Scott Luhmann, MD, the author of this blog, is a pediatric orthopedic surgeon at Washington University Orthopedics in St. Louis specializing in pediatric and adolescent spine surgery. He practices at St. Louis Children’s Hospital and Shriners Hospitals for Children in St. Louis, Missouri. Your comments and feedback are encouraged.
Friday, December 23, 2016
What organ systems are affected by Early-Onset Scoliosis
Scoliosis, at any age, causes distortion of the body from
the neck to the waistline.Though on the
x-rays (or radiographs) that are obtained to evaluate for scoliosis the spine only
appears to curve in a lateral direction, however it actually has become
deformed in three dimensions (front, side and axial).The front view is shown below in the first
x-ray or radiograph.It is easy to see
the severe curve, causing the right shoulder to be higher than the left, but
also it is easy to appreciate the shift of the body to the right relative to
the pelvis and hips.
As the spine starts to curve to the side it also twists on
itself, and it is this twisting which causes the ribs to be differently
oriented between the left and right sides of the body.In the x-ray below one can also appreciate
the difference in the ribs, both in their position, shape and spacing.The ribs on the left side are more
horizontal, while those on the right are more vertical, especially at the
middle of this severe curve.Also the
ribs on the left are very close together, and those on the right more spaced
apart.This is because the spine on the
concave side of the deformity is relatively shorter than the convex side, so
the ribs are more close together.Also
as the spine curves to the side the distance of the spine, from the neck to the
hips, shortens which can cause the body to look uneven, with the leg looking
longer than they should be.
In Early-onset scoliosis (<10 years of age at detection)
the main organ system of concern in the lungs.The two main issues impacting the child’s lungs are the shortening of
the spine (neck to pelvis) and the twisting of the spine.In general as the spine shortens the
abdominal contents (liver, spleen, stomach, intestines, etc…) relatively move
upward into the chest.Since the lungs
are very compliant or soft, compared to the abdominal contents, this
effectively creates less room for the lungs.In other words the lungs become squished.
3-d Computed Tomography (CT) scan of the lungs in a patient
The graph above is from a study by Emery and Mithal in 1960
which is looking at the alveoli in the young child’s lung.The alveoli are the air sacs which permit us
to get oxygen into our blood stream and get rid of carbon dioxide.It is important that the development of the
lungs is optimized early in life as the alveoli multiply in number up to
approximately 8-10 years of age.Thereafter it is mainly the alveoli mainly increase in size, not in
numbers.So it is important to maximize
the growth, or length of the spine, during the first 10 years of life as this
impacts how well the lungs develop.
The other organ systems
(heart, gastrointestinal) are impacted to a lesser degree.These two systems are impacted only in severe
(>100 degrees) of scoliosis.However,
unlike the lungs, the impact of scoliosis on theses two systems is much more
reversible.When the scoliosis is
treated these systems will return close to normal status.
Pediatric spine deformity
surgeons focus much of their attention on maximizing the development of the
lungs in children unde 10 years of age.This is why performing definitive, long spine fusions in this age group
is rarely performed.A long, multi-level
spine fuison will permanently shorten the spine, and secondarily decrease the
volume of the lungs.To treat spine
deformity in children <10 year pediatric spine deformity surgeons use
“growth-friendly” techniques, which corrects/manages the scoliosis but permits
growth of the spine.Bracing and casting
are nonsurgical techniques which are “growth-friendly” have already been posted
on this blog earlier.In subsequent
blogs surgical techniques which are “growth-friendly” will be explained.
If one searches the web for information on chiropractic care
and scoliosis, the American Chiropractic (ACA) Association would be a logical
to the ACA, “chiropractic is a health care profession that focuses on disorders
of the musculoskeletal system and the nervous system, and the effects
of these disorders on general health. Chiropractic services are used most often
to treat neuromusculoskeletal complaints, including but not limited to back
pain, neck pain, pain in the joints of the arms or legs, and headaches.”
So scoliosis is not a diagnosis directly referred to, but the “not limited to” part
of this statement does not eliminate scoliosis from the conditions they may
advocate to treat.
Further digging around on the ACA website
one finds very little information about scoliosis or chiropractic treatment of
scoliosis.One item that is posted is a
patient information handout produced by the ACA which states “Spinal manipulation, therapeutic exercise, and electrical muscle
stimulation have also been advocated in the treatment of scoliosis. None of
these therapies alone has been shown to consistently reduce scoliosis or to
make the curvatures worse. For patients with back pain along with the
scoliosis, manipulation and exercise may be of help.”Let’s break down and analyze these three
sentences.Sentence one is factually
correct, these therapies along with many others have been advocated in the
treatment of scoliosis, with most therapies eventually being shown to be
ineffective.The second sentence of this
quote one can essentially boil this down to this revised statement: we (the
ACA) can’t come right out and say it, but there really isn’t any evidence spinal
manipulation, therapeutic exercise and electrical stimulation really prevents
scoliosis from getting worse.The third
sentence is partially accurate, short-term back pain may be helped with
manipulation and exercise may be of help.Long-term back pain related to scoliosis has not proven responsive to
Another website to search on this topic is from the Scoliosis
Research Society (SRS).This is the most
authoritative website, produced by medical doctors and doctors of osteopathy
who specialized in spinal deformity in children and adults.This website has a section of FAQs on
scoliosis, and it is here one can find the following information:
Will chiropractic treatment help my scoliosis?
Chiropractic is a controversial
method of treatment that seems most effective in treating acute, short-term
pain. Chronic conditions do not seem effectively managed by long-term
chiropractic care. Patients who have scoliosis and choose chiropractic treatment
should be referred to a spinal orthopaedist or neurosurgeon if their curves
keep increasing. Insurance may or may not cover chiropractic treatment.
Thee two large organization can
obviously be biased in their position on this subject, and one would expect
both organization to support their mission and members.So let’s look at the science behind this
topic.In this era of evidence-based
medicine we should constantly strive for the highest level of evidence to
support our treatments.By searching Pubmed,
the U.S. National Library of Medicine and National Institute of Health’s online
search engine, one can search over 26 million citations for biomedical
literature from MEDLINE, life science journals and online books.This is a good place to search for information
on “scoliosis and chiropractic treatment”.If one does this the results of the search will demonstrate a lack of
scientific evidence supporting the position that chiropractic treatment/manipulation
alters the natural history of scoliosis (prevents progression or worsening of
the deformity).The existing literature on
this topic is replete with cases reports and small, retrospective, single
center case series which lack control groups, have inadequate numbers of
patients, insufficient follow-up, lack rigorous statistical analysis and are
generally underpowered statistically.Testimonial
medicine advertisements, however appealing, should not be used as evidence a
treatment is helpful and safe.
Hence based on the
currently available data, there is
no scientific evidence that chiropractic therapies alter the natural history is
scoliosis.This statement, though
grounded in evidence based medicine, is often vigorously contested by some
chiropractic or homeopathic practitioners. Often talking about chiropractic
treatments with families is much like discussing politics and religion,
individuals often have firm beliefs in either direction and will not be swayed
by a five-minute conversation in the office.
When my patients ask me about my perspective of chiropractic
treatment of their child/adolescent with a spinal deformity I state the
should never be done on a spinal deformity.Catastrophic injuries (fractures, paralysis, etc…) have occurred when
the spine was “manipulated”.
2.There is no scientific
chiropractic treatments prevent progression of scoliosis.
3.Often when chiropractic
treatment is initiated the recommended plan of treatment (with multiple x-rays)
to parents/caregivers is for several treatments per week for months or
years.This can be extremely expensive,
and time consuming, for families and can drain Health Savings Accounts quickly.
4.The only benefit
chiropractic treatments may help is acute, short-term back pain.
5.The most effective
interventions for pediatric and adolescent back pain related to scoliosis are:
a.Rule out more serious and
non-muscular causes of back pain (such as urinary tract infection, hip
pathology, and fractures).
b.Develop a physical
fitness program in which the individual is doing some type of aerobic activity
(raising the heart rate and breaking into a sweat) for 20-30 minutes a time, 3
times per week.
c.Maintain ideal body
d.Do not use tobacco
I hope this helps. Let me know if there are any questions.Happy Holidays.
in EOS is a commonly utilized nonsurgical intervention.Braces are constructed of either rigid or
semi-rigid plastic, and are designed on an individual basis. The orthotist (the
person who makes the brace) analyzes each patients’ anatomy and radiographic
deformity, then constructs the brace.The brace is contoured to place pressure points on the ribs and pelvis,
with padding, and that force is then transmitted to the spine, ideally
EOS one of the concerns of bracing is altering the rib development and
alignment.Hence, most often brace use
in EOS is not recommended to be worn full-time.Conceptually, having time out of the brace the chest can develop more
normally.This is more of a theoretical
concern, as there is little information that bracing can permanently deformed
the chest in a negative way.
there are medical centers and providers which report, and sometimes advocate or
market, for one brand of spine brace over another, there are three main types:
flexible, semi-rigid and rigid.Flexible
braces, typically constructed from a highly-elastic material like neoprene
(with straps), may be appropriate for children with mild to moderate
deformities and have low neurologic tone.This brace exerts less force to the spine so it cannot be used in
patients with normal or increased tone or moderate to larger deformities.In my practice these have been used
occasionally in the neuromuscular patient (cerebral palsy, spina bifida, spinal
muscle atrophy, etc…) who are low demand physically and have low muscle
tone.Semi-rigid braces are a step up in
stiffness, and subsequently can exert more corrective force to the body and
spine.These braces are more typically
used in children under 3 years of age with milder deformities.
braces (TLSO: thoraco-lumbo-sacral orthoses) are the most commonly used brace
in EOS and in spine bracing in general.There are several subtypes of rigid braces: Boston, Wilmington,
Charleston, etc…which have different
corrective forces and wear schedule.Regardless of which brace is used a key issue to brace is simply that
the brace must be appropriately worn by the patient for the recommended length
of time each day.A brace will not have
the ability to help the patient if it not being worn. The goal of a spine brace is to maintain the
deformity, not to correct the deformity.In EOS it can be used a primary treatment for milder, more flexible
deformities or after a series of spine casts.It is difficult, if not impossible, to create a long-term plan for each
patient, so the length of time each patient will need to be braced is difficult
blog post: Chiropractic treatment of scoliosis
Surgical treatment of scoliosis in adolescents, in
2016, is most commonly a posterior spinal fusion with instrumentation
(PSF/PSSI).Though this blog is, in
general, dedicated to the “growing spine” this entry will focus on adolescent
idiopathic scoliosis (AIS) and the many questions that are asked by
parents/caregivers about PSF/PSSI.
Top Frequently Asked Questions
about PSF/PSSI in AIS:
How strong will the spine be after surgery? Do I need to be careful?
Your spine will not be fragile. Multiple screws and rods are used, in a linked
fashion, which corrected your spine deformity and will be holding it firmly in
place. Activities of Daily Living (ADLs) will not harm the outcome of surgery
or your spine.
What plans need to be made at home?
1. When you go home you will sleep in your regular bed, in your regular
bedroom, wear regular clothes, eat regular food, go on walks, car rides, and
see your friends.
2. You can walk up and down stairs, we are not doing surgery in your legs. You
will be fully mobile though you may not walk as fast as you did prior to
surgery, at least temporarily.When you
do walk up and down stairs, it is recommended someone stand below you to make
sure you do not fall down the stairs.
3. You can eat in the kitchen and walk to the family room. You will not be a
"patient" at home.
4. No physical therapy or braces are needed after discharge from the hospital.
5. Regular clothes may be worn. Tight fitting clothes may be uncomfortable.
6. For those patients who were driving cars before surgery it is recommended to
avoid driving until after the 6-week postoperative clinic visit.
7. Driving home from the hospital does not require any special vehicle. If
there is a long drive home you may need to stop more frequently and take
8. You will eat regular food at home. Fatty salty, and spicy foods may not
taste good after surgery for several weeks.Don’t worry the taste of food and your appetite will return to the way
it was before surgery.
How will I sleep at home? You can sleep in any position you choose. If you
prefer to lie on your stomach then use a flatter pillow than normal. It is fine
to sleep on your back.
When can I take a shower or bath after surgery? The first shower or bath can be
taken at 2 weeks after surgery. Before then sponge baths are recommended.
How will the pain after surgery be handled? Postoperative pain will be managed
by the Pain Service, an anesthesiologist driven service. They have a detailed,
thoughtful plan to manage postoperative pain. You will go home with pain
medications that work for you in the hospital. After discharge from the
hospital you will be able to contact the Pain Service if any problems or issues
occur. Most patients are off the prescription narcotic pain medication at 2 weeks
What is the follow up after surgery? The first follow up is at 6 weeks after
surgery. Routine follow up is at 6 months, 1 year, 2 years, 3 years and 5
How do is the fusion assessed after surgery? Radiographic imaging of the fusion
mass is difficult, even with a 3-d imaging like a CT (computerized tomography)
scan. During follow-up visits plain radiographs will be obtained to evaluate
the implants integrity. If the implants are intact at 5 years postoperative
then the fusion is intact.
What are the activity limits after surgery? Competitive athletics is not
recommended for 6 months after surgery. There is no PE or gym class for 6
months. Athletic training and fitness activities are usually acceptable but
must be approved by the surgeon.
Is there any limitation of lifting?There
is a 10 pound lifting limit for the first 6 months after surgery.
What is the chance of needing a second surgery? The historical reoperation rate
at our children's hospital is 3.9%. The spine implants used will stay in place
permanently.This is a one-shot surgery,
Will the implants need to be lengthened? No. When a fusion is done the spine
growth is stopped over the length of the spine implants.
Will the fusion stop all future growth? The fusion will stop growth only over
the part of the spine that has spine implants. The spine above and below will
continue to grow, and your legs will continue to grow.
What type of metal is in the implants to be used in surgery? The spine implants
used will be a combination of titanium and cobalt chrome.
What sports are not recommended after surgery? In general collision sports,
such as American football, rugby and wrestling are not recommended. In addition
tumbling and gymnastics are not recommended due the stiffening of the spine
fusion and since the repetitive, excessive motion may loosen the spine
implants, prevent fusion and require repeat surgery. All other contact and
noncontact sports are acceptable.
How much school will be missed?
It is expected you will return to school part-time in 2 weeks and full-time 4
weeks after surgery. Contact the school to inform them of the surgery date and
the time out of school. Let us know what paperwork is needed.
What are risks of surgery? In general there are two types:
1. There are some risks which are common with all surgeries. General anesthesia
is necessary and though the risk of an adverse event occurring is low, it is
not zero. Also an incision is made and incisions can have problems healing and
get infected. Antibiotics are given before, during and after surgery to
minimize the risk of a deep wound infection. There are also many other things
which are done to decrease the risk of infection as close to 0% as possible.
2. There are other risks which are unique to the spine. The spine surgery will
be on the spinal column, or the bone of the spine. Inside of the bone is the
spinal cord, and nerves, which runs from the brain to the lower extremities.
For the purpose of the surgery the spinal cord and nerves acts like a wire from
the brain to the legs, enabling muscle function and sensation in the legs and
controls bowel and bladder function. During surgery the spinal cord function is
continuously monitored by a Neuromonitoring specialist. If the spinal cord function
becomes abnormal this is usually detected quickly using motor and sensory tract
monitoring. This usually, but not always, occurs during correction if the
spinal deformity, typically as the deformity is maximally corrected. If this
happens the surgeon is alerted quickly and several actions are taken
simultaneously to get return of normal spinal cord function.If this happens there is over a 90% chance
that the neurologic condition will return to baseline. We are always prepared
for neurologic problems during surgery.
What are the most likely complications after a spine fusion? As mentioned above
anesthetic problems, wound infection, neurologic deficit (paralysis, bowel or
bladder incontinence, nerve problem, etc...), failure of fusion, implant breakage
or pullout, cerebrospinal fluid leak, need for additional surgery, and
How do you choose what spine implants to use for each surgery? Most spine
fusions currently are performed from the back through one midline incision. The
implants used are mainly based on patient size. There are different sized
system to maximize correction and fusion yet to be as low profile as possible.
Where is the incision for a fusion and how long is it? There is one incision in
the middle of the back and it is as long as the planned fusion.
How is the skin closed at the end of surgery? Staples vs. sutures vs. glue? A
plastic surgery-type closure is performed leaving no sutures/stitches above the
skin level. All sutures are absorbable and will dissolve and disappear with
time.On the skin there will only be
glue, much like the Super Glue you can buy at the store, which gradually falls
off in 3-4 weeks.
Can I put vitamin E on the incision? After the skin had completely healed, and
the glue falls off, can lotions be applied. It is inconclusive that vitamin E
lotion improves the appearance of surgical scars.
Will I need a brace after surgery? No
Will I need physical therapy (PT) after discharge from the hospital? No.
casting is a time-tested intervention which was first described, in modern
literature, by Cotrel and Morel in 1964.At that time there were no other effective means to correct spinal
deformities and maintain the improvement, since spine instrumentation as we now
know it was not yet created. In 1963 Dr. Harrington developed the first
effective, posteriorly-based spine instrumentation, using mainly two points of
fixation on the spine and distraction as it main treatment force.It was common to supplement fusions
postoperatively with casts and braces for an extended period of time
(years).The technique of spine casting
was advanced by Risser in 1976 with the utilization of a three-point molding
technique.It was around this time the
first segmental spine instrumentation was created by Cotrel and Dubousset and
made spine casting less needed for scoliosis treatment.Since that time spine instrumentation has
evolved significantly, enabling physicians to better correct the spine
three-dimensionally without a need to use spine casting.Hence casting was performed less and less for
the treatment of scoliosis until in 2005 when Min Mehta reported the use of
Cotrel spine casting technique in children younger than 2 years.Her results re-invigorated interest in spine
casting as a method to improve and, at times, definitively correct scoliosis.
two main factors that occur between 0-5 years of age, which makes spine casting
effective is the rapid growth of the spine and the child’s spine
flexibility.So castings will be more
effective if the child is less than 18 years of age, with a highly flexible
deformity which is mild to moderate in magnitude.It is in this age group spine casts have the
greatest chance of permanently “curing” the scoliosis.In the older children, say 2-5 years, casting
can be helpful but will only be a “cure” if the scoliosis is very mild.Even if the casting doesn’t “cure” the
scoliosis it may delay the need for surgical correction.
spine casting is deemed appropriate for a child’s scoliosis, the number of
casts and the length of application is individual specific.No two children are treated exactly the same,
since no two scoliosis deformities are the same.Each doctor who using spine casting is attempting
to correct the child's spine deformity optimally with the minimum number of
anesthetics and surgical procedures.Hopefully the child will never need a surgical intervention.
last point: it is important not to get pre-occupied with the “name” of the
spine casting the surgeon is recommending.Parents have, on occasion, come to think that only Mehta casting works
and that a cast by any other name does not.Sometimes the casts are referred to as Risser casts, but any surgeon who
cares for early-onset scoliosis in 2016 will do the technique which is
attributed to Mehta.As mentioned
earlier the actual technique was described by Cotrel and Morel in 1964 and can
be called by many names: derotation casting, Cotrel casting, Cotrel derotation
casting, Extension-derotation casting, etc…….What is most important is the surgeon focuses the corrective maneuvers
of casting to unspin the spine’s abnormal twist with scoliosis.
Y, Morel G.The elongation-derotation-flexion
technic in the correction of scoliosis.Rev Chir Orthop Reparatrice Appar Mot 194;50:59-75.
JL, Sanders JO.Casting and traction
treatment methods for scoliosis.Orthop
Clin N Am 2007;38:477-84.
MH.Growth as a corrective force in the
early treatment of progressive infantile scoliosis.J Bone Joint Surg [Br] 2005;87:1237-47.
JC.Scoliosis treated by cast correction
and spine fusion.Clin Orthop Relat Res
are many treatment options in early-onset scoliosis (EOS), but all can be
lumped into 2 broad groups: nonsurgical and surgical.The nonsurgical options include: observation,
physical therapy, bracing, and casting. Surgical options include: traditional
growing rods, MAGEC growing rods, vertebral body stapling, vertebral body
tether, Shilla growth guidance procedure and fusions (bilateral and unilateral)
+/- resection.Often a combinations of
therapies (nonsurgical and surgical) are used simultaneously during treatment,
such as growing rods (surgical) with a brace (nonsurgical).
has not been shown to control/modify/alter the natural history of scoliosis
based on a reasonable level of scientific evidence are: spine manipulation, massage, electrical stimulation, accupuncture, accupressure, and inversion
general milder spinal deformities and moderate ones which are not progressing
(getting worse) the nonsurgical methods are the first-line and, commonly, the
second-line of treatment.When the
spinal deformity becomes severe or moderate (but progressive, getting worse)
the surgical procedures become treatment options.
will discuss each type of nonsurgical and surgical options, listed above, over
a series of blogposts.The first
treatment which will be presented is observation.While observation, or as some have called
“watchful waiting”, may not seem like an actual treatment option, it can be
quite helpful in EOS.
is the most basic method of treatment, can be the most difficult one for
physicians to recommend.Sometimes
pressure to “do something” from caregivers, family and patients makes
observation challenging.However, rarely
is there a reason, or need, to urgently perform surgery (such as worsening muscle
weakness or walking ability, or the loss of bowel or bladder control).Observation permits time to pass, and allows
the spine to grow, which may help to determine if the spinal deformity is
static (not changing) or getting worse.In
the outpatient setting intermittent evaluations, with radiographs, are done anywhere
from 3 months to 2 year intervals.The
time between evaluations depends on many factors, such as patient age, type of
deformity, underling medical diagnoses, the location of the deformity,
magnitude of the deformity and the recent history of the spine deformity progression.
other benefit of observation is it gives parents/caregivers time to obtain
information and learn about their child’s spine problem.Though spinal deformity may be commonly seen
by the child’s pediatric orthopaedic surgeon, it is a new, and often
overwhelming, problem in which parents do not have any previous experience and are
not comfortable.It is mportant
parents/caregivers are fully informed on all aspects of their child’s diagnosis
and treatment options.They, along with
the physician, are the leaders of their child’s care.In addition, parents may need to obtain a
second opinion to obtain more perspectives of their child’s spine problem and
feel comfortable with the decision-making process.
remember, observation is often a reasonable option in the treatment of EOS.Parents/caregivers should not be “rushed”
into a decision about surgery in EOS.
pain in the young athlete is very common. It has been reported that up to 75%
of adolescents will experience back pain by the time they reach 18 years of
age.As more youth sporting activities
are performed year-round, there is a greater risk of sports-specific repetitive
activities over-loading the athletes back.Too much activity applied too quickly to the back can cause pain.In athletes less than 10 years of age, back pain
is uncommon, for many reasons. However, as the athletes grow, add more muscle
mass, generate more force and speed and training more (frequency, intensity and
duration) the risk of back pain increases. In general, a gradual change in
sporting activities and training will minimize the risk of developing back
pain. The good news is >90% of back pain in adolescence is muscle-based and
due to overloading the muscles.
many orthopaedic injuries the commonly recommended treatment is the
"RICE" treatment, which partially applies here. Rest, ice,
compression (hard to do for back injuries) and elevation (also hard to do) is
recommended for the first 4-6 weeks after back pain develops. This is
especially true when the athlete can relate the onset of back pain to an event
in their sports. Over-the-counter pain medications (acetaminophen, ibuprofen or
naproxen) can be helpful for pain control. Pain which came on without a known
injury or activity, fevers, numbness in legs, bowel or bladder difficulties or
other neurological symptoms is more concerning and should be evaluated by a
physician early.Depending on the amount
of pain, the athletes level of participation and upcoming events a course of
physical therapy can be helpful.A
course of paraspinal muscle strengthening, core strengthening and stretching
can speed up recovery.Back braces are
not recommended, in general, because they can cause the back muscles to become
too weak.Similarly, narcotics and
muscle relaxers are not recommended, except in extreme situations.
An evaluation for back pain is appropriate if the back pain has been present for longer than 6 weeks, there is lower extremity numbness or weakness, or bowel or bladder problems develop.
If you break the word spondylolysis
down to its Latin roots and then translate to English you get spondylo- which
means "vertebra" and lysis which means "crack or
break".So spondylolysis is when
there is a crack in the posterior, or back part, of the bony arch of a vertebra
at the pars region (see figure).This
area has a relatively thin area of bone, with a poor blood supply.Hence it has a lower-capacity to heal when it
is stressed.The most concerning
repetitive motion is back hyperextension, with or without rotation. This
typically occurs in the low back (or lumbar spine) in the lowest vertebra (L5
or L4), where there is maximal back motion.
The cause of this crack is likely
a stress fracture due to repetitive back motion (hyperextension).It is most common in athletes who do
repetitive hyperextension of their back, such as in American football linemen
and gymnasts. Why some individuals get this problem and others don't is
unknown, but it is likely some individuals have a predisposition to developing
a stress fracture. Interestingly there is a higher frequency of this occurring
in Inuit Eskimos, hence some populations appear more at risk. Evaluation of
this problem starts with plain radiographs but can include CT, MRI, and bone
scans. Treatment is dependent on the previous treatments and how long the
problem has been symptomatic. In general the first level of treatment is
nonsurgical with rest, limitation of activities and bracing (possible).In situations with longstanding pain, a
surgical repair may be the best option. The surgical repair is aimed to simply
getting the crack in the vertebra to heal, without a fusion between vertebra,
so no back motion will be lost. If a spondylolysis occurs in a younger patient,
<12 years of age it is important to get intermittent radiographs of the low
back to watch for any potential slippage of the vertebra forward.
This post has been previously posted in
the Young Athlete Blog
Scoliosis is a spine deformity in the
side-to-side (or lateral) plane of more than 10 degrees of angulation.The majority of the time this occurs
spontaneously during the pubertal growth spurt in an individual with normal spine development, up until that time.Currently this type of scoliosis is called
“idiopathic”, meaning there is no known cause.However genetic researchers are finding more and more associations
between patients’ genetics and the development of scoliosis.There is nothing the patient or caregiver
did, or didn’t do, to cause the scoliosis to occur.Most individuals with idiopathic scoliosis
are involved, to some degree, in athletic endeavors whether it be recreational
or high-level competition,
at the time they are diagnosed with scoliosis.Often sports are interwoven into their
day-to-day activities, so a new diagnosis of scoliosis raises questions about
what sporting activities, and level of participation, a person with scoliosis
may participate.Despite the lateral curvature of the spine, the bony stability of the
spine is normal, without instability
or weakness.There is no increased risk of damage to the spine during athletic
participation when compared to a similar individual whose spine does not have scoliosis, or is absolutely
straight.We encourage all patients with
scoliosis to be as athletically active as they desire, as the benefits of an
active lifestyle are well-known.The
best way to prevent back pain in scoliosis is to remain athletically active, specifically to be aerobically fit.For those individuals who do not participate
in an organized athletic activity we encourage every other day workouts.These should be 20-30 minutes, at a minimum,
in which the patient raises their heartrate and
breaks into a sweat.More elaborate
methods to quantify heartrate are commercially available, but are not
Even patients whose scoliosis requires
brace use we encourage sports participation.The brace can be removed and
they can participate in their sport
at full capacity.After completion of
the sporting activity the brace
can be re-applied.It is not desirable
to have the patients who are wearing a brace to stop their athletic
activities.There are many negative
implications of being sedentary.
So go out there and Play Ball!
Next Blogpost: What is Spondylolysis or
a Pars Fracture?
posed with a pediatric spinal deformity in their child, parents/caregivers must
decide on the optimal treatment for their child.This can be a daunting task because each
patient is unique and there are often multiple treatment possibilities.In addition, the perspectives and beliefs of
the parents/caregivers about their child and their particular problem are
significant factors in the decision process. Interestingly, early in my career about
half the parents said I was too surgically aggressive, while the other half
said I was too surgically conservative when presented with similar treatment
options for the same musculoskeletal problem.To me, this highlighted the importance of parent/caregiver perspectives
and thoughts which are often the product of their personal experience, culture,
and religious backgrounds.
general, the treatment of pediatric spinal deformity centers around two main
factors: age of the patient and the magnitude of the spinal deformity.The age is important as this gives us a rough
idea of the child’s short-term and long-term spinal growth.Spine growth is the engine that pushes spine
deformity to worsen.Hence, the faster
the spinal growth the greater the risk of deformity progression.The periods of time in which the child has
the greatest spine growth is 0-5 years of age and during the pubertal growth
phase.The time between these two
periods, specifically around 5 years to the start of puberty, the child and
spine does grow but not as rapidly as those earlier and later time periods.Hence, a slower progression of a spinal
deformity is typically expected during this time period.
second factor in treatment decision-making is the Cobb measure on the spine
radiographs (standing or upright sitting).This measurement, named after the surgeon which first describe it, Dr.
John Robert Cobb of New York, allows physicians to quantify a spine
deformity.It is now the mainstay
measure when talking about the magnitude of spine deformity.There are other measurements physicians use
in the treatment of spine deformity but, at present, these assume a secondary
when a physician describes a patient it may sound something like: A
two-year-old male with idiopathic scoliosis and a 35 degree right main thoracic
curve.This child has a much greater
risk of deformity progression than a 14-year-old female with idiopathic
scoliosis with a 35 degree right main thoracic curve.This is mainly due to the fact the
14-year-old female has much less spine growth remaining, as compared to the
2-year-old male who has much greater growth ahead of him.
general lower magnitude deformity, less than 20 degrees of deformity, often
does not need any treatment more than observation.When deformities are >20 degrees, then
physicians will need to consider the patient age, diagnosis, medical history,
previous treatment, medical condition, and other aspects of the spine deformity
when constructing possible treatment options.Typically there are often there are at least 2 options, if not more, for
children with a spinal deformity > 20 degrees.Be sure to ask you physician to describe all
the treatment options which are available for your child and why they are or
are not good options.
do I find a physician for my child with spinal deformity?
looking for a physician to care for pediatric spinal deformity it is
recommended to seek out providers who are member of the Scoliosis Research
Society (SRS) and the Pediatric Orthopaedic Society of North America (POSNA).The SRS is an organization which requires its
member surgeons to have the care of spinal deformity occupy a majority of their
clinical practice, and they must contribute to the scientific advancement of
spinal deformity knowledge through research.POSNA is a professional organization centered on the musculoskeletal
care of children, from head to toe.So
for both organizations, pediatric spinal deformity occupies a part of their
overall focus.By selecting a physician
who is a member of both organizations you will have someone who understands the
musculoskeletal system of children and possesses the technical expertise, and
interest, in spine deformity surgery.
are some other factors should I consider?
Does the physician work (do surgery)
at a tertiary-care children’s hospital?
Does this hospital have ALL the
services my child may need?
A 24-hour pediatric
intensive care unit (PICU) staffed by 24-hour pediatric intensivists
trained general surgeons
full spectrum of pediatric medical specialists (i.e. cardiology, neurology, etc…)
full-service pediatric radiology department (MRI, CT, ultrasound, bone scanning, etc…)
reputation (both word-of-mouth and U.S. New and World Report ranking)
Physician training and experience
Physician’s annual surgical volume
of spine deformity
blogpost: Treatment Decision-making: Age and Magnitude
the last 20 years the development of the internet and digital medical records
has changed medicine dramatically.For
physicians, the rapid access and exchange, of important information about
patients has enabled the delivery of faster medical care than ever before.For patients and parents/caregivers, there is
an ever-growing amount information which is accessible, about nearly every
possible subject in medicine.The
difficulty is filtering the information, first in terms of topic and secondly
determining the accuracy and validity of the information.Search engines such as Google, Bing, etc…
provides the ability to pull in information at lightning speed from across the
globe and then list them numerically in order of how close the information
matches the search words.We commonly
perceive the higher a website is listed on the search engine the more
important, valid or relevant is its information to our question. However in
reality, this is not always the case.Owners of websites can pay the search engines to raise their site to a
higher to increase their “visibility” to people using their search engine.
have long known the value of marketing and that the internet provides a cheap,
rapidly-accessible, customizable method to reach millions of potential
customers.Healthcare providers and
institutions have also realized this, albeit slower, specifically that this can
be a valuable way to market themselves and their services.The quality of any information available on
the internet must be evaluated on an individual basis.Be wary of claims made by individuals or
organizations promising excellent treatment outcomes, over a short period of
time, with low recurrence rates, using simple, painless, minimally-invasive or
times these are marketing ploys and not scientifically-proven methods which are
based in any high-level medical evidence.If the promises seem to be too good to believe, they probably are not
good options of treatment.Often these
promises play on parents/caregivers emotions, who are trying to find the best
treatment for their child.
blogpost: How do I find a physician for my child with spinal deformity?
aim of this blog is to provide parents and caregivers with clear, concise
information on the problems, issues and treatment of pediatric and adolescent
spine deformity topics.We will try to
demystify and focus our postings around spine deformity topics (scoliosis,
kyphosis, spondylolysis, spondylolisthesis, etc…), in the
cervical-thoracic-lumbosacral spine, in patients 0-21 years of age.Our discussions may wander outside of this
area at times, but we will always re-center our attention to the core area of
this blog: pediatric spinal deformity.
is a significant amount of information available on pediatric spinal deformity
topics.Accessing this information can
be easy.However, it often leaves
individuals in a state of confusion, and frustration, when attempting to find
current, relevant information on a pediatric spinal deformity topic for their
child’s situation.If you are searching
for the best general information available, there are a few websites which can
be useful to help obtain peer-reviewed, relevant, unbiased information on
pediatric spinal deformity:
three websites are professional, physician-society websites which are without
industry or marketing influence.Their
aim is to provide scientifically-based information without bias.
you have questions, concerns, or issues in which you are searching for answers
please leave a post.We will routinely
review the blog to address new inquiries, answer questions and we will continue
to post new information on a variety of pediatric spinal deformity topics.Thanks for reading!