Online Health Chat with Dr. David Gurd & Dr. Richard Schlenk
March 8, 2011
Cleveland_Clinic_Host: Scoliosis is an abnormal sideways curvature and rotation of the spine. About 2 percent to 3 percent of the U.S. population, or 7 million people, have this condition. Scoliosis may be detected in infancy, childhood, adolescence, or adulthood. While this condition affects both males and females, females are 10 times more likely than males to need corrective surgery for it. Take advantage of this chat to speak to a pediatric scoliosis specialist, David Gurd, MD, and an adult scoliosis specialist, Richard Schlenk, MD.
ScoliScore, a new diagnostic test, is available for children ages 9 through 13 who have spinal curvatures greater than 10 to 25 degrees. This convenient offices test, available at Cleveland Clinic, checks the saliva for the presence of certain genes that help to predict how much the curve will progress.
It is important to monitor for scoliosis progression. Curves that are larger have a greater chance of progressing than smaller curves. However, even mild curvatures may worsen as a child’s spine grows. Progression can lead to severe consequences in adulthood, including lung and heart problems, and potential back pain. That’s why it’s important to detect scoliosis as early as possible, monitor its progress, and intervene when necessary.
David Gurd, MD, staff physician in the Center for Pediatric Orthopaedics, sees patients up to age 21. Dr. Gurd received his medical degree from The Ohio State University, then went on to complete his residency at Cleveland Clinic and his fellowship in pediatric orthopaedics at Texas Scottish Rite Hospital for Children in Dallas, Texas. His specialty interests include scoliosis, pediatric trauma, lower extremity deformity, and children’s hip conditions.
Richard Schlenk, MD, staff physician and surgeon in the Center for Spine Health, sees patients ages 21 and older. Dr. Schlenk received his medical degree from New Jersey Medical School then went on to complete his residency at University of Medicine and Dentistry of New Jersey-University Hospital and his fellowship at Cleveland Clinic. His specialty interests include scoliosis, complex spinal reconstruction, minimally invasive spine surgery, and spinal tumors.
To make an appointment with David Gurd, MD, or any of the other specialists in the Orthopaedic & Rheumatologic Institute 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 Richard Schlenk, MD, or any other of the specialists in the 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/neuro.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Drs. David Gurd and Richard Schlenk. We are thrilled to have them here today for this chat. Let’s begin with the questions.
Healthyin2011: How accurate is the saliva test to determine the prognosis for progression of the curve? Is it covered by insurance?
Dr__David_Gurd: The saliva test is a relatively new test. It has been quite good at helping to find curves that are very likely to progress. With this being said, about 75 percent of people are still within the indeterminate grouping, meaning that these are unlikely to progress, but still could. Most commonly, it is covered by the insurance company, but I would recommend asking the insurance company prior to the test.
firebird56: Our 32-year-old daughter was diagnosed with scoliosis in her teens. As an adult, she is experiencing lower back pain and numbness in both legs, and was told the trouble is within the nerve root beds at the base of the spine. Since hyperparathyroidism runs in our family, other than monitoring her calcium/PTH & D, is there any other way to determine if her present difficulties are related to HPT?
Dr__Richard_Schlenk: Often, adolescent scoliosis can be progressive when someone reaches adulthood, and it results in increasing back pain and neurological symptoms. It is not uncommon that patients with adolescent scoliosis develop degenerative scoliosis, which can result in encroachment upon the nerves in the lower part of the back. We try aggressively to manage the symptoms with conservative medical treatment and to avoid surgery unless we fail to make any improvement. I would forward any questions regarding hyperparathyroidism to her family physician. He or she would be better poised to answer such a question.
CMB: I have scoliosis and need a knee replacement. I have limped for years because of this and am concerned that when it is replaced, it will cause problems with my spine because of the scoliosis.
Dr__Richard_Schlenk: I do not think there is anything to worry about in regard to worsening of your spine condition with knee replacement. Conversely, if the pattern of ambulation is altered secondary to knee arthritis, this can cause lower back issues.
HOCKEYMOMINPA: Do you recommend an MRI be done to rule out any other issues with an infant with infantile scoliosis? We asked for an MRI prior to the first cast, but we were told it was not necessary. Should I pursue a second opinion to get an MRI done to make sure that infant, a 1 year old, has only infantile scoliosis and nothing else?
Dr__David_Gurd: An MRI will likely be helpful at some point. If there is any neurological concern at present, then I would push for an MRI sooner rather than later. If the neurological exam is normal, then an MRI may be done later in life.
grjadon: Is weakness in the right leg a symptom of adult scoliosis?
Dr__Richard_Schlenk: Weakness in the extremities can be a symptom of degenerative scoliosis as a secondary result from spinal stenosis. However, a very small percentage of patients who present with leg weakness as an isolated finding have scoliosis as the cause of their symptoms. An MRI, CT scan, or plain X-rays could be helpful in assisting with pinpointing if there is a spinal cause for this problem.
mini4mom: My 8-year-old son has left hemiplegia. He was diagnosed with scoliosis last year. The physician’s assistant said there would not be much we could do because it is caused by the weakness on his left side due to the brain damage. I want to be practical, and the only suggestion she had was to keep him active, maybe martial arts. Are there more things we should be doing?
Dr__David_Gurd: An 8-year-old with hemiplegia does have a risk for progression of a curve. The benefit of martial arts is that it can help with trunk strengthening that can help stabilize the curve. If the curve is progressing, brace treatment may also be warranted.
jjack: I had scoliosis as a child and had a Harrington rod placed in the lower spine at age 14. What is the likelihood that my daughter will develop scoliosis? She is 10. At what age should I have her evaluated?
Dr__David_Gurd: Multiple genes are involved with the transmission of scoliosis to family members. We do not fully understand all of the genetics to date. With a family history of scoliosis, it would be wise to have your pediatrician follow her for scoliosis beginning now with clinical checks. If there is any clinical sign of scoliosis, then referral to a specialist and X-rays would be warranted.
Scoliosis Curve Progression
Bkpain_1: Can the medical profession predict when curving will stop in adults? Now in my 60s, my curve is increasing at a rate of 1 degree per year.
Dr__Richard_SchlenkX-ray imaging can provide a spine surgeon with excellent information surrounding the natural history of your specific spinal deformity. Some patients' progression varies little over a long period of time, and a smaller number progress rapidly over a few years. A progression of 1 degree per year is in the very slowly progressive category and is unlikely to require surgical intervention. Patients with slowly incremental increases in curvature can cease to progress at some point, but this is variable and difficult to predict.
HOCKEYMOMINPA: Our 1-year-old son was diagnosed with infantile scoliosis in January. He had his first cast put on Feb 22. His curve was 35 degrees and in the cast, it is 22 degrees. Do you see the curve decrease after they take off the first cast? Also, what are the percentages of the curve staying at a low degree after all the castings are done? They are telling us around five casts would possibly be needed to correct to 0.
Dr__David_Gurd: The overall outcome of treatment for infantile scoliosis with casting can be difficult to predict. This means that it is hard to predict curve progression versus improvement. We have found that the sooner treatment is begun, the better chances of having a good outcome. The progression is also determined genetically, for which we do not have a great understanding at the present time.
tbjornstad: My wife was diagnosed with scoliosis as a child. Her curve is now 40 percent, and she is experiencing back pain and numbness in her feet. I am sure the pain is related to the curve. Is the numbness also related?
Dr__Richard_Schlenk: The rate of scoliosis progression is probably more important than the degree of curvature found on imaging. For instance, if your wife had a 35 degree scoliosis curve as an adolescent and now she's at 40 degrees, there is less concern than if her curvature was 15 degrees as an adolescent. Curves over 40 degrees indeed have a tendency of progressing over time and should be followed with yearly X-rays.
man: My daughter was diagnosed with very mild scoliosis at age 14. She is now 16 and has had no progression and is done growing. Does this mean she will never have any further progression or is this something we will have to watch out for and have checked throughout her lifetime?
Dr__David_Gurd: At age 16, with a very mild curve and no evidence of progression to date, there is a very low likelihood of progression occurring. It may be wise to be reassessed in one to two years to ensure no progression. Therefore, this would be unlikely to cause difficulties later in life.
lbjornstad: How stable are adult curves that have been there for over 50 years arising from childhood scoliosis. How can a double curve of seven years ago (18 degrees thoracic and 20 degrees lumbar) morph into a single lumbar curve of just over 40 degrees in seven years. What does this mean for someone in their late 50s as they get into their 60s and 70s? Yes, there is pain, but little to no central canal stenosis.
Dr__Richard_Schlenk: This is a very good question. It is not uncommon for patients with adolescent scoliosis to develop progression of scoliosis in their fourth or fifth decade. The presence of scoliosis can put somewhat of a significant increased risk for degenerative scoliosis. Given the description of the curve that you have outlined, it is likely that a degenerative component has resulted in progression of the curvature. Spinal curves that rapidly progress to 40 degrees over a very short period of time are at increased risk for further progression. If the curve has slowly progressed to that magnitude, and if the symptoms are managed well with conservative treatment, I would continue to try to avoid surgical intervention. When curves rapidly progress or when scoliosis results in spinal stenosis with resultant neurological symptoms (that are refractory to conservative medical treatment), surgery can be indicated. We try to avoid major deformity corrective intervention in patients with major medical problems or advanced age.
Scoliosis Treatment Options
tulip: My son is 15 and still growing, should we wait for him to have surgery for his scoliosis or do it at this age?
Dr__David_Gurd: Fifteen is a safe age to have the surgery performed. If the curvature is greater than 50 degrees, then this can definitely be pursued.
Healthyin2011: What are the options for scoliosis treatment for someone who does not want surgery?
Dr__Richard_Schlenk: That would depend upon the age at which the scoliosis was diagnosed. In adults, we aggressively attempt to manage symptoms related to scoliosis with physical therapy and other modes of conservative medical treatment. Surgical intervention is only entertained if there is progression of the deformity, progression of neurological symptoms, and failure to improve with non-operative treatments.
LJE: What non-surgical options are there for adults with scoliosis?
Dr__Richard_Schlenk: Physical therapy with a focus on core strengthening, stretching, and general conditioning can often be very beneficial for patients with adult scoliosis. Over-the-counter analgesics are often all that is necessary for pain.
grjadon: What are treatments for adult degenerative scoliosis?
Dr__Richard_Schlenk: Conservative medical treatment is the primary mode we utilize for patients with symptoms related to degenerative scoliosis. This begins with physical therapy, over-the-counter analgesics, and -- if needed -- mild prescription medications, typically in the form of anti-inflammatories. If symptoms are related to neurological symptoms, occasionally an epidural steroid injection can decrease symptoms temporarily. Surgery is withheld in the majority of cases. However, if required, it will certainly be a major interventional procedure that carries significant risks and recovery. Surgical outcomes in patients with adult degenerative scoliosis tend to be favorable in any carefully selected patient population.
chadbourne: What is the best way to manage back pain for moderate scoliosis in an adult female age 44? Is a chiropractor a good way to manage scoliosis?
Dr__Richard_Schlenk: Undoubtedly, the best way to manage back pain in someone with moderate scoliosis as an adult is conservative medical treatment. I employ an active physical therapy program and focus on core stability, stretching, and strengthening exercises. Chiropractic treatment is not contraindicated, but the benefits of such treatment have not been well-documented in our medical literature for patients with spinal scoliosis.
alm123: My daughter has progressive AIS with a thoracic curve of 21 degrees and lumbar of 27 degrees. We are trying the "alternative," but promising, treatment of torso rotation strength training using a torso rotation machine and lumbar extension, both of which are found at our local gym. A PT is managing our care. The purpose of this treatment is to correct the back muscle asymmetry that is present in AIS patients. Dr. Vert Mooney (now deceased) did some promising studies on this therapy (stabilization in most kids and regression in many). What do you know about this and why isn't this non-invasive treatment tried more? Even though it is not 100 percent proven, it seems like it is something that makes sense to try. From what I've heard, the effectiveness of bracing is also questionable. Also, what type of bracing do you use there? Your literature mentioned the braces were lightweight and usually needed to be worn only at night. (My daughter was prescribed the Boston brace for 23 hours a day.) This doesn't sound like the Boston brace, and is nighttime wear enough?
Dr__David_Gurd: To begin with, what is the age of your daughter? Torso rotation treatment may be of benefit, but we do not have great literature (clinical studies) to support this yet. Torso rotation will definitely cause no harm. More studies have been performed on bracing; and although these studies can be conflicting, most of the newer literature on bracing shows that it can be beneficial. For lower lumbar curvatures, the nighttime brace is recommended. A 23-hour brace is used for thoracic curvatures.
alm123: My daughter is 12, just had her menses.
Dr__David_Gurd: This is helpful. She is likely in a rapid growth spurt at present and this is the time that a curvature is more likely to progress. A girl's spine typically grows for 18 to 24 months after their first period. This is the time period where close observation is important.
Scoliosis & Bracing
Jeanne: What non-surgical treatments are available to a 13-year-old boy with thoracic scoliosis that has progressed from 12 degrees to 33 degrees in only eight months?
Dr__David_Gurd: The only non-surgical treatment that has been shown to be beneficial is bracing. For a curve with this progression, I would recommend brace treatment. Surgical stapling is currently being investigated, but we don't have definitive literature stating it is an excellent treatment choice.
Healthyin2011: Would you recommend a brace for scoliosis for an adult?
Dr__Richard_Schlenk: Bracing is utilized in the adult and pediatric patient population on carefully selected cases. In the adult population, there is no indication for bracing to arrest deformity progression. Bracing may have detrimental effects with weakening of the muscles around the spine in the adult population. This may lead to an exacerbation of symptoms. Often, our goal with conservative medical treatment is to strengthen and to stretch the adult spine with physical therapy modalities.
Healthyin2011: What kinds of braces for scoliosis have been most effective in reducing the curve?
Dr__David_Gurd: Braces are not intended to decrease curvature but to help prevent curvature progression. For lower curves (lumbar spine) a nighttime brace can do very well. For upper curves (thoracic spine), a 23-hour, custom molded brace has been shown to be better.
PD: My daughter is 15 premenarche. A doctor told her she could wear her brace less and her curve progressed from 37 to the present 55. She does not want surgery though. We are moving on to a RIgo cheneau brace. Are we wasting time?
Dr__David_Gurd: Bracing is beneficial for growing children with curves between 25 to 45 degrees. Once a curve gets beyond 50 degrees, it is likely to progress even without further growth. A brace may be simply delaying possible operative intervention.
Healthyin2011_1: My nephew is 10 and has congenital scoliosis. He has a curve that is 33 degree thoracic. He wears a soft brace. Should he be in a more supportive brace?
Dr__David_Gurd: Bracing has not shown to be as helpful with congenital scoliosis. If there has been progression of the curve, then more sturdy bracing could be attempted but with less likely chance of success.
Corrective Surgery & Hardware
cfn: What are the long-term effects from corrective surgery done for scoliosis patients back in the 1980s? Is there ever a time when this type of surgery needs to be revised or replaced with newer "hardware"?
Dr__Richard_Schlenk: That is a very good question. There were problems with certain types of instrumentation that were placed in that era. Often, any attempts at correction for the scoliosis patient meant they were placed in a kyphotic (bent forward) posture. This is most often seen with the old Harrington rod instrumentation. The patients who had been treated with this instrumentation occasionally had to have correction to the kyphosis that was induced with that surgery. The most common long-term problem that we see with someone who had been instrumented several decades prior is a progression of degeneration below the region of the instrumentation. When this was treated surgically, this required extension of instrumentation and surgical decompression of the nerves. There is no indication to remove hardware in someone who has done well with surgery, regardless of how long that instrumentation was in place.
jjack: My Harrington rod was placed when I was 14. I am now in my 40s. Will I ever need to have it replaced, and how will I know? I haven't seen an orthopaedist in years. Should I be followed?
Dr__Richard_Schlenk: Full spine scoliosis X-rays would give us a good idea at the position of the hardware and your overall spinal alignment. A primary care physician can order such a study. Replacement of prior instrumentation would only need to take place if there was a definitive problem seen on X-rays that correlates with symptoms that the patient currently has. It is not uncommon to see a broken rod decades later. The presence of such does not require surgical intervention unless there is a related problem from hardware failure.
alm123: I have seen some literature on the possible benefit of melatonin in preventing scoliosis progression in the adolescent who is melatonin deficient. What are your thoughts on this?
Dr__David_Gurd: There have been studies showing that melatonin deficiency and calcium deficiency may contribute to scoliosis. We can do blood studies to determine if this is the case.
alm123: In light of your previous answer regarding melatonin deficiency and scoliosis, would there be any harm in supplementing our 12-year-old daughter with melatonin just in case? We have long suspected that she was deficient even before her diagnosis of scoliosis. Getting her to sleep has always been a problem.
Dr_David_Gurd: I think that it would be absolutely fine to supplement, but I would first check with your pediatrician.
Demra: My daughter is 11 and has been a pitcher for her softball team, the doctor found a small curvature and said we would need to keep an eye on that. Could this be from her training and pitching?
Dr__David_Gurd: It is very unlikely that the scoliosis is caused by this training. I typically feel that it is important for children to stay fit and flexible. Doing these activities should not improve or worsen the scoliosis.
grjadon: Would you recommend yoga or tai chi exercises for the adult patient?
Dr__Richard_Schlenk: Absolutely and without reservation, I recommend yoga. It focuses on stretching, strengthening of the core, and balance. I have less experience with tai chi as a form of exercise for patients with spinal deformities.
Cleveland_Clinic_Host: I'm sorry to say that our time with Drs. David Gurd and Richard Schlenk is now over. Thank you both again for taking the time to answer our questions about Scoliosis in Children and Adults.
Dr__David_Gurd: We tried to get to as many questions as possible. Thank you for joining the chat.
Dr__Richard_Schlenk: It has been a pleasure and a privilege to take part in this web seminar.
- To make an appointment with David Gurd, MD, or any of the other specialists in the Orthopaedic & Rheumatologic Institute 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 Richard Schlenk, MD, or any other of the specialists in the 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/neuro.
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