Online Health Chat with Ryan Goodwin, MD, R. Douglas Orr, MD, and John O’Connell, MD

September 24, 2014

Description

Your spine is the backbone of your body. It is made up of 33 vertebrae 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.

Scoliosis is an abnormal sideways curvature and rotation of the spine. Although most common in young teenagers, scoliosis affects children as well as adults. Scoliosis affects about 2 percent to 3 percent of the pediatric population and up to 30 percent of adults worldwide. Scoliosis may be detected in infancy, childhood, adolescence or adulthood. 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, or abnormalities with the inner ear and balance functions. 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.

Take advantage of this chat to speak to a pediatric scoliosis specialist, Ryan Goodwin, MD; adult scoliosis specialist, R. Douglas Orr, MD; and physical medicine and rehabilitation specialist, John O’Connell, MD.


About the Speakers

Ryan C. Goodwin, MD, is Director of the Center for Pediatric Orthopaedics and joined the staff at Cleveland Clinic in the Department of Orthopaedic Surgery after completing special training in pediatric orthopaedics and scoliosis surgery at Children’s Hospital San Diego/University of California at San Diego. Dr. Goodwin completed his residency training in orthopaedic surgery at Cleveland Clinic in 2003. He also served his surgical internship at Cleveland Clinic and received his medical degree at Case Western Reserve University in Cleveland. Dr. Goodwin earned his Bachelor’s degree in biomedical engineering from Tulane University. His primary interests include pediatric and adolescent hip disorders, scoliosis and spine deformity, pediatric trauma and clubfoot. Dr. Goodwin devotes the majority of his time to patient care, but is also involved in clinical research as well as resident and medical student education. He currently serves as Assistant Program Director for the Orthopaedic Surgery Residency and holds an appointment as Assistant Professor at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.

R. Douglas Orr, MD, is a staff physician in the Center for Spine Health and the Department of Orthopaedic Surgery. 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 received his medical degree from the University of Toronto Faculty of Medicine, where he also completed his residency in orthopaedic surgery and fellowship in orthopaedic spinal surgery. He also completed a fellowship in spine surgery at the University of Wisconsin Hospital and Clinic.

John O'Connell joined the staff at Cleveland Clinic Florida in the Section of Spine Health and Physical Rehabilitation Medicine within the Neurological Center in 2008. Dr. O'Connell completed his internal medicine residency at the United States Air Force-Keesler Medical Center in Biloxi, Mississippi. He later completed his second residency in physical medicine and rehabilitation at Temple University in Philadelphia. Dr. O'Connell received his medical degree from the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical Center in Camden, New Jersey. His specialty interests include lower back pain, neck pain and sports injuries. Dr. O'Connell also serves as Adjunct Assistant Professor at Florida Atlantic University Charles E. Schmidt College of Medicine in Boca Raton, Florida.


Let’s Chat About Scoliosis in Children and Adults

Moderator: Good afternoon and welcome to our chat about scoliosis in children and adults. Welcome, doctors, and thank you for taking the time to be with us to share your expertise and answer our questions about scoliosis. Let’s get to the questions…


Simply Scoliosis

PASue: What are the long-term medical implications of scoliosis in adults?

R._Douglas_Orr,_MD: There are very few if any long-term medical implications of scoliosis in adults. It had been thought that large curves may lead to restrictive lung disease and potentially heart problems, but this has not been shown to be the case for the vast majority of idiopathic scoliosis patients. It is very rare for idiopathic curves to progress above 80° or 85° and, in general, these curves do not produce significant medical effects. Similarly, scoliosis does not lead to "displacement of the internal organs", which has been claimed in the past. Over the long-term, people with scoliosis may develop degenerative change in the curve, particularly in the lumbar curves, which may lead to symptoms requiring treatment in adulthood.

sallyirene: At age 80 I found out I have scoliosis. What should I be doing or not doing at this age?

John_O’Connell,_MD: Scoliosis can result from asymmetric degeneration of the spine leading to a curve. As far as doing; remain as active as possible to keep the muscles that support your spine strong and the lower limb muscles flexible. This is best done initially through a physical therapist after an evaluation by your physician. Try to avoid sitting for long periods, and make sure your bone density is tested regularly by your physician.

kayakmom: Our 20-year-old daughter has been diagnosed with scoliosis. In her annual check-ups these past 19 years, she was asked to bend at the waist and was never flagged. Now a sports doctor has found it. She's a runner (35 miles per week while in college). What's our next step? She's been seeing a physical therapist for hip soreness from lack of stretching her hamstrings. Thanks.

John_O’Connell,_MD: One of the most important things to know is the degree of scoliosis. I assume the sports doctor found it as a result of performing an x-ray. She has finished growing at this point and if the curve is minimal, the only treatment may be periodic observation. Tight hamstrings are common in distance runners and may have no relation to scoliosis.

SATURN9: All I am offered is a yearly x-ray to check the degree of my thoracolumbar curve. Is there nothing else (besides core building exercises) I can do to help myself? I am a 71-year-old female.

John_O’Connell,_MD: The exercises are very important. Maintaining bone health by regular bone density testing and supplementation/medication based upon the degree of bone mineralization is important as well.

GeorgeBMac: If idiopathic scoliosis, by definition, means that the vertebrae are unaffected and intact, that means that the cause must be in the soft tissue. Has any research been done to investigate whether treatments for the soft tissue (such as physical therapy) could be effective? We keep hearing there is “no evidence.” Has there been any research?

Ryan_Goodwin,_MD: Patients who have idiopathic scoliosis actually undergo morphologic changes to their vertebrae. There have been studies that clearly demonstrate changes to the vertebral bodies, including pedicle size in diameter as well as endplate changes in those who have idiopathic scoliosis. These changes can also be very clearly seen on three-dimensional imaging studies. The underlying cause for developing idiopathic scoliosis is still unknown. Most postulate that it is a multifactorial process involving gross asymmetry of the vertebral column, a subtle neuromuscular imbalance that is triggered in adolescence. Many studies are ongoing, but no answers are currently available.

Melonlady17: I have had scoliosis since I was a teenager. I wore a back brace for four years in high school, which did stop the progression of the curve, but have not had surgery on my spine due to having severe pulmonary hypertension. I do not feel as if my scoliosis has worsened, but I have not seen a doctor for it since having the brace. (I'm now 39.) How can I tell if it's getting any worse? Are there options for someone like me who can't have major surgery?

R._Douglas_Orr,_MD: In adults, the indication is for treatment of symptoms not the magnitude or progression of the curve. If you do not feel that your scoliosis is significantly limiting your activity, there is no need for any treatment. It would be reasonable, however, to see a specialist in adult spinal deformity in order to establish a relationship with someone and have your curve checked intermittently.

A very quick way to know if your scoliosis is getting worse is to measure your height. As we age, we all lose height to some degree but a loss of height of more than two inches in someone with scoliosis can be an indication that the curve has progressed. Of vital importance to someone like yourself, particularly with lung problems, is to be involved in an ongoing exercise program to maintain your fitness.


Physical Therapy and Exercise

PASue: I understand exercise is very important, particularly for adults with scoliosis and possibly severely limited lung capacity. How do folks exercise if they need oxygen to do that? I wouldn't think gyms would welcome people bringing oxygen, and if they need oxygen, they may not be strong enough to walk outside or at a mall and carry the oxygen or oxygen concentrator. Can you please give some tips? Thanks so much!

R._Douglas_Orr,_MD: Much of the answer to this question depends on the reason for the severely limited lung capacity. In general, loss of pulmonary function is NOT the result of the scoliosis. In the past, it was thought that idiopathic scoliosis could progress to the point where it caused severe restrictions of the lungs, but this has not proven to be the case. In patients with neurologic causes for their scoliosis or scoliosis developing very early in life (< eight years old), this may be true, but it is actually very rare. For patients with underlying lung disease requiring oxygen who need to exercise, a good resource is to speak to someone from the American Lung Society and see what resources are available in your area.

beaton: I am fearful of exercise since my first episode of scoliosis-related pain occurred after I spent time working out with a personal trainer. I have recently completed a series of physical therapy visits. These visits focused on low-level core strengthening and stretching. I would like to progress, but don't know where to turn for guidance. I do not live in the Cleveland area. Do you have any suggestions?

John_O’Connell,_MD: Ideally, your therapist advanced you to a program that you can do on your own. At this point, you should be able to perform those exercises and can advance as tolerated to more advanced exercises. Yoga and Pilates are good choices of exercises for you.

FrancesC: What can I do to help my scoliosis that's not invasive? My physical therapist taught me to do side planks on my weak side. While it does strengthen my weak side, my muscle on the scoliosis side is still hard as a rock.

John_O’Connell,_MD: I agree with your therapist. The scoliosis side will feel hard since the curve pushes the muscles outward, making them easier to feel and there is likely spasm contributing to this. Side planks and prone planks are great exercises to condition your core muscles. Also, pay attention to keeping your lower limb muscles flexible, as they control the movement of the pelvis.

mstahl: I get injections periodically from a pain management doctor. I am pain free for several weeks after the injection. Is there any other therapy besides injections? Will physical therapy help? Thanks.

John_O’Connell,_MD: I am a huge proponent of physical therapy. I do injections either for diagnosis or as an adjunct to therapy. Injections as sole therapy tend to be very short lived. A course of PT and, most important, a regular exercise program after completing PT can do an excellent job of treating your pain.

pan: Does scoliosis in adults affect hip and knee function? Does scoliosis make you more prone to falls and what can you do? What kinds of exercises are helpful for scoliosis?

John_O’Connell,_MD: Scoliosis can affect function in the limbs due to the fact that the joints all work in conjunction as part of the kinetic chain. Anything that affects balance can make you more prone to falls. The best kind of exercises are those that condition the core muscles of the low back, abdomen, flanks, diaphragm and pelvic floor, as well as those that stretch and increase flexibility of the hip girdle muscles of the lower limbs.

PASue: I have a follow-up to PASue question. The diminished lung capacity is secondary to the scoliosis that was identified at age six. Surgery resulted in fusion of 11 vertebrae. Given that information, do you have any tips as to exercise for someone who only uses oxygen for exercise? I don't believe most gyms would welcome someone using oxygen. It is hard to walk outside or at a mall when carrying oxygen, as the oxygen is heavy for me. Any advice would be appreciated.

R._Douglas_Orr,_MD: If you were to contact a local pulmonologist, he or she would be able to tell you about any respiratory rehabilitation programs in your area. The pulmonologist would have the best idea as to what programs are available locally.

Ryan_Goodwin,_MD: I agree with Dr. Orr.

myrtleirene: Is there any advantage to exercise in a swimming pool over the yoga and Pilates that you have mentioned?

John_O’Connell,_MD: The benefit to exercising in a pool is the fact that buoyancy helps facilitate movement.


Scoliosis Surgery

bikinginfinity: At present, I have severe left sciatic pain. X-ray shows moderate to severe narrowing of all lumbar disc spaces and a curvature of the dorsolumbar spine to the right with an angle measured between D10 and L3 being 27 degrees. I have had prior (2009) spinal fusion (L4-5) to correct left sciatic stenosis. If surgery is indicated to correct my sciatic pain, would it be advisable at the same time to surgically intervene to correct, or at the least stabilize, my scoliosis.

R._Douglas_Orr,_MD: The decision to correct and stabilize a scoliosis is multifactorial. The magnitude of the curve does not dictate whether surgery should be performed. One of the key questions is whether your spine still remains "balanced." To a spinal surgeon, balanced means that in the standing position the head is clearly over the pelvis and the hips are in both the front to back and side planes. In someone who is balanced, it may be possible to treat only symptomatic or unstable levels and follow the scoliosis. If someone is out of balance, then addressing the deformity is required in order to treat the symptoms and prevent progression.

GeorgeBMac: For a child with idiopathic scoliosis, what are the criteria for determining when surgery is necessary? Is the decision based on the curvature or his functional/physiological issues?

Ryan_Goodwin,_MD: The indication for surgery is based on the curve magnitude as well as the child's skeletal maturity. Curves that reach 45° to 50° are best treated with surgery, as they are extremely likely to progress throughout adulthood. Younger children with curves that reach 40° are also candidates for surgical intervention. The decision is largely based on the magnitude of the curvature and the patient's growth remaining and not so much on the patient's functional or physiological issues.

KB0718: Has VEPTR surgery been performed at Cleveland Clinic Children's before?

Ryan_Goodwin,_MD: No. Our surgeons at Cleveland Clinic have preferred more of a growing rod spinal construct over the rib-based VEPTR system.

kaparsons24: If there are no breathing or organ constraints and no pain (possible discomfort from time to time, but no pain), are there other reasons to rush into corrective surgery on a young lady? (Background information: 12 years of age, only one or two mild menstrual events in past six to 12 months, Risser growth shows not quite full maturity but almost.)

Ryan_Goodwin,_MD: The decision to move toward surgical intervention on this child should be based on the magnitude of the curve (number of degrees), as well as the patient's growth remaining. The magnitude of her curve is not listed here but if it reaches 45° to 50°, then surgery would be indicated. It sounds like, based on the information you have provided, that she is within one to two years of the end of spine growth. There is almost never a rush to proceed with surgery as the procedure is essentially the same for patients who wait a few months or years. The risk is continued progression of the curvature if surgical intervention is delayed significantly. If surgery is indicated, however, it is best accomplished before adulthood, as children are much better equipped to recover from the surgical event than adults are.

Jc6n: I am a 61-year-old woman. After a lifetime of living with scoliosis and back pain that continues to get worse, including degenerative disk disease and arthritis, doctors are now recommending two-stage fusion and scoliosis correction. My concern is that pain from muscles pulled in one direction will only be replaced by pain from being moved to a different direction. What are your thoughts?

R._Douglas_Orr,_MD: In general, most patients having scoliosis surgery after exhausting the non-operative care options find a significant improvement in their pain after surgery, but nobody becomes completely pain-free. They are, however, able to do all of their normal daily activities with a tolerable level of discomfort. This is particularly true in patients who are unable to stand completely upright at the time and undergo surgery. If we can get them so that their heads are square over their pelvis in the front to back and side planes, most find major improvements in their pain.


Bracing and Instrumentation

mandy: I have a Harrington rod for a thoracic curve. The surgery was done almost 30 years ago, and at the time it was a good correction down to about 30 degrees. I have had so few problems, even after several spills skiing, that I haven't had it x-rayed in about 25 years. The last few years I have had some left shoulder blade and neck discomfort. I can see that my head is not centered on my neck. Should I have it x-rayed to see if whatever curve I still have might be a cause for the discomfort?

John_O’Connell,_MD: I would definitely see your doctor. The asymmetry may not be related to the scoliosis and may be due to an imbalance of the muscles that support the head and neck. You should have a thorough exam and most likely an x-ray to go along with it. Interestingly, the x-ray can show abnormalities, but would not say whether those abnormalities are causing your pain.

KB0718: Is it possible that the new MAGEC growing rod will be useful in the treatment of pediatric scoliosis, specifically congenital scoliosis with hemivertebrae?

Ryan_Goodwin,_MD: Yes. This device is very promising. We already have had good early success with this device at Cleveland Clinic. I think it will be most useful for patients with early-onset scoliosis of any type to help manage curve magnitude during the critical early growing years.

Mollis: What is the “growing rod” that I am hearing about for pediatric scoliosis?

Ryan_Goodwin,_MD: A growing rod is a type of surgical procedure designed to treat early-onset scoliosis. In children with advanced disease that are very young, sometimes spinal instrumentation such as a growing rod is placed to help partially correct and maintain trunk and chest height throughout the growing years. It essentially acts as an internal brace providing some early correction of the curvature but mostly maintenance of the curvature as the child grows. Unfortunately, growing rod constructs require repeat surgery roughly every six months to lengthen the instrumentation as the child grows.

There is a new magnetic system that we have experience with here at Cleveland Clinic that will allow the lengthening process to occur in the office without surgery using a magnetic transducer. This significant new technology will hopefully eliminate the need for multiple lengthening surgeries in these children with early-onset scoliosis.

bmwillis: For adolescent scoliosis, I have read that the amount of in-brace correction, combined with compliance of wearing the brace, is key to effectiveness. What percentage of in-brace correction do you expect to get from a brace to consider the brace effective? For example, if the patient has a 35 degree thoracic curve, what percent would you look for? And what type of brace (e.g. Boston, Rigo Cheneau, other) do you recommend to achieve the desired in-brace correction?

Ryan_Goodwin,_MD: Perhaps the most important component of brace effectiveness is patient compliance. There is good evidence that suggests that if patients wear their braces according to the recommend guidelines that they're significantly more likely to be effective than those who do not. The amount of in-brace correction is likely less important. That being said, an in-brace x-ray should show some correction of the curvature in brace to confirm that it can potentially be effective. The bottom line here is that if the patient is a candidate for a brace, they must have a brace that does improve the curvature somewhat on x-ray, and it should be worn according to the prescribed guidelines as best as possible.

suzysampson: Hello, I was hoping you could tell us if there are proven statistics in regard to children wearing the brace that does improve the spine or does it just prevent it from getting worse, and how effective do you believe the brace is or is not?

Ryan_Goodwin,_MD: To date, there is no medical evidence that suggests that any brace can improve a patient's curvature. Occasionally, we may see a brace effect on an x-ray when a patient has been wearing a brace with some regularity. Ultimately, however, the brace cannot improve a patient's curve. There is good evidence that a proper brace can slow down the progression of a patients curve in a growing child. Success rates are anywhere between 50 percent and 85 percent, and are very closely linked to patient compliance.

Beth123: My 85-year-old mother's back is severely curved to the right and is also twisted. She has no pain when she sits or sleeps, thankfully. She has been very active all of her life: eats right, exercises and is trying so hard not to give up her mobility. She has amazingly good balance due to her continued activity around the house and in her gardens. However, her back starts hurting as soon as she starts walking. The pain doctor has tried many times to administer shots to relieve the pain, but they do not help at all. Her pain doctor says that if she gets a back brace, to help hold her torso in place, (not to try to correct the curve at this point) that her back muscles will weaken and it will make her situation worse. Her back doctor seems to think it is worth a try to see if the brace will allow her to be on her feet longer, or at least with less pain. What is your opinion about back braces in a situation like my mother's? Thank you.

John_O’Connell,_MD: Back braces, even soft ones, have been shown to cause the muscles that support the spine to weaken, so theoretically, I agree with the pain specialist. That said, the brace may provide support to allow her to be more active. There is little harm in trying a brace. My recommendation would be to minimize use of the brace and continue exercising, specifically to condition the muscles that support the spine.

mountaingirl3: What does the data say about the number of hours prescribed for wearing a brace? Is there a significant difference in outcome if an adolescent wears the brace 16 hours a day versus 23 hours a day or just at nighttime?

Ryan_Goodwin,_MD: The brace wear schedules are different for a Boston versus Providence or other nighttime brace. The evidence would seem to indicate that a minimum of 16 to 18 hours of brace wear can produce the desired results in a Boston-style brace. There does not seem to be significant evidence that increasing this to 23 hours a day improve things significantly. There is less evidence on the nighttime bending brace; however, compliance tends to be quite good with them. They work differently and there is less brace wear, only when the patient is sleeping. The evidence here, however, suggests that if worn nightly that the bending brace can be effective at slowing curve progression in a majority of patients as well.


Curve Progression

Mommyto2: My daughter is nine, will be 10 on Tuesday. She was noted to have a curve of seven at her initial exam and x-ray in March of 2014. In July, she had a follow-up exam and x-ray, which showed that the curve increased to 15. The pediatrician said that we would just continue to watch her. However, in the last month or so, my daughter has been experiencing pain in her back. She also, within the last two weeks, is having pain in her leg and heel when running. The pain is bad enough that she can't continue physical activity. I approached her doctor about going to see an orthopedic doctor. The pediatrician doesn't think it is necessary because her curve isn't at or above 20 yet. What are your thoughts? Could the pain be related to the diagnosis of scoliosis?

Ryan_Goodwin,_MD: Interesting question. Your daughter’s heel pain is most likely not related to the scoliosis whatsoever. This would require an independent evaluation by a pediatric orthopedic specialist. If she's having back pain, she should also be seen by an orthopedic specialist. I would agree that curvatures that progress to 20° require evaluation and treatment by an orthopaedic specialist. Your best bet is to obtain a referral at this point to address both problems.

Sunflowers5: Is it possible to "train", through yoga and stretches, a curved spine to straighten? Can pregnancy and childbirth cause spine curvature?

R._Douglas_Orr,_MD: It is not possible to straighten a spine with idiopathic scoliosis through exercise. Exercise, however, can be vitally important particularly in adults. Exercises such as yoga and Pilates are very good at strengthening core muscles and are very effective in managing the pain that can sometimes be related with scoliosis in adults. Pregnancy and childbirth do not cause spinal curvature. In the past, it was thought that pregnancy was associated with increased progression of curves, but this has been shown not to be true. There may in the late stages of pregnancy be some increase in the curve but this tends to resolve by about one year after the cessation of breast-feeding.

Ryan_Goodwin,_MD: Stretching and yoga have both been shown to improve pain associated with scoliosis and other back conditions. Currently, there is no medical evidence that suggests that either yoga or stretching can affect the natural history of curve progression. The only two things that have been shown to do this are a brace or an operation.


Other Treatment Options

beaton: I am told by my orthopedic surgeon that surgery will put me out of work. I am female, 59 years old, and learned only two years ago that I have 58 degree levorotoscoliosis. I had been suffering from sacroiliitis for the better part of two years. The surgeon related the sacroiliitis to the scoliosis. Injection to the joint with cortisone did not help. I cannot – will not – take narcotics. In desperation, I tried chiropractic treatment, which has been very successful. I was able to start physical therapy and have been much more functional, yet no one in the medical community would recommend chiropractic treatment. My insurance limits the number of chiropractic visits to 20 per year, although this is the only treatment that helps. What is your stance on chiropractic treatment for this type of problem?

John_O’Connell,_MD: Chiropractic has been shown to provide short-term relief of acute pain, and a good chiropractor may be able to mobilize the joint to provide temporary relief. I'm glad that you mentioned physical therapy and exercise, it is important to continue to do those exercises regularly.

jschol: Can a chiropractor effectively manage scoliosis (particularly in a teenager)? If so, what should we watch for that might indicate it is not being managed well?

R._Douglas_Orr,_MD: Most of the management for adolescent scoliosis consists of monitoring the curve for progression. Many chiropractors are able to do this. Some chiropractors also prescribe braces and exercise, which may help lessen progression or symptoms related to the scoliosis. There is, however, no good evidence that chiropractic treatment can reverse scoliosis, even though this has often been claimed.

Ryan_Goodwin,_MD: Chiropractic care can be very useful in some cases at managing pain associated with scoliosis or other back conditions. Currently, there is no medical evidence that chiropractic care can effectively manage the progression of the curvature. The only two things that have been shown to affect the natural history of scoliosis are a brace or an operation.

koober: The patient is 47 and has a marked dextroscoliotic curve in the upper lumbar region measuring 40 degrees with multilevel degenerative changes associated with varying degrees of central stenosis, subarticular stenosis and intervertebral foraminal stenosis. The patient also has a prominent scoliosis in the thoracic spine with a shift to the left with a hypokyphosis noted in the thoracic spine with decreased range of motion noted. The patient has had an open sternal reduction due to severe pectus excavatum. The patient also has a lung FEV of 35 percent. The patient is unable to keep his O2 level above 90 percent during exercise and many times during daily activity. The patient is a state champion bowler and has a goal to get rid of back and hip pain on the lower left side and improve O2 levels to a point of being able to exercise, sleep and fly without oxygen. The patient hopes moderate improvement could do that. The patient has worked his adult life on managing symptoms via exercise, chiropractic care, massage, physical therapy and NSAIDs. He has been told he is not a good surgery candidate. Do you have any suggestions?

John_O’Connell,_MD: I agree with the exercise, PT and chiropractic. As far as pain control, injections may be a beneficial adjunctive to exercise. Also, hip pain has multiple causes. A thorough examination by a physical medicine specialist of the hip, spine and surrounding muscles would be in order if not recently done.

bmwillis: What are your thoughts on vertebral body stapling and tethering to correct scoliosis through retarding growth on the convex side while allowing growth on the concave side? Do you ever recommend these procedures in adolescents with significant growth remaining? If so, at what curve levels?

Ryan_Goodwin,_MD: The indications for this procedure are essentially the same as the indications for brace treatment. Patient must have significant growth remaining and curvatures between 25° and 40°. In my practice, I recommend bracing for these patients and encourage compliance with the brace wear schedule. Bracing does have good medical evidence that suggests it positively affects the natural history of the disease process in the majority of cases, and the risks of bracing are significantly less (essentially zero) than those of stapling or tethering surgeries. I think that significant further evidence should be available before we apply this technique more widely, as there are significant risks compared to bracing. This technique has been employed in very few centers around the United States and the rest of the world. It is usually performed via a thoracoscopic approach, which is for the most part minimally invasive. It does, however, violate the patient's chest and, in so doing, will reduce the patient's maximum pulmonary function tests a small degree. The risks of any surgery are going to be inherent here as well.

rhodge9732: Is traction a practical treatment for scoliosis?

John_O’Connell,_MD: There is no evidence to my knowledge to show traction to be effective in the management of scoliosis. Cervical traction may be beneficial in upper limb pain caused by a pinched nerve in the neck, but this is unrelated to scoliosis.


Pain and Other Problems

myrtleirene: I am an 82-year-old female, diagnosed with Parkinson's disease 12 years ago. I have exercised daily (aerobics and walking) for 40 years. My back pain has gradually increased for the past year and now prevents aerobics and walking more than 1/2 mile. My doctor determined the cause of the pain to be scoliosis and prescribed physical therapy. The PT stretching exercises help only slightly, and I can't stand up straight for the first one and a half to two hours of the day until the PD medications (carbidopa/levodopa) take effect. Exercise is essential to prevent the rigidity of PD. I am advised not to take over-the-counter pain relievers. Do you have suggestions for relieving the pain caused by scoliosis in this situation?

John_O’Connell,_MD: I agree about the importance of regular exercise. If the pain is severe, you may want to be evaluated by a spine specialist for consideration of spinal injections for pain control.

loveitaly: My daughter is 32 years old. She has developmental disabilities and multiple conditions (seizures, GERD, non-ambulatory, cerebral palsy). At six years old, she had hip subluxation surgery in the left hip. After a year, they removed the metalware, and it has always been OK. At nine years old, the doctors did the same surgery in the right hip, but the metalware came out of place. The doctors tried to fix it again with no success. The doctors said the reason it was coming out was due to her scoliosis. It is severe, but the curve is in the lower part of her back, so it doesn't affect her upper organs. For years, she used scoliosis jackets, even for horseback riding. The curve continued to be stable, it didn't increase. They never did surgery because of the risks and complications. The right hip eventually dislocated, and there is a big discrepancy in length. Any suggestion now that she is an adult to maintain it? Because of severe GERD, scoliosis jackets are not an option anymore. Thank you.

R._Douglas_Orr,_MD: In most cases such as your daughter's, the scoliosis can be managed by adjustments to their chair. This essentially acts as a brace for someone who is non-ambulatory. The indications for surgery are severe pain or problems with skin breakdown over bony prominences that may be related to the deformity. The scoliosis may have complicated the management of the dislocated hip but it did not cause it. Because the pelvis is often tilted, it is sometimes difficult to get control of the ball in the socket of the hip joint. In someone who is non-ambulatory, a major spinal surgery to realign the pelvis in order to contain the dislocated hip is generally not indicated, as it does not provide a significant functional improvement and does contain significant risks. Spinal deformity surgery in adult cerebral palsy patients has an extremely high complication rate and is only done as a very last resort.

pa2four: I have one of those curvatures in the cervical spine that makes my neck have the look of a turtles as it comes out of its shell. I am 58. Is there any hope of "changing" this, invasive or non-invasive?

John_O’Connell,_MD: What you are describing sounds more like postural dysfunction than scoliosis. This may respond to physical therapy for stretching the muscles in the front of the neck and conditioning the ones in the back that support the neck.


The Schroth Method

mataki: Do you have knowledge of the Schroth method to treat scoliosis? It appears they have had much success with their method, yet there are so few practitioners in this country who practice it or even know of it. It would be a great option for those of us with scoliosis. Why isn't it used here more?

Ryan_Goodwin,_MD: This method employs some specific stretches in an attempt to modulate incorrect scoliosis. It is a very intense an aggressive program which can produce some early improvement inpatient curvatures.

mountaingirl3: What are your feelings on the Schroth method of physical therapy to treat scoliosis? My daughter is 13 and we found out about four weeks ago that she has scoliosis. She has been wearing the Boston brace for about two weeks. We have our first "in brace" x-ray next week to see if the brace is doing its job. We are considering Schroth, specifically going to a clinic for a one-week intensive treatment.

Ryan_Goodwin,_MD: This method seems to provide some early improvement in patients’ curvatures. It may also help reduce any pain that may exist. Unfortunately, it has not been shown in the medical literature to alter the natural history of curve progression in its patients. There is, however, good medical evidence that a Boston brace, if worn according to the recommend guidelines, is indeed able to alter the natural history of curve progression in a majority of cases. No brace can permanently improve a patient's curvature, but a good brace if worn properly can be very effective at slowing down or even stopping curve progression in a child who has growth remaining.

mountaingirl3: Do you use the Schroth method at the Cleveland Clinic? Do you have any data on this method's effectiveness? Also, do you prescribe the Rigo Cheaneau brace or the Boston brace?

Ryan_Goodwin,_MD: We do not use this method at Cleveland Clinic. Our center uses either the Boston brace or Providence brace for management of potentially progressive curves in patients with growth remaining.

bmwillis: A follow-up to the earlier Schroth question; Would you agree with programs like Schroth: to get past "early improvement", this requires dedication by the patient/family to be consistent with the exercises throughout the growth period?

Ryan_Goodwin,_MD: Most of the evidence shows that early improvement is all that is obtained by this method. There have been no medical studies that I am aware of that suggest that the natural history of scoliosis is altered by this method. Certainly, any treatment method will work better if the patients and families are dedicated to the treatment protocol and adhere to it. This is perhaps best demonstrated by brace wear studies involving heat sensors that clearly demonstrate that patients who wear the braces according to schedule have better outcomes than those who do not.

kaparsons24: Are there any published studies, large or small, for the Schroth method (either US or abroad)?

Ryan_Goodwin,_MD: There are not many. Most of them are short-term and used relatively small numbers. Many of them are descriptive studies only and not large-scale randomized control trials, which are best for medical decision-making.

mountaingirl3: Are there any studies being done on the Schroth method?

Ryan_Goodwin,_MD: See prior answer. We do not have any studies ongoing here at Cleveland Clinic to study this technique.


General Information

kaparsons24: Unfortunately, we know that scoliosis patients vary with degree, age, growth, type of curve and type of scoliosis, and they especially vary with compliance to treatment procedures. Therefore, most studies are small-scale and very limited sets. Could you point us to any studies on both classic bracing and surgery, as well as alternatives such as the Schroth method, even if these are only small and observational? I have been told that Europe is far more aggressive with non-surgical experimental methods. Where could we find these studies? I am not arguing a specific agenda, only seeking knowledge and helpful data. I greatly appreciate your help.

Ryan_Goodwin,_MD: You are correct that European practitioners are much more aggressive with stretching and other nonsurgical methods. www.pubmed.gov is probably the best search engine for any medical related studies/literature. There are many free text articles available at that location. http://www.srs.org is the website for the Scoliosis Research Society, which has a good collection of links to data that is scientifically collected and assembled. They have information on many different modalities that have been attempted to treat scoliosis and other spine deformities.


Closing

Moderator: I’m afraid that’s all the time we have today for questions. Thank you everyone for participating today; and thank you, Drs. Goodwin, Orr and O’Connell, for your insightful answers to our questions about scoliosis.

R._Douglas_Orr,_MD: Thank you for all of your questions, and I hope we have been able to answer them for you. Most adult scoliosis will not require surgery, and most symptoms can be managed conservatively. There are many varied surgical options available for when non-operative care is no longer sufficiently effective. If looking into surgery, it is important to see a spinal surgeon who specializes in adult deformity surgery at a center with experience handling these often complex operations.

John_O’Connell,_MD: Thanks for all of your questions.

Ryan_Goodwin,_MD: Thanks everyone for all of the great questions. Have a great day.


For Appointments

To make an appointment with Ryan Goodwin, MD, or any of the 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 Neurological Institute 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.

To make an appointment with John O’Connell, MD, or any of the specialists in our Neurological Center at Cleveland Clinic Florida, please call 877.463.2010. You can also visit us online at clevelandclinicflorida.org.


For More Information

On Cleveland Clinic Center for Pediatric Orthopaedics

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On Scoliosis - Health Information

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