Thursday, September 29, 2016

The Spectrum of Treatment Options

There 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). 

What 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 treatments.

In 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. 

We 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. 

Observation 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.

The 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.

So 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.

Next blogpost: spine casting

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