Online Health Chat with David Gurd, MD, and Jason Savage, MD

Tuesday, June 21, 2016

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 two percent to three percent of the pediatric population and up to 30 percent of adults worldwide. Scoliosis may be detected in infancy, childhood, adolescence or adulthood. Chat with pediatric scoliosis specialist, David Gurd, MD, and adult scoliosis specialist, Jason Savage, MD, and get all the answers to your scoliosis questions.

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. 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.


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 in orthopaedics at Cleveland Clinic and a fellowship in pediatric orthopaedics at the Texas Scottish Rite Hospital for Children. Dr. Gurd's specialty interests include pediatric and adolescent orthopaedics, scoliosis and spine deformity, pediatric trauma, lower-extremity deformity and children's hip conditions.

Jason Savage, MD, is a staff physician in the Cleveland Clinic Center for Spine Health. Dr. Savage received his medical degree from UMDNJ-Robert Wood Johnson Medical School. He completed his residency in orthopaedic surgery at Northwestern University and his fellowship in orthopaedic spinal surgery at University of Wisconsin. Dr. Savage's specialty interests include adult spinal deformity, scoliosis, degenerative conditions of the spine, lumbar spinal stenosis, spine trauma and spine tumors.


Let’s Chat About Scoliosis


Halting Curve Progression

pb: Should a young adult be worried about his or her 40-degree curve getting worse with time? What are some ways to decrease spinal curvature?

David_Gurd,_MD: It depends on the person’s age. If there is a lot of growth remaining, this certainly could progress and may benefit from bracing. Core stretching and strengthening or the Schroth Method of physical therapy may be beneficial.

cpolatas: As a parent of a 16-year-old that is currently having frequent backaches (which my daughter describes as six in one to 10 pain level - she has S curve with approximately 45 curve each), what can she expect as she ages if surgery is not performed?

David_Gurd,_MD: At 45 degrees, she is right at the degree measurement where the curve should be followed, as it has a higher chance of further progression. If it were to progress, surgery can be helpful to prevent further deformity but also to create better alignment of the spine. In the meantime, I would advocate core stretching and strengthening to minimize discomfort and hopefully prevent further progression.

Olivia 32: Can anything be done to stop progression of scoliosis?

David_Gurd,_MD: Studies show that the use of braces and the Schroth Method of PT can help prevent growth of scoliosis progression.

cannfleming: I am a 59-year-old female who is very active. My upper back curve is 47 degrees and I have a 34-degree lumber curve. I have been searching for ways to keep my curve from advancing and am frustrated by the lack of information. A year and 1/2 ago, my upper curve was 52 degrees. I started doing Schroth exercises with a PT trained in the method. I also started doing a side plank every day after reading about a study that was done in NY. My last x-ray showed 47 degrees. I am aware that there is a five degree margin of error on reading the x-rays; however, at least it has not gotten worse. I am not going to have a metal rod put in my back; I ride a horse four times a week and compete. Please tell me where to get more information on exercises that will help me keep my back stable. I am very, very motivated.

Jason_Savage,_MD: Adult idiopathic scoliosis curves typically progress 1/2 degree per year. The fact that your curve has been stable is great. At this point in time, there is nothing that "slows or prevents" progression. Staying active is very important. The best information for scoliosis is found on the Scoliosis Research Society's website: http://www.srs.org/.


The Topic is Treatments

thatrobyn: I am a 43-year-old adult with two 65-degree curves in my spine. I am trying to avoid surgery, but do have chronic pain that differs in intensity from day-to-day. I'm having specific trouble with my quadratus lumborum on the right side and have for several years. It can be incapacitating. I'm wondering if you recommend any treatment or therapy that could a) help keep the pain at bay, and b) assist in my muscle imbalances and, as a bonus, c) keep my curvature from worsening. I've tried PT (regular and Schroth Method), massage, rolling, yoga, strength training, acupuncture and Pilates. Do you suggest any combination of the above or other modalities? Thanks.

Jason_Savage,_MD: You are doing all of the right things. In general, the best treatment for the back pain component of scoliosis is a regular exercise program (focus on core strengthening and aerobic exercise). Chiropractic care and massage are other good options. These modalities will not correct the curve or prevent it from progressing, but they tend to help manage the symptoms. It is rare for curves to significantly progress during adulthood.

mikal77: Are there any dietary recommendations/counseling you provide to your adolescent scoliosis patients?

David_Gurd,_MD: There are studies showing that patients with scoliosis have decreased calcium levels. A well-balanced, nutritious diet is very much the key. Patients who live in the North may benefit from Vitamin D and Calcium supplementation.

sunsetfriday: I am a 61-year-old female with untreated scoliosis that was diagnosed in my teenage years. It was described as a double S curve. It has gotten considerably worse, and the only thing my physical therapist has suggested along with exercise is to use a heel lift in my shoe on my short leg. I have constant pain, which I just try to live with as I do not want to take excessive pain medications. I have noticed in the last year, that quite often when I walk I can feel a popping in my lower spine. Is this something to be concerned about? What are the treatment options for someone of my age for scoliosis or for pain management?

Jason_Savage,_MD: A heel lift is often helpful if there is a mild leg length discrepancy due to a scoliosis. The "popping" in your back is likely muscular in nature, and I doubt it is anything to be concerned about (from a stability standpoint). In the absence of radiating leg pain (sciatica, usually caused by arthritis at the lower part of your spine), it is rare that surgery is recommended, but this is something you can talk to us about in the office.

mbrown925: How serious is a 30-degree curve in a 16-year-old? She says she is in a fairly constant state of discomfort and does not want to do much in the way of exercise, participation in sports, etc. Should we be pushing her to get more active? Is yoga something good? She does seem to get relief from her chiropractic visits.

David_Gurd,_MD: Thirty degrees is a moderate curve. It does not require surgery. At 16 years of age, she should be done with spine growth, which also means that the curvature should not progress and get larger. The back pain she has is not typically because of the scoliosis, but more typically because of tight back muscles and deconditioning. I would highly recommend yoga, stretching and a gradual increase in low-impact cardio.

moriah: Are there any new treatments for scoliosis patients who have back stabilization problems? Involved surgery is out of the question, but are there any minimally invasive procedures that are available?

Jason_Savage,_MD: Minimally invasive surgery (MIS) has become quite popular over the past five to 10 years. MIS procedures are often a good option if there is a very "focal/specific" area of concern. I personally do not do MIS scoliosis surgery.

cpolatas: My child is in that grey area as to whether surgery is recommended. She wore a night time brace for approximately two years, but no longer wears it since minimal if any growth remains. She has an S curve and is very balanced, but curvature has increased approximately one to two degrees over the past year that she hasn't been in the brace (she's 15). Her back pain seems to be increasing within the past six months. Are there any options other than surgery?

David_Gurd,_MD: The only other option is getting involved in the core stretching and strengthening and the Schroth Method of physical therapy. Once growth has decreased, if progression is going to occur, it does tend to do so at one to two degrees per year.

Olivia 32: Is physical therapy necessary?

Jason_Savage,_MD: Physical therapy is a great way to learn a good home exercise program for your back (core and pelvic stabilization) that you can do on a regular basis.

las123: Does scoliosis with more rotation than curvature respond differently (better or worse) to bracing?

David_Gurd,_MD: All scoliosis is involved with rotation toward the area of curvature. The amount of rotation correlates with the degree of curvature. Therefore, the more rotation or the larger the curve, the less functional the brace will be.


Late Notice

Canterbury: I am an 83-year-old woman who has just recently been told that I have scoliosis. I lean both forward and to the left side. I am otherwise in good health, not overweight, have a healthy diet and walk three miles a day, summer and winter, mostly outside. I have some lower back and neck pain. I'm currently seeing a chiropractor once a month and do physical therapy twice a week (plus stretches at home twice a day). What more can I do, and what is the prognosis for significant improvement?

Jason_Savage,_MD: Scoliosis is a relatively common diagnosis in adults over the age of 60. In the absence of any leg pain (sciatica), the best treatment for the muscle spasms and back pain is exercise (core and pelvic stabilization, swimming, walking, etc.). You are doing all of the right things, and I would encourage you to continue with the chiropractor, PT and exercise. The prognosis is generally good.

Nasus: My adult son (28) recently had a physical that included an x-ray and discovered he has a distinct curvature of the spine. Is this likely to get worse? If so, what are the consequences? Are there measures that should be taken now to improve the future?

David_Gurd,_MD: It depends on the magnitude of curvature. If the curve is mild to moderate (less than 50 degrees), it should not progress now that your son is done growing. Working with core stretching and strengthening is very important for overall spine health and can help prevent progression. If the curvature is greater than 50 degrees, there is risk of further progression.


Particularly Painful

rosalia: Dr. Savage, I have scoliosis that is very painful, plus I’ve had two hip replacements. My right leg is about 2” shorter than the left. My back pain is very severe, unless I take an oxycodone. I only take it once or twice a day, only when needed. Is the back pain due to the scoliosis or the shortness of the leg, or a combination of both? I have relief after taking the medication. I would like to be able to handle this without taking it. Should I continue what I am doing, or is there a therapy to alleviate this?

Jason_Savage,_MD: The leg length discrepancy is likely putting more stress/strain on your hip and back muscles. A regular exercise program (low back and hip abductor exercises) will likely help stabilize your spine and pelvis, and may help with some of the pain. Anti-inflammatory medications are the first line of medication management, and avoiding narcotics is generally a good idea. Injections are typically best for radiating leg pain (sciatica) as opposed to back pain.

Dakotathunder: I am 46 and had a C5-C6 fusion in 2005. Since then, I have developed scoliosis in my mid back. It gives me lots of muscle spasms that, in turn, twist my left ribs to the right and raise my left shoulder three inches. I have been doing PT for many years and using many muscle relaxants. I would like to stop the drugs; is there anything else that can be done for this issue?

Jason_Savage,_MD: The change in your posture (ribs and shoulder) may be due to the muscle spasms or from the underlying curve. Scoliosis is a 3D deformity that causes spinal rotation. Sometimes, trigger point injections help with localized muscle pain. Otherwise, continuing with the scapular stabilization exercise program is the best line of treatment.

KLR: I have a 30-degree T5-10 curve to the right and a 40-degree T10-L3 curve to the left with lateral listhesis of L2 to the left. I am 58 years old and, until recently, have experienced occasional aching, sometimes burning pain that can usually be relieved with stretching exercises and Tylenol or Aleve. Lately, I have been experiencing some knife-like pain in my right lumbar area that stops me in my tracks until I can change my position. Would you recommend physical therapy as a proactive attempt to decrease my pain/increase stability in addition to the trunk-strengthening floor exercises I already do? I am concerned with the increased pain, but also concerned what effect any ongoing progression could have not only on my mobility but also on my vital organs.

Jason_Savage,_MD: In general, physical therapy and a regular core strengthening exercise program are a great way to treat back pain, especially in the setting of scoliosis. It is very rare (unlikely) that the curve will cause any ill effect on your vital organs, unless the curve is greater than 90 to 100 degrees.

Olivia 32: What exercises can I do to relieve pain?

David_Gurd,_MD: A lot of back pain comes from tight back (paraspinal) muscles and hamstring muscles. It is very important to gain forward bend mobility. It is also very important to work with core stretching and strengthening with activities such as yoga. Routine low-impact cardio activities can also be beneficial.

suziq121: I had scoliosis surgery in 1983 with the Harrington rod inserted. I was fused from T4-L1. In 1998, I had the Harrington rod removed, as I was complaining of pain and they thought it was from the rod. I have been relatively pain free, but I am having more pain now in my lumbar area. I try to stay in shape and fit (including keeping my abs strengthened), but I am getting frustrated with the pain in my lumbar area. Will I always have pain?

Jason_Savage,_MD: It is common for people to have low-back pain, even without a history of surgery for scoliosis. You are doing all of the right things. It is unlikely that you will continue to have pain long term, and continuing with a regular aerobic and core strengthening exercise program is the best treatment at this time.


Considering Surgery

rlcarmen: How valuable is a second opinion? How standardized is the surgery now; do all surgeons use the same procedures and rods?

David_Gurd,_MD: If you are confident and comfortable with your surgeon, you may not need a second opinion. If you have any questions or concerns, it can certainly be helpful to obtain more input. The surgery is fairly standardized, but the more fine aspects of technique will differ between surgeons. There are many types of implants and instruments that can be used, so the use of a certain rod would be at your surgeon’s discretion.

rlcarmen: My 16-year-old daughter was diagnosed with scoliosis nine months ago. She is at skeletal maturity and her curve continues to progress. Her lumbar curve is now at 52, and posterior fusion surgery has been recommended. What are some of the key issues we need to discuss with the surgeon before planning the surgery?

David_Gurd,_MD: I would have a thorough conversation with your physician, ensuring that he or she has comfort and confidence with the procedure and that you have comfort and confidence with your physician. Ask about risks, alternative treatment plans, surgical expectations and postoperative expectations.

carlaclcb: Can you tell me about surgery for scoliosis. How long is the operation? What is involved in recovery short-term and long-term?

David_Gurd,_MD: The surgery for scoliosis is basically placing anchors into the spine and using these with rods to realign and then stabilize the spine in an improved position. The bone of the spine is then prepared to allow it to heal together. The typical scoliosis procedure takes approximately four hours. The typical hospital stay for children with scoliosis is three days. We strive for early mobilization and walking to help get them back to their normal lifestyle. For approximately six months, we limit bending, lifting and twisting to allow for complete healing to occur.

Czechgirl: My scoliosis operations were in 1977. How long will the procedures last?

Jason_Savage,_MD: In general, 25 percent of patients who have a "fusion procedure" require an additional surgery at some point in their life. The fact that you had surgery many years ago and are doing well is a good sign.

carlaclc: I have severe scoliosis and am 52 years old. Can you describe surgery options including recovery times?

Jason_Savage,_MD: Not all patients with scoliosis benefit from surgery. There are many different options for treatment, and the specific treatment is often are dictated by the type and magnitude of the curve, as well as the symptoms. Some surgeries are "bigger" than others, but the recovery time is typically six months to a year.

cpolatas: What is the long-term health outlook for a teenager who has had the spinal fusion? Have studies followed patients throughout adulthood to see what complications/limitations/pain are often associated with having the surgery?

David_Gurd,_MD: There are no great long-term studies following pediatric patients into adulthood. Our expectation is that once a patient has healed from their fusion that they should be able to return to most activities without difficulty and lead a very normal and pain-free life. We suggest avoiding American football and high-diving after this surgery.

lorelei_0813: After back surgery (eight-level fusion) for spinal stenosis, disc degeneration and scoliosis, will the scoliosis ever improve? It has been three years since surgery and I still cannot stand up straight. I walk with a cane at 62 years old in spite of PT and aqua therapy. Would re-examination of my spine be worthwhile?

Jason_Savage,_MD: It's never a bad idea to get another opinion.

cpolatas: At what degree of curvature is surgery usually recommended?

David_Gurd,_MD: For pediatric patients, thoracolumbar curves have a higher chance of progression when greater than 40 degrees; thoracic curves have a higher chance of progression when greater than 45 to 50 degrees. At those measurements, surgery would be recommended.

cpolatas: What are the biggest risks/side effects involved with surgery (both upper and lower curve most likely would require fusion)?

David_Gurd,_MD: 1) The infection rate is approximately two percent to three percent, and we do everything we can in order to minimize this. 2) The spine is realigned and held together with metal. If there is too much motion early after surgery, the metal has a chance of failing and could require further surgery. Due to this, we limit bending, lifting and twisting for six months after surgery. 3) The most concerning risk would be neurological compromise as the spine houses the nerves to the lower legs, bowel and bladder. We do neurological monitoring for every scoliosis case to ensure that we do not run into neurological complications.


Related Disorders

Olivia 32: Can scoliosis contribute to a protruding stomach?

David_Gurd,_MD: Scoliosis is a curvature of the spine to the side and does not typically correspond with a protruding stomach. Sometimes, there is excessive curvature of the spine in a front/back plane known as kyphosis and lordosis. If lumbar lordosis is excessive, it can certainly lead to a protruding abdomen. If you are worried, an assessment by your physician and or an x-ray may help you better understand your condition.

hoganm: My 23-year-old daughter has double scoliosis. Will this affect her ability to have children?

David_Gurd,_MD: This should not affect her ability to have children. Scoliosis can progress during pregnancy and should be followed. It may make it a bit more difficult to receive an epidural, but it should still be possible.

msmithmitsky: Is the problem of osteoporosis in postmenopausal women who will need surgery justification for the use of estrogens to avoid the great bone loss early in menopause?

Jason_Savage,_MD: Osteoporosis is a relatively common problem (in women and men). There are many different treatment strategies for osteoporosis, but calcium and Vitamin D supplementation are typically first-line treatment. I usually refer patients to our bone health team for evaluation and treatment.

Mary S: I am a 69-year-old with severe thoracolumbar scoliosis not treated with surgery or brace. My general health is very good, but my lung capacity is not. A pulmonary doctor said that it’s due to the compression of ribs from scoliosis. Recently, a physical therapist told me that my diaphragm is hardly moving – kind of frozen. What do you recommend to maintain the best lung capacity possible for the future?

Jason_Savage,_MD: The best non-operative treatment is a regular aerobic exercise program to maximize cardiovascular/respiratory health.


Screening Suggestions

Madibona: How early should a child be checked for scoliosis? What's the best way to determine if it's present?

David_Gurd,_MD: Most pediatricians will check at each well-visit. The most common time to identify scoliosis would be around 10 to 12. Clinically, one would notice one shoulder elevated compared to the other shoulder or when bending forward one side of the ribs being more prominent than the other. Girls grow earlier, so scoliosis might be identified a bit earlier.

nmaclarren1: I understand the exact cause of scoliosis is not known. However, now that I have children, I was wondering if there are any measures that could be taken to try and ensure my daughter does not get it at some point in her life. I know she is at higher risk with it running in the family.

David_Gurd,_MD: There are no preventive steps to stop scoliosis. However, early detection by a pediatrician is advised. Screenings are typically performed at each child's well-visit, but a shoulder appearing higher than the other or the ribs protruding on one side versus the other when a child is bending should be brought to the pediatrician’s attention.


Determining Diagnosis

granny of many: My test results read: Roto scoliosis with Cobb measuring 68 degrees right thoracic spine and 55 degrees left lumbar spine, coronal decompensation with coronal measuring -4, thoracic kyphosis measuring 62 degrees and lumbar lordosis measuring 55degrees. The bones are demineralized and multilevel spondylosis. Sacral balance measured from the C7 plumb line: the plumb line falls behind the anterosuperior sacrum by 1 cm. Left iliac crest is positioned approximately 1cm above right. Osteophytosis present at L1-L4, a decrease in disc space height at T12-L1 through L3-L4. Facet joint arthropathy at L2-L3 thru L5-S1 tear L3-4. There is a diffuse annular bulge that is causing mild left neural foraminal narrowing, borderline acquired central canal stenosis, a small Schmorl's node at left anterior aspect of the inferior endplate of L4. Mild left neural foraminal narrowing at L3-4. This is all the information that I have. What is your guess at my prognosis? What would be your guess at a plan of treatment? I am 55 years old. What about injections in my back?

Jason_Savage,_MD: Unfortunately, it is difficult to comment on the prognosis and/or treatment plan without seeing the x-rays and examining you. Injections are typically indicated for radiating leg pain (sciatica).


Research Review

las123: Is there any new research on the effectiveness of nighttime-only bracing versus full-time bracing?

David_Gurd,_MD: In a growing child, bracing can be effective at preventing progression of scoliosis. Most of the literature is on full-time bracing, and this can be effective if the bracing is worn 16 to 18 hours per day. There is not much information on nighttime bracing. I feel it is helpful for lower curves or thoracolumbar curves.

las123: Are there any advances in less invasive surgical techniques for scoliosis?

David_Gurd,_MD: There was an early push for minimally invasive scoliosis surgery. The excitement for this has lessened. Studies do not support minimally invasive over current techniques.

moryan13: Is there any research that points to scoliosis being hereditary? My daughter has it and I'm wondering if her children are at risk for developing it.

David_Gurd,_MD: Yes, there is a genetic component to scoliosis. We currently know of 54 different genes involved. Because there are so many genes, we do not know how to predict the likelihood of family members developing scoliosis.

las123: Is there any new learning on alternative therapies like physical therapy or other treatments?

David_Gurd,_MD: There has been more literature out of Europe showing beneficial effects of the Schroth Method of physical therapy in reducing progression of curvature. Also, core stretching and strengthening is beneficial to all of us from a physical fitness standpoint.


Closing

That is all the time we have for questions today. Thank you, Dr. Gurd and Dr. Savage, for taking time to educate us about scoliosis.

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.


For Appointments

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 Jason Savage, MD, or any of the other 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

About Cleveland Clinic

Cleveland Clinic Center for Pediatric Orthopaedics
At Cleveland Clinic, our pediatric orthopaedic specialists are dedicated to helping children and adolescents return to an active lifestyle. Our team works hand-in-hand with experts from Cleveland Clinic Children’s – including physical therapists, child life specialists and pediatric anesthesiologists, rheumatologists and neurologists – to accurately diagnose your child’s condition and develop the most appropriate treatment plan. We understand that children are not just small adults. Our staff feels strongly that the care of children’s orthopaedic problems differs immensely from adult orthopaedics – and we treat our patients according to their age, development and size. We pay special attention not only to their medical/surgical needs, but also the relationship among the caregiver, child and his or her family.

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Nationally recognized in orthopaedic surgery, neurosurgery and medical spine, the Cleveland Clinic Spine Center provides patients with the latest, most innovative, most effective medical and surgical treatments available for back and neck problems.

Cleveland Clinic Health Information

Learn more about symptoms, causes, diagnostic tests and treatments for scoliosis in children and adults:

For additional health information, visit clevelandclinic.org/health.

Treatment Guides

Scoliosis Treatment Guides - Pediatric & Adult
Please use this guide as a resource to learn about the causes of scoliosis and your treatment options. As a patient, you have the right to ask questions and seek a second opinion.

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