SPINE DISORDERS

Pediatric Spinal Deformity: Idiopathic Scoliosis
By Laurence E. Mermelstein, M.D.

Continued from page 1

TREATMENT AND FOLLOW-UP
The overall goal of scoliosis treatment is to prevent a child from entering adulthood with scoliotic curves larger than 45 degrees or with a curve which is cosmetically unacceptable. Specific treatment is based on the size of the curvature, the skeletal age of the child, the location of the curvature in the spine (thoracic or chest area vs. lumbar or low back area) and the rapidity of progression of the curve. The vast majority of curves (80% to 90%) require no treatment other than periodic follow-up. For these patients, an evaluation in the doctor's office every 3 to 6 months with radiographs at every other visit is indicated. Children entering their adolescent "growth spurt" or being treated actively in braces are evaluated more frequently.

Although there have been many treatment modalities prescribed for scoliosis, the only non-operative form of treatment shown to have a significant affect on altering the natural history of this process is external spinal bracing. Exercise, manipulation, and electrical stimulation are no longer advocated, although an exercise program is frequently suggested in order to maintain the child's overall fitness and positive mental outlook. A diagnosis of scoliosis does not prohibit children from participating in athletics, even so-called contact sports. A patient being actively treated in a brace may be allowed out of the brace for short periods of time for practice or athletic competitions.

Children considered for brace treatment undergo a careful selection process. The goal of spinal bracing is not to correct a curve, but to hold a curve from progression. Curves under 20 degrees are not indicated for bracing. Occasionally, a very skeletally immature adolescent with a curve between 20 and 30 degrees may be selected for a brace wear, but, in general, these curves should show some progression before thev are braced. Curves between 30 an 40 degrees are treated aggressively in braces as long as the adolescent remains skeletally immature. Once a person reaches skeletal maturity, or the curve progresses past 45 degrees, bracing is no longer effective.

Braces used today are usually able to be fitted under the arms so that for the most part, the brace is completely covered by clothing. Curves higher in the thoracic spine require braces that are worn around the neck, but this is less common. The modern underarm braces are fashioned from lightweight plastic and are specially formed to hold the spine in a corrected position.

Traditional brace wear has been "full-time" i.e. 23 out of 24 hours with time out for sports and bathing. Some physicians have advocated part-time brace wear, but various studies have shown that the more the brace is worn, the more effective it is. Newer braces which hold the spine in an "over-corrected" position have been used only at night ("bending braces"). The efficacy of these braces is under investigation presently.

The indications for scoliosis surgery are usually relative, but there are some well accepted guidelines that have been proven over the long term. These include failure of brace treatment to prevent curve progression, curves over 45 to 50 degrees in skeletally mature adolescents or young adults, a cosmetically unacceptable deformity, or progressive pain or discomfort secondary to trunk imbalance caused by the spinal deformity.

Modern surgical treatment involves the use of metal implants (rods, hooks, screws) that correct the curvature and hold the spine fixed until a bony fusion occurs. At present, a fusion procedure is the accepted surgical treatment for scoliosis, which involves the creating of a bony bridge across all the vertebra in the scoliotic curve. This prevents any further progression of the curve. Whereas the final deformity can be significantly corrected, the motion of the spine is decreased to a variable degree depending on the area of the spine that is fused. Because of the advancement in spinal implants, a post-operative brace or cast is rarely needed. Children usually spend less than a week in the hospital following scoliosis correction.

Because the surgery results in immobility of a portion of the spine, contact sports (or sports requiring extremes of spinal motion e.g. gymnastics) are generally prohibited after surgery. An active lifestyle is encouraged and most patients return to sports such as running, swimming and tennis without difficulty.

SUMMARY
Great strides in the detection and treatment of scoliosis have been made over the last 50 years. Although researchers continue to search for the cause of idiopathic scoliosis, early detection of scoliosis has allowed early treatment, whether it be bracing or surgery, and has restored many affected children to healthy, active, pain free lifestyles.

Back to Spine Disorders