Ask Dr. Pat · Health

How Do I Manage My Scoliosis?

Dr. Alana Serota’s Perspective:

As a consequence of the mechanical challenges to the spine from scoliosis, it is extremely important that bone health be optimized. Vitamin D deficiency, osteoporosis, and other metabolic bone diseases are extremely common comorbidities in patients with scoliosis, and their incidences increase with age. Specialists in metabolic bone disease include, but are not limited to, primary care doctors, rheumatologists, and endocrinologists. They can assist in the identification and treatment of these underlying conditions, which are often silent or asymptomatic, just like the onset of hypertension and diabetes. Like these medical conditions, osteoporosis can pose real and serious health dangers.

Osteoporosis is defined as decreased bone density and/or diminished bone quality that predisposes patients to fractures. Those with osteoporosis present with low energy fractures with little or no antecedent injury; they are also more likely to have severe fractures with high-energy injuries. Vertebral compression fractures are the most common type, and two-thirds of these are clinically silent, meaning that they are asymptomatic and they do not come to medical attention. Vertebral compression fractures are both more common and more significant in those with an abnormal spine. Take, for example, a patient with scoliosis, who will commonly have kyphosis as well; the compression fracture turns a block-shape vertebra into a wedge shape that further rounds the spine (aka worsening kyphosis). This secondary complication can negatively impact appearance, upright posture, mobility, balance, and even lung function.

Identifying osteoporosis and other metabolic bone diseases, correcting underlying causative or contributing factors, and attenuating increased fracture risk with appropriate lifestyle, nutritional, and pharmaceutical interventions will optimize the objectives of non-surgical and surgical treatment of scoliosis. These are systemic “software” problems that impact on the progression and treatment of the “hardware” issues.

Finally, I find it important to teach my patients about the warning signs of worsening scoliosis and secondary spinal problems. These include spinal pain, radiating pain, weakness and/or numbness in the arms or legs, impaired bowel and/or bladder function. Under these circumstances it may be necessary for a physician re-visit, repeat imaging tests such as spinal X-rays and/or MRI’s, and even spine surgery referral. In my opinion, the spine surgeon that you refer to or choose to see needs to be have specialized training and expertise with spinal deformities such as scoliosis. One such surgeon is Dr. Matthew Cunningham, and in the remainder of this post he presents a surgeon’s perspective on adult scoliosis.

 

Dr. Matthew Cunningham’s Perspective:

Adults and children with scoliosis differ in that their spinal curves have dramatically different potentials to worsen. Scoliosis—or, more broadly, spinal deformity (to include kyphosis, kyphoscoliosis, and others)—tends to worsen during periods of rapid growth, such as during adolescence. During these times, patients’ curves are at risk for progression (up to 15 to 20 degrees in a year) and they should be monitored very closely. In adulthood, patients’ curves progress not because of growth, but more because of muscle imbalance, degeneration, and, to some extent, gravity; and they progress much more slowly than during childhood—perhaps a degree per year or so. These differences in the natural history of curve progression have an impact on how they are managed from a surgical perspective. In children, we are concerned with how big the curve is and how big it will eventually get, while in adults, the size of the curve is not as important as the associated symptoms experienced (back pain, leg sciatica, walking limitation [e.g.,  stenosis]). As was discussed in the prior post, efforts are made to limit curve progression in children by using braces, and non-surgical techniques are used as the “first line” management options for adults to treat symptoms—options such as physical therapy for low back pain and posture complaints, oral and injected medicines for other inflammation-based problems. Surgery is considered when the non-operative treatments have been attempted and have been ineffective.

In a very simplified view, spine surgeons do two things: we make bones grow together (spine fusion), and we make more room for the nerves within the spine (decompression). Some patients need fusion only (progressive scoliosis in an adolescent who has no pain symptoms), some need decompression only (an adult with a thoracic scoliosis and sciatica pain from an unrelated disc herniation in the lumbar spine), and some patients need both (an adult or child with unstable spine deformity in the lumbar area who complains of low back pain and sciatica). Children with scoliosis rarely require decompression, and much more commonly have surgery through an incision on their back, where the fusion surgery is done. Adults with scoliosis have a more difficult time with surgical fusions, and will frequently require fusion procedures from the front of the spine to have a successful outcome. The fusions in the front of the spine are at times done from the back (transforaminal or posterior lumbar interbody fusion), using minimally invasive techniques from a lateral approach (lateral lumbar interbody fusion), or from the classical anterior approach (anterior lumbar interbody fusion).

Specifics for these different surgeries are beyond the scope of this post, but suffice it to say that adult spinal fusions require more surgery to be successful than those done on children. Regardless, excellent results can be expected for both populations in appropriately treated patients.

Recovery following surgery is also different between the two groups: Children tend to heal faster and get released to full activity, typically at six months post-procedure when they are pain free, while adults are commonly advised to restrict vigorous activity for up to a year.

The difference in return to activity has to do with the kinetics of bone healing in the respective age groups and the physician’s desire to allow the spine to heal and become stable before allowing patients to “stress-test” their new backs.

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