symptomatic problem. In your case, this is the spondylolisthesis, and following the scoliosis is a very good option as well. If the curve becomes a problem, you have not burned any bridges by treating the symptomatic problem. Additionally, you may avoid a much bigger operation that you did not need by pursuing the more limited surgery.
Harrington Rod Side Effects and Treatment
pilatesgirl: How has treatment of scoliosis in children changed historically? What is the thinking about rods that were surgically implanted in decades past? Finally, how has the health of the patient progressed over years?
Ryan_Goodwin,_MD: The surgical treatment of scoliosis has evolved significantly. Prior to the availability of metal instrumentation, patients were placed in a corrective body cast and fusion surgery was performed through a hole cut in the back of the cast. Patients were maintained in the cast for six to 12 months until fusion was obtained. Earlier generation rods and hooks worked well to provide modest correction and curve stabilization. Many remain implanted in patients and are quiescent, requiring no action if patients are symptom free. Newer generation metals and pedicle screws provide significantly more rigidity and corrective power. Ultimately, patients who have successful balanced fusions should stay stable for a lifetime without rod removal.
NEWYORKER: I am a 58-year-old female. In 1967, at the age of 12 years old, I had scoliosis surgery. At that time it consisted of insertion of Harrington rods and nine months in a partial-to-full body cast. I now have spinal stenosis and degenerative disc disease, but neither is severe yet. Could these issues be related to the scoliosis surgery and rods? Can anything be done other than muscle relaxers or trigger point injections?
R._Douglas_Orr,_MD: Degeneration of the lumbar discs and the development of spinal stenosis is a normal phenomenon of aging. However, patients who had surgery with Harrington rods—especially if the bottom end of the rods is at the L3 or L4 level—tend to develop a little bit more degeneration. The first line of treatment is the same as it would be in someone without previous surgery, and consists of a program of core-strengthening exercises. Often anti-inflammatory medications will also be of benefit. If the dominant symptoms are the leg symptoms of stenosis, epidural injections also play a role in the treatment. If you get to the point that you have symptoms on a daily basis that prevent you from doing your normal activities in spite of these nonoperative measures then further surgery may also be an option. If you are investigating surgery as an option, you should make sure that the surgeon you are seeing has extensive experience dealing with adults who have had previous scoliosis surgery. This is not an operation that should be done by someone without this type of experience.
persh1: I have congenital scoliosis, and have had several operations and procedures. My health is generally considered good except for my back. My surgeon wants to me to have a myelogram and CAT to see if I have stenosis. If I have stenosis, how long before I have to have surgery? I really don't want to go through any more surgeries, but I am not sure of the consequences of not having surgery. Is there a possibility of not being able to walk? I am 61 years old and very hesitant to have any more procedures.
R._Douglas_Orr,_MD: In patients with and without deformity we operate for stenosis based purely on the symptoms it causes and how it limits their activities. If someone does not have symptoms of stenosis, there is really no indication for surgery. I would not do a myelogram and CAT scan to look for stenosis in the absence of symptoms. If stenosis is present on the CAT scan and myelogram, this does not mean there is inevitable progression. The chances of losing the ability to walk due to stenosis is a very low unless of the stenosis is occurring higher in the thoracic or cervical spine. In the absence of symptoms, the risk of losing the ability to walk is actually higher with surgery than without.
Sports: With Scoliosis and After Surgery
KL3: Are any sports contraindicated with scoliosis—specifically in children? What about tackle football with an unbraced 15-degree top curve in an 11-year-old old boy?
Ryan_Goodwin,_MD: There are no activity restrictions or contraindicated sports in children with scoliosis. Patients who have undergone fusion surgery may be limited by their surgeon on a case-by-case basis. Most kids return to all but true collision sports after a solid fusion is obtained. A child with a mild 15 degree curve should have no restrictions on sports or other activities.
clrosc: My 17-year-old son is a high school wheelchair basketball player with a competitive team. He has been diagnosed with scoliosis with a 40-degree curvature. If at some point he needs surgery, what are his chances of playing basketball again? What can we do to avoid increasing the curvature of the spine?
R._Douglas_Orr,_MD: The answer to your question would depend somewhat on why your son is in a wheelchair. If he has a fixed neurologic problem, such as a previous spinal cord injury, the risk is a little less than if he has a progressive neurologic deficit such as muscular dystrophy. Returning to playing basketball after scoliosis surgery would depend on how extensive the surgery needed to correct the scoliosis. If he is asymptomatic, I would not proceed to surgery—but would just follow the scoliosis. Progression occurs independent of activities. This means there is likely nothing he can do to prevent it from happening if it is going to happen, but neither will any of his activities increase the risk unless he were to start smoking. Smoking will increase progression.
Nutrition as Treatment
ccquestions: Can scoliosis happen during pregnancy in someone with a short torso? Also, can eating certain foods, taking vitamins and exercising slow the progression if it is degenerative?
R._Douglas_Orr,_MD: Progression of a degenerative scoliosis is actually determined predominantly by genetics. Certain foods and diet will not change the risk of progression. Exercise will not alter the rate of progression, but the more exercise someone does the less likely they are to have symptoms related to that progression. Any exercise program would include core muscle strengthening exercises.
If someone has a pre-existing scoliosis, it will progress slightly during pregnancy on the order of about five degrees due to the activity of the hormone prolactin, which softens connective tissue to allow the baby to be delivered. Six to nine months after breastfeeding stops, the curve will return to its baseline.
Sealove: Are there any natural herbal remedies for inflammation and pain?
Moderator: Earlier this year we had an excellent chat with integrative medicine entitled ‘Using Wellness Approaches to Manage Pain.’ One focus of the chat was on the anti-inflammatory diet.
Experimental Surgical Techniques
Granolove: My daughter was diagnosed with scoliosis when she was one year old and is four and one half years old now. She has had five Risser casts and she wears her brace every day. What do you know and think about spinal tethering? Also, do you think spinal fusion is becoming obsolete with vertebrae stapling and this new tethering procedure?
Ryan_Goodwin,_MD: I am familiar with spinal tethering. It is still in its infancy and is not yet being used widely. I think it is a promising technique but needs significant additional study before it can be implemented on a wide scale. Fusion surgery remains the gold standard and will remain so for quite some time. Other techniques need to be validated and shown superior to fusion before fusion would become obsolete. This would likely take many years to accomplish.
cpa98: Can you please discuss some of the advances in scoliosis surgery in children? How soon will some of the more advanced surgical options be available? Where can I learn more about the medical research taking place that may help my daughter?
Ryan_Goodwin,_MD: Significant research is being performed to develop new techniques to help advance scoliosis treatment in children. The greatest challenge remains maintenance of growth while preventing curve progression. Fusion surgery remains the gold standard, but, unfortunately, it stops growth in the spinal segments that are fused. Newer techniques, such as stapling and growth modulation, are in their infancy and more research is needed to validate the efficacy of these treatments. They are currently being performed in small numbers in select centers. Probably the best resource for information on these topics is the scoliosis research society website at www.srs.org.
Moderator: The hour has gone fast. I'm sorry to say that our time is now over. Thank you, Dr. Goodwin and Dr. Orr, for taking the time to discuss scoliosis in children and adults. Your answers were very detailed and personal.
R._Douglas_Orr,_MD: Thank you for joining us today.
Ryan_Goodwin,_MD: Thank you all for your questions. They were very insightful and intelligent. I hope our responses were helpful. Thanks again for joining us today!
To make an appointment with Ryan Goodwin, MD or any of the other specialists in our Center for Pediatric Orthopaedics at Cleveland Clinic, please call toll-free at 866.275.7496. You can also visit us online at clevelandclinic.org/ortho.
To make an appointment with R. Douglas Orr, MD or any other of the specialists in our Center for Spine Health at Cleveland Clinic, please call 216.636.5860 or call toll-free at 866.588.2264. You can also visit us online at clevelandclinic.org/spine.
For More Information
Cleveland Clinic’s Center for Spine Health helps thousands of patients each year with condition of the back and neck, ranging from the most common to the most complex. Whether your goal is to get back to sports, work, hobbies or just enjoy life, the specialists at the Center for Spine Health can help.
We treat a range of diagnoses, including scoliosis, Chiari malformation, deformities and degenerative back and neck conditions, spinal fractures, spinal stenosis, spinal tumors, chronic back pain, and peripheral nerve injury.
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Our specialists are nationally recognized in orthopaedic surgery, neurosurgery and medical spine, and provide patients with the latest, most innovative and most effective medical and surgical treatments available for back and neck problems.
Neurology and neurosurgery at Cleveland Clinic is ranked best in Ohio and among the top 10 nationally by U.S. News & World Report.
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