Online Health Chat with David P. Gurd, MD, and R. Douglass Orr, MD

Tuesday, June 2, 2015

Description

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.

Your spine is the backbone of your body. It is made up of 33 vertebrae and stretches from your head to your tailbone. The 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, ligaments or 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 hips. 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.

About the Speakers

David P. Gurd, MD, is the head of Pediatric Spinal Deformity Surgery at Cleveland Clinic. He received his medical degree from The Ohio State University and completed residency training at Cleveland Clinic and a fellowship in pediatric orthopaedics at the Texas Scottish Rite Hospital for Children. Dr. Gurd's main interests include scoliosis, pediatric trauma, lower-extremity deformity and children's hip conditions.

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 a fellowship in orthopaedic spinal surgery. He also completed a fellowship in spine surgery at the University of Wisconsin Hospital and Clinic.


Let’s Chat About Scoliosis in Children and Adults

Moderator: Welcome to our chat about scoliosis in children and adults with Cleveland Clinic specialists, Dr. David Gurd and Dr. Douglass Orr. Dr. Gurd and Dr. Orr, thank you for taking the time to be with us to share your expertise and answer questions.

Let’s get started with our questions.


With Other Disorders

Valpat: Does scoliosis increase the occurrence and severity of osteoporosis in one's spine?

R._Douglas_Orr,_DO: Scoliosis does not increase the occurrence or severity of osteoporosis. In fact, actually the opposite can be true. Patients with osteoporosis and scoliosis will sometimes develop worsening deformity due to fractures of the spine secondary to the osteoporosis. That is why it is very important for women with scoliosis to monitor their bone density as they age to prevent or treat osteoporosis.

sanddollargirl: I have scoliosis and spina bifida 3 and many other back problems. My question is: Are these all connected from one disease or all separate? I have some autoimmune diseases, too (lupus and Sjogren's). I am almost 55 years old, and I have a lot of pain. It seems like no one has an answer for me.

R._Douglas_Orr,_MD: Scoliosis, spina bifida and back pain can be interrelated. The scoliosis can develop in spina bifida due to the abnormalities in formation of the vertebrae. If you are having significant back and/or leg pain, it is possible that there may be treatments for your scoliosis. At your age, it is unlikely that the spina bifida itself is a cause of pain. Scoliosis is not associated with autoimmune diseases such as lupus and Sjogren's syndrome.

loveitaly: My daughter is a young adult who has CP and developmental disabilities. She is non-ambulatory due to her neurological condition. At seven years old, she had a successful hip surgery on the left to avoid dislocation. At 10 years old, she had surgery on the right. After a year, it was coming out of place. At the time, she was having some scoliosis [issues], and they told us that the hip didn't want to stay in place, even with the metal ware inside, due to the scoliosis pulling the muscles. The doctors thought about doing the scoliosis first. A new doctor arrived from Boston, and he said that before, it was routine that all children/teens with CP should have the scoliosis fixed. He explained to us that it depends on each individual patient's case. In my daughter's case, she has severe GERD and seizure disorder, and recovery was going to be very risky. So, it was never performed. For years, she used jackets, but stopped due to the GERD. She stopped growing years ago and is petite for her age. There is a big leg discrepancy. Thank you for your input.

David_P._Gurd,_MD: The hip issues can also be due to, and are commonly associated with, very tight adductor (groin) muscles. But worsening scoliosis that creates a tilting of the pelvis can also "uncover" the hip and make it more likely to dislocate. The treatment of scoliosis in patients with static encephalopathy is very much decided on a patient-by-patient standpoint. Not all require surgery for this, but some do significantly benefit from surgery. How large is the curvature?

loveitaly: She had the surgery for releasing the adductor muscles when she had the first hip surgery in 1987. Since the right hip was corrected twice and it went back to dislocate, the doctors decided it was better to leave it like that.

David_P._Gurd,_MD: OK, but it is still important to stretch and keep as much mobility as possible.

loveitaly: Since they tried to correct the right hip twice without success, the doctors decided to leave it like that. She was in her teens. When she had the metal ware inside, she was in a lot of pain, and her exercises were difficult to do. At that time, she was doing horseback riding (therapeutic) and she couldn't tolerate it. When they removed all the pins, she went back to the horses, using the prone stander equipment, with no problem at all. The doctors told us trying to force the hip into place was more harmful for her. It's been totally dislocated for more than 18 years. She did have surgery to release her adductor muscles in her first hip surgery. The size of the curve, I don't remember exactly, I don't want to give you a wrong number. Thanks.

David_P._Gurd,_MD: I think this sounds like safe advice. Thanks.


Everything About Exercise

Nama4: I read a report of a study suggesting the Yoga "planking" move could help straighten the spine. Is this true?

David_P._Gurd,_MD: There is some European literature that core stretching and strengthening can prevent scoliosis progression. Also, these exercises can limit many of the degenerative changes that can occur in the spine, so I would highly recommend these as "spine healthy."

LESLIEW: My daughter is 14 years old and was diagnosed with scoliosis two years ago. She is a tumbler for her cheerleading squad and took up powerlifting through a program at her high school this winter, along with her older brother who plays football, to build muscle tone. I felt it may be good for her to take up powerlifting to build muscle and get stronger for her overall health and tumbling. She began having some minor back pain that began to affect her tumbling. I called our DO. Through spinal x-rays, he found out recently that her curve has progressed to 22, when he had told us two years ago it was minor. He has recently told her to discontinue all heavy squatting and deadlifting. She loves the powerlifting and competitions and is devastated. Her father and I have both agreed she needs to discontinue the heavy lifting and the pressure it places on her back. I was just curious as to what your thoughts are on scoliosis and powerlifting? We trust our DO, but wondered about your thoughts?

R._Douglas_Orr,_MD: A 22-degree curvature is still on the mild side. Powerlifting should not cause further progression of this. Powerlifting, though, can cause back pain as it puts excessive stress on the back area. I typically see this worst with squats, deadlifts, and power cleans. Also, many powerlifters do not focus on core stretching, which can also lead to pain. Have you had an x-ray to check for a stress fracture in the lower part of the spine? This could also be a cause of the pain.

SATURN9: What exercises are okay for thoracolumbar scoliosis besides swimming and core strengthening? I'm am a 72-year-old female.

R._Douglas_Orr,_MD: Any exercise that you can do without pain is okay in scoliosis. In general, the people who are more active have fewer symptoms, so I would strongly encourage you to continue with an exercise program. I generally tell patient's that you are more likely to continue with an exercise program that you enjoy so find something you enjoy and do it.


Origins and Effects

hodge: Does adult unset scoliosis cause significant loss of height? I'm 68 and have gone from 6'2" to 5'11." I have an S shaped curvature through the neck and back.

R._Douglas_Orr,_MD: Loss of height is, in fact, one of the most common ways for scoliosis to present in adults. As the curve develops and progresses, people often lose one to three inches of height. In the absence of symptoms, this is not something we would treat. It is important to note, however, that everyone loses height as they age. Height loss with aging can be up to two or three inches in the absence of a scoliosis.

pan: At the age of 60, I am living with scoliosis without problems. Can osteoarthritis of the knee and hip be affected? Can scoliosis affect breathing? Thanks in advance.

R._Douglas_Orr,_MD: Scoliosis does not affect osteoarthritis of the hip or knee. In the past, it was felt that scoliosis could affect breathing if the curves became very large. Since then, it has been shown that with typical idiopathic scoliosis this is not true. Certain types of scoliosis, particularly those caused by underlying neuromuscular diseases, can progress to the point of causing lung compromise but these curves are rare.

luch24: Can scoliosis be a result of poor posture, or is it congenital and you are born with the curvature? My scoliosis is slight and I have not needed any treatment, but no one ever mentioned it to me until I was an adult.

R._Douglas_Orr,_MD: There are actually multiple types of scoliosis. A true congenital scoliosis occurs because the vertebrae form abnormally in the uterus. This is however rare. Idiopathic scoliosis is an abnormality of growth typically beginning during adolescence. In spite of what my mother always told me, posture is not something that you voluntarily control. Your standing posture is actually dictated to a large extent by the way your pelvis is oriented. It is dictated genetically. Your standing posture is the position in which your body maintains your head balanced over the pelvis while expending the least amount of energy. Poor posture does not create scoliosis, kyphosis or a tendency toward back pain.

elber: My 15-year-old daughter has scoliosis. She has recently seen Dr. Goodwin in Orthopedics. She has been having a hard time with pain in the middle of her back for more than two years. She is asking for alternate options for pain relief because Aleve® and anti-inflammatory medications [are not helping]. What are some suggestions? Physical therapy, massage, chiropractor, acupuncture.

David_P._Gurd,_MD: Back pain is most likely not caused by the scoliosis. What I typically find is there is a muscular component to the pain. Is the pain worse when sitting and standing for a long period of time? Has there been pain shooting down the legs or difficulty with using the bathroom? If it is more muscular pain, rest, anti-inflammatories, massage, ice, etc. can all help but are very temporary. Stretching of the muscles and working with core strengthening tend to be the treatment that will help for the long term. I am a big advocate of Yoga for this, also.


Tolerable Treatments

daveh: My daughter has a 12-degree curvature, which is not progressing so far. Is there anything to do to keep it this way? Thanks.

David_P._Gurd,_MD: How old is your daughter? If she is done growing, then this shouldn't be an issue. The only time when a small curve would worsen is if there is significant growth remaining. The curve would be too small to recommend bracing. Some studies out of Europe show that core stretching and strengthening can minimize the chance of scoliosis progression. This is the Schroth method of therapy.

RMB118720: Hello. My 11-year-old son has Marfan syndrome and scoliosis with a 24-degree curve. Within the last two months, he started wearing a brace at night or for up to 12 hours a day. Although he is already 5'6", he still hasn't started puberty or had a major growth spurt yet. I know treating scoliosis as it's related to Marfan syndrome is different than when the cause is idiopathic. Could you elaborate on the difference with regard to surgical and non-surgical treatments? It's difficult to encourage an 11-year-old to wear a brace when surgery might be inevitable, but I feel it's our best option at this point. Please share your thoughts. Thank you.

David_P._Gurd,_MD: With a 24-degree curve, surgery is certainly not inevitable. There is a very good chance that surgery will not be needed. The curve is more likely to progress as the spine grows. For children with moderate sized curves and still with significant growth, bracing has been shown to be our best and safest way of preventing scoliosis progression. In regard to differences in surgical and non-surgical treatments, surgery is a definitive fix of a progressing curve that is over 50 degrees. We do not need this in curves that are not progressing and smaller than 50 degrees. Nonsurgical options are bracing and core muscle treatments like the Schroth method of therapy that help to prevent scoliosis from worsening and, hopefully, preventing the need for surgery.

baglady: What is the treatment for adult scoliosis for someone who has been diagnosed with osteoporosis?

R._Douglas_Orr,_MD: Osteoporosis becomes a factor in the treatment of adult scoliosis only at the point where surgery becomes involved. Most people with adult scoliosis can be managed non-operatively with a combination of exercise, medications and occasionally injection therapy. It is, however, crucial to be sure you are optimally managing your osteoporosis, as there can come a point where the osteoporosis is too severe to allow surgical treatment. I would strongly encourage discussing osteoporosis with your primary care physician.

Decisions about surgery are based on the symptoms experienced, the response to treatment and a detailed analysis of the actual deformity, particularly whether the patient's head is "balanced" over the pelvis. Not all patients coming to surgery need to have the scoliosis corrected. In many cases, the symptoms can be treated with lesser surgery.

greenacre: How long does a child need to wear a brace (hours per day)? Also, does bracing stop when the child is done growing?

David_P._Gurd,_MD: It depends on the type of brace. For thoracic curves (upper spine or those in the chest), I still think it is better to use a Boston-type orthotic that is ideally worn 23 hours a day. However, newer studies show that if it is worn more than 18 hours a day, then it is still very helpful. For the thoracolumbar curves (lower spine - waist), a night-time bending brace, which is only worn during sleep, has also been shown to be very helpful. Once growth is complete, the brace can be discontinued.

jschol: Can scoliosis be controlled or reversed through chiropractic care?

R._Douglas_Orr,_MD: There have been no studies showing the ability of chiropractic care to correct or slow the progression of scoliosis. There have been some weak studies showing that chiropractic care, combined with a good trunk strengthening exercise program, can control the symptoms, typically back pain of scoliosis.

amy: How do you determine when to brace? Up to what age is bracing effective?

David_P._Gurd,_MD: Typically, a progressive curve above 25 degrees in a growing child would be considered for bracing. Once growth is accomplished, then the brace is no longer helpful. A girl's spine typically continues to grow for 18 to 24 months after her first menstrual cycle. Boys are more difficult to determine, but we use closure of growth plates in the pelvis on the x-ray to help determine when they are done with spine growth.


Specifics of Surgery

marathon: What are the rods made of? I am allergic to metals.

R._Douglas_Orr,_MD: The rods and screws currently used in spinal surgery are made either of cobalt chrome or titanium. Occasionally, stainless steel is still used. Stainless steel contains nickel. Most people with mental allergies are actually allergic to nickel, and we would not use stainless steel. There is no nickel in either of the other metal alloys. Allergy to titanium is virtually unheard of.

michele: Are there any limitations to activity after surgery – both short term (within the first six months) and long term? What about mogul skiing?

David_P._Gurd,_MD: For the pediatric population, I will typically avoid torso bending, torso rotating and lifting of > 10 lbs. for six months. I then get aggressive with stretching and core strengthening at the six month mark. I try to avoid serious roller coasters and mogul skiing for a year, but then they may return to those activities also.

koleaz: Do the rods stay in forever or are they removed?

R._Douglas_Orr,_MD: In general, the rods are left in. After the fusion has healed, the rods actually do not really have any ongoing function and they can be removed, but as with any operation, there is a risk to doing so. In rare patients, the hardware itself can cause some discomfort, and, in these patients, we do remove the rods, but in someone who has no symptoms from the hardware, they are left in.

hjkl: What is a MAGEC growing rod?

David_P._Gurd,_MD: Typically for very young children with significant curves that have failed other more conservative types of treatment – meaning the curve continues to progress – then we have to go to early surgery in the form of growth rods. We do not want to do spine fusion at a young age, as that can cause its own problems. The growth rods allow distraction, or growth, of the spine while the child grows and allows control of the scoliosis. Standard systems require surgery every six months to elongate the rods. The MAGEC rod is a mechanical rod that can grow without surgery by utilizing an external magnet. So with this, we can still control the curve and allow the spine to grow with the child without repeat surgery.

koleaz: Will I set off the alarm at airports when going through TSA? Should I always ask for the body scan instead?

R._Douglas_Orr,_MD: Titanium rods will not set off a typical airport metal detector, although the hand-held detectors will occasionally pick them up. Cobalt chrome rods are more likely to set off the traditional detectors. The new back scatter scanners do not penetrate, and we generally recommend for patients with any metallic implant to use the newer scanners.

nana: If your spine is fused, doesn’t that affect your flexibility? What will I notice after having scoliosis surgery?

R._Douglas_Orr,_MD: Spinal fusion does remove any motion through the levels where the spine is fused. In many patients, however, the spine moves very little through the curve, and many patients do not notice much change in their range of motion. Other patients, particularly adults who have long fusions down to the pelvis, do find some problems with activities such as putting on their shoes and socks, but usually they can adapt to this.


Facing the Future

Nama4: My 17-year-old grandson was diagnosed at age 13 and wore a brace for a couple of years. He plays football and has had no problems. His goal is to have an Army career. Will he be able to follow that plan and pass the physical? Do you know if the Army waives this issue if the prospective soldier can prove athletic prowess?

David_P._Gurd,_MD: Just having scoliosis and treatment with a brace should not limit one's military career. I think that if he can pass all of the physical requirements, then this should not be an issue. Do you know the degree of curvature?


Closing

Moderator: That is all the time we have for questions today. Thank you, Dr. Gurd and Dr. Orr, for taking time to discuss scoliosis in children and adults.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at http://my.clevelandclinic.org.

R._Douglas_Orr,_MD: I hope you found this web chat useful.

David_P._Gurd,_MD: Thank you all for your time and interesting questions today. If I can help in any way further, please call my office at 216.445.8001. Thanks, Dave Gurd.


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To make an appointment with David Gurd, 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.


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Cleveland Clinic Health Information

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