Online Health Chat with Thomas Kuivila, MD and Jason Savage, MD

Tuesday, June 6, 2017


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. 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 and functional limitation, and the cosmetic appearance of the spine. Bracing may be used to temporarily halt the worsening of the curve during a growth spurt.


About the Speakers

Thomas Kuivila, MD, is staff physician in pediatric orthopaedic surgery with the Department of Orthopaedic Surgery at Cleveland Clinic. He is the vice chair for education of the Orthopaedic & Rheumatologic Institute and is the residency program director in orthopaedic surgery.

Dr. Kuivila’s special interests include congenital and developmental spinal disorders to include scoliosis, kyphosis, and sponylolysis and lithesis. He is also an expert in pediatric orthopaedic traumatology. His research interests include bioabsorbable fixation and minimally invasive scoliosis surgery.

He did his orthopaedic surgery residency at Cleveland Clinic, served as an A-O international orthopaedic traumatology fellow in Graz, Austria and was a pediatric orthopaedic surgery fellow at Brown University and Rhode Island Hospital in Providence, RI. Dr. Kuivila then spent six years in the United States Air Force Medical Corps. There, he served as orthopaedic department chair at Keesler USAF Medical Center in Biloxi, Miss., and subsequently as the chief of pediatric orthopaedic surgery at Wilford Hall USAF Medical Center in San Antonio, Tex.

While in San Antonio, Dr. Kuivila was also the USAF residency program director in orthopaedic surgery and a consultant to the Air Force Surgeon General. Dr. Kuivila brings to the department considerable experience and expertise in the management of complex acquired and congenital pediatric and adolescent orthopaedic disorders of the spine and extremities.

Jason Savage, MD, is staff physician at the Cleveland Clinic Center for Spine Health, Orthopaedic Surgery. Dr. Savage graduated from Boston College and completed medical school at UMDNJ – Robert Wood Johnson Medical School. He completed his orthopaedic surgery residency at Northwestern University and completed his spine surgery fellowship at the University of Wisconsin.

Dr. Savage’s special interests include spine surgery, pathology, ridiculopathy, shooting arm pain, shooting leg pain, alleviating pain to function for a normal life, adult deformity, adult scoliosis and restoring daily activities.


Let’s Chat About Scoliosis in Children and Adults


Subsequent Steps

Cutie: Doctor, I have been diagnosed with thoracic mild dextroscoliosis. What should I do?

Thomas_Kuivila,_MD.: This would depend on your age and degree of curvature. A scoliosis specialist would answer your questions about curve management.

phillips24: Does the location of the curve dictate what type of treatment is chosen?

Thomas_Kuivila,_MD.: If surgery is needed, most curves are managed in a similar fashion through posterior surgery.

ssvil: What can be done for mild scoliosis in children since no clinical intervention is indicated.

Thomas_Kuivila,_MD.: Maintaining flexibility is important, but will not change the curve. If no clinical intervention is indicated, regular observation would be important.

Soccer MoM: My daughter, who is 12 years old, was sent home with a note from the school nurse stating she had or might have scoliosis. I made an appointment with her pediatrician, who said she should get checked out by an orthopedist. We have an appointment scheduled next week. Can you suggest some important questions to ask? I am nervous that she might need surgery.

Thomas_Kuivila,_MD.: Ask what her level of maturity is and how likely is it that the curve would progress. It is unlikely that a subtle curve picked up at a school screening is already at the point of where she would need treatment let alone surgery. Treatment begins at 25 degrees of curvature and is typically treated with a brace. Surgery is not indicated unless the curve is in excess of 40 degrees.

Shar: Our 15-year-old daughter at age 6 had a curve of 28 degrees. Her curvature at present is 49 degrees.

Jason_Savage,_MD.: The curve will likely continue to progress/increase with time. I would recommend seeing a pediatric scoliosis specialist to discuss treatment options, possibly surgery.


Broaching Bracing

Laura52: My daughter is still young; she’s 10 years old. Why would a brace not be recommended?

Thomas_Kuivila,_MD.: A brace is only recommended for a curve over 25 degrees and the patient has at least two years of growth remaining. Therefore, a brace would be recommended if your daughter’s curve magnitude exceeded 25 degrees.

Nedlessly21: It was recommended that my daughter wear a brace to prevent the curve from getting worse. Are there different options? If so, what type do you recommend?

Thomas_Kuivila,_MD.: There are no other peer-reviewed treatment options that show reliable results. The Shrock Method has some advocates, but doesn't have the same track record with good results. This is an intensive physical therapy regiment by a specially trained Shrock therapist. There are some other soft braces that advertise good results, but are less proven. Remember, the purpose of a brace is to prevent progression. It will not permanently improve the curve.

jhbell: Is there an over the counter posture brace that really works to improve your posture?

Jason_Savage,_MD.: Not really. The best "brace" is to strengthen your core muscles (abdominal and paraspinal muscles). Some people wear a "corset" for comfort, but in general, bracing is not indicated in the adult population.


Symptoms and Diagnosis

Grassmere: With great effort, I am able to stand erect; but the moment I let my muscles relax, I "collapse" onto my right leg and slump over. I am unable to hold myself erect while standing for any extended time or while walking. I do not slump over because of the pain. It is as if I don't have the muscular strength to hold up the right side of my body.

Jason_Savage,_MD.: Your postural issues may be muscular in nature or due to a degenerative scoliosis. It would be helpful to evaluate you in clinic with x-rays to determine the etiology of your problem.

Shar: My daughter is 15 and has a curve measured at 49 degrees. We are worried that if we wait too long to do corrective surgery she will be disabled for life, but are reluctant to proceed as she is very nervous about the surgery.

Thomas_Kuivila,_MD.: Forty-nine degrees is clearly in the operative range. While the surgery is not urgent, the curve will potentially increase and get stiffer as time progresses. It is important to remain flexible (physical therapy) in the meantime. Surgery is probably best in the next one to two years.

Shar: I prematurely sent my question regarding my 15-year-old's curve of 49 degrees. I am concerned that the extreme change will continue and not stop with adulthood. If this was your daughter, how would you handle this case – just watch it, surgery? What concerns would you have at this time in her life regarding any further changes? Will it be likely that the curve will continue to increase rapidly? Her curve and hump are visually noticeable when looking at her fully clothed. Do you have any thoughts?

Thomas_Kuivila,_MD.: If my daughter had a 49 degree curve, I would have it fixed operatively. It is unlikely the curve will progress rapidly at this point given her age. However, it is likely the curve will continue to creep upward at a degree or so per year. If she has a visible deformity fully clothed, she would likely feel better about her appearance after surgery.


Condition Complications

Dakotat69: Hi and good day to you:) I had a cervical fusion at C5-C6. Since then, I have developed 12 autoimmune diseases and scoliosis at the lumbar spine. My spine turns every day, causing my clavicle, left shoulder and ribs to move in horrible directions that cause extreme pain and breathing issues. I have been doing physical therapy for five years to put my ribs back where they belong. I am unable to get steroids shots due to allergies, and would like to know how I can keep my spine from moving daily? I would love to get at least some of my life back. I have cervical and lumbar disc issues, as well as a healed broken sixth left rib. Thank you for your time, Shelley

Jason_Savage,_MD: Hi Shelley. I would recommend seeing a scoliosis specialist for a thorough evaluation to determine what treatment would be best for you. Physical therapy is often very helpful, and I would continue doing the core strengthening exercises. You would need scoliosis x-rays to determine the magnitude of your curve.

richard5326: I have a 57 degree curvature in my spine now. What is the best treatment for nerve pain at the present time? I had a neurostimulator placed in my spine in September 2014. It has helped some, but I still have a lot of nerve pain. I am on Neurontin 300mg, two capsules three times a day. Is there anything new to try for my discomfort?

Jason_Savage,_MD.: It is difficult to determine the best course of treatment without x-rays and an MRI or CT myelogram. If you have persistent nerve pain, surgery may give you some relief. You may or may not need your scoliosis corrected at this time.

jhbell: Hello. My son's back curve is so bad his lower rib cage is actually turned toward his back, causing a "hump." Can this be corrected, and if so, how?

Thomas_Kuivila,_MD.: Almost all curves have a rotational component, which is what is causing his hump. Surgery for scoliosis attempts to improve as much as is safely possible for the three dimensional deformity that includes the rotation.

jhbell: I do not know if I am able to add to my previously submitted question (not yet addressed by the doctor) that my son is 15, and the curve/lump was not there last summer. The first doctor we saw reported, "upper thoracic level reveals the towering curvature to the left compensating for the right word curvature at the thoracolumbar junction where there is a 30 degree curve, predominance of the right sided rib cage at the thoracolumbar junctions." The doctor told us just to "keep an eye on it."

Thomas_Kuivila,_MD.: Some boys at age 15 are still bracing candidates depending on their level of skeletal maturity. Skeletal maturity can be determined by the scoliosis x-ray itself. There may be benefit in obtaining a second opinion.

PetuniaMarie: My scoliosis is different in that I have a dip in my middle back, and the spine has pushed forward. I have been told it is a "structural" problem. If I do have surgery, I would need to have one extended piece inserted. I hope I have explained this well enough.

Jason_Savage,_MD.: I wonder if you have a kyphosis, instead of a scoliosis. It is difficult to determine the exact treatment without x-rays. If it is a structural problem and you have significant problems with posture and pain, then surgery may be indicated.

Grassmere: My scoliosis was apparently the consequence of an injury to my right iliopsoas muscle back in 1998. At the time, it incapacitated my right leg and I was never told it might have any consequences for my back. It was only about five years ago that I started having any back pain and x-rays disclosed the scoliosis. The right leg and hip continue to bother me from time to time, and the scoliosis has worsened. I do regular core strengthening exercises and receive regular medical massages. Do you have any other suggestions?

Jason_Savage,_MD.: I would recommend seeing a scoliosis specialist to determine the etiology/cause of the scoliosis and magnitude of the curve. It is difficult to determine the "issue" without seeing the imaging studies. I would continue the exercise program on a regular basis.


Surgery Suggestions

PetuniaMarie: Is there a list on which a person can be placed to be considered to participate in new developments and research, such as in back surgery for scoliosis?

Thomas_Kuivila,_MD.: You can check the Scoliosis Research Society website and/or contact your local scoliosis expert to see if there are any new protocols they are using. At Cleveland Clinic, we have an in-depth care path that is quite innovative with regard to length of stay following surgery and postoperative pain management. We use state-of-the-art surgical techniques and scoliosis implants.

Shar: Is it true that corrective surgery for scoliosis can be successfully performed up to age 30?

Thomas_Kuivila,_MD.: It can be performed at virtually any age. The degree of correction is dependent upon curve flexibility and bone quality. Also, the younger you are, the speedier the recovery.

PetuniaMarie: I am relatively new to this. What are scoliosis implants?

Thomas_Kuivila,_MD.: Implants are the rods, screws and occasionally hooks that are attached to the spine to correct the deformity and hold it in the corrected position until the spine fuses.

jhbell: Is the ultimate goal of surgery to physically straighten the spine forever, since a brace is just to control the progression of the curve?

Thomas_Kuivila,_MD.: Surgery for scoliosis involves a fusion (permanent stiffening) of the involved area of the spine. Flexibility is maintained above and below the area fused. Loss of mobility/flexibility is proportional to the number of vertebrae fused.

Sperin: I'm age 63 and have osteopenia. Would surgery be contraindicated?

Jason_Savage,_MD.: I would try to "optimize or maximize" your bone health (Calcium and Vitamin D supplementation, possible other medications) before having spine surgery, as osteopenia and osteoporosis can increase the risks of surgery. With that said, osteopenia is not an absolute contraindication to surgery.

PJones78: Are the risks associated with surgery on the spine worth having a procedure? I am in pain every day, and some days it is so bad I can't function. Surgery was mentioned during my last visit, but I have read about complications that can occur. I am scared that things could get worse and not better.

Jason_Savage,_MD.: That is a hard question to answer, as some patients need a "small spine surgery," whereas others require a larger procedure to correct their problem. In general, the bigger the surgery, the more risks involved. With that said, if patients have debilitating pain, the benefits of surgery often far outweigh the risks. You would need to have a thorough discussion with your surgeon regarding the risk/benefit ratio of the actual surgery.

jhbell: If you are not experiencing pain, will doctors typically not perform surgery to correct the curve?

Jason_Savage,_MD.: That depends on several things, most importantly patient age and curve magnitude. In general, adult patients should not have surgery for scoliosis in the absence of significant pain.

PetuniaMarie: I am 76 years old, and the surgeon did mention surgery. At my age, wouldn't this be a problem due to age? It would involve severe fusion of my spine.

Jason_Savage,_MD.: The risks of surgery increase with age, but the benefits oftentimes outweigh the risks (which are often few).


Lifestyle and Limitations

MannyR24: Is there a recommended or preferred way to sleep? I find that it is most comfortable to fall asleep on my stomach, but I seem to always have some pain in my back.

Thomas_Kuivila,_MD.: There is no recommended position. If you have back pain from sleeping on your stomach, it is likely that your mattress is not providing enough support for your body.

Grassmere: What can be done to improve posture? I am able to stand straight, but slump over as soon as I start to walk or if I have to stand for more than a minute or so.

Jason_Savage,_MD.: A course of physical therapy with a focus on postural/core strengthening exercises will likely help with your posture.

PetuniaMarie: Please inform us about managing the pain. Also, should I continue daily activities enduring the pain or would this be harmful?

Jason_Savage,_MD.: In general, the best way to manage the pain is to engage in a regular core and pelvic stabilization exercise program. The stronger the "muscles/brace" are in your back, the better you will feel. In terms of medications, nonsteroidal anti-inflammatory drugs often help if you can tolerate them from a medical standpoint. Avoiding other types of pain medications is a good idea.

PetuniaMarie: I go to a chiropractor twice a week and do exercises to strengthen my core. Can this help to postpone?

Jason_Savage,_MD.: The short answer is YES. Chiropractic care and core strengthening often help to manage symptomatic back pain. The more exercise the better!

bzames: Is there a treatment to slow or stop the progression of scoliosis as one ages? Thanks. Bob

Thomas_Kuivila,_MD.: It depends somewhat on the degrees of curvature and any underlying causes for the scoliosis. In general, maintaining a healthy weight, good bone quality and good flexibility (yoga and Pilates are great) are keys to preventing further issues with your curve.


Closing

That is all the time we have for questions today. Thank you, Dr. Kuivila and Dr. Savage, for taking time to educate us about Scoliosis in Children and Adults.

Jason_Savage,_MD.: Thank you for participating in this webchat. It is always a pleasure interacting with patients about this complex topic of scoliosis. We have several pediatric and adult spine surgeons here at Cleveland Clinic who specialize in treating scoliosis. Please reach out to us if you have any other questions or concerns.

Thomas_Kuivila,_MD.: For those who require surgery, modern surgical techniques and implants have made the surgery reliable, safe and effective. While adolescent scoliosis can be frightening for parents and kids, the majority of scoliosis is treated non-operatively. In the modern era, when surgery is necessary, no post-operative bracing is necessary, patients are only in the hospital for two to three days, corrections are excellent, and complications are rare.

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.


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To make an appointment with Thomas Kuivila, MD or any of the specialists in our Center for Pediatric Orthopaedics at Cleveland Clinic, please call toll-free at 216.444.2606. You can also visit us online at clevelandclinic.org/ortho.

To make an appointment with Jason Savage, 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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