Sunday, 24 July 2011

Understanding Scoliosis

Published in Panorama

Diagnosing and Treating Scoliosis

20% of children in a general population are likely to have Scoliosis, which is a lateral curvature of the spine, says Dr.Jamil Ahmed, Orthopedic Surgeon and Director, Prime Medical Centre, Dubai. A scoliotic spine often appears like a “C” or an “S” on X Ray and in a physical sense may make a person’s waist or shoulders appear uneven.

About 80% of Scoliosis is Idiopathic or cause unknown and they may either be of early onset, before the age of six years, or late onset, after that age and usually in adolescence.
It is believed that roughly 2-3 out of every 1000 people will require treatment for progressive scoliosis and 1 out of every 1000, require surgery to tackle the condition.

Hereditary factor may contribute to Scoliosis and although boys and girls are affected the same at the onset, there’s a greater predisposition for the condition to worsen in girls and the best time to deal with the problem is when the body is still growing and can best respond to treatment with braces.

Dr.Thomas Chandy, Chief of Orthopaedics, Dr.J.Lakshmikanth, Specialised Spine Surgeon and Dr.Madhusudan Specialised Neuro Spine Surgeon, HOSMAT Hospital Bangalore explain that Idiopathic scoliosis starts generally around the age of 10 –11 years, increases rapidly when teenagers have their growth spurt, and it can be mild, moderate or severe.”

The doctors explain that Scoliosis is a developmental disorder which is rarely present at birth though congenital Scoliosis is not unheard of. Infantile Scoliosis can develop after the age of 2 and these cases have a good chance of resolving with growth.

Dr.Jamil points out that the onset itself can be during childhood, adolescence or even adulthood. Further, 20% of Scoliosis may be the result of an intraspinal tumour in the spinal cord or due to hip herniation with pressure on the nerves, causing sciatic scoliosis. Other causes would include Scoliosis after a polio attack, from neurofibromatosis and Tuberculosis of the spine, add Drs.Lakshmikanth and Madhusudan.

Explaining the course of the condition, Dr.Madhusudan says, “The normal spinal curve would have a practically zero degree incline. We’d say a 20 degree incline of the spinal curve is mild Scoliosis and a 50 degree one to be a severe one. In the case of Idiopathic Scoliosis, when children stop growing, the scoliosis also stops. Normally, bone growth stops around the age of 15 years. So the curve does not generally progress further after this period.”

An important category of Scoliosis patients are individuals who are just about to reach puberty, says Dr.Lakshmikanth. “This is a huge group who can develop the deformity. The curves are visible only at this stage in these cases, usually between the ages of 10 to 13. Or, they may have a minor curve which will become very, very obvious at this time since it can become major at this time because these children are growing rapidly at this time. Most often, adolescent scoliosis is only a cosmetic problem and these individuals usually don’t complain of pain or any other symptom. It happens more often in girls.”

What are the symptoms of Scoliosis? “None at all,” say Drs.Chandy and Madhusudan. “A curious thing about Scoliosis is that there is no pain. Sometimes, the mother may observe it from the back or if the shirt is more prominent on one side. In girls sometimes, one breast is bigger than the other. Also, if the curve is pronounced in the back, the chest moves in a way as to make one side of the chest look more prominent than the other. That’s how the condition is initially noticed. Many teenage girls will notice it since they keep looking at their image in the mirror. In boys sometimes, the condition can be missed because only in severe cases, does the curvature become obvious. However, in early onset Scoliosis when the patient has congenital malformation of the spinal cord or vertebral column or there is a growth within, this is visible, probably from around 6 months of age since the spine looks bent. Treatment is necessary in these cases at the earliest since it could involve the lungs, making breathing difficult.”

Dr.Jamil differs on this aspect of pain. He reveals, “The most common symptom of Scoliosis could be pain, but this again depends on whether it is infantile, juvenile or adult scoliosis. In adolescents, while pain is the main symptom, you see the obvious deformity, change in body contour, body mechanics, changes during walking sitting and postural changes.”

What are the complications of untreated Scoliosis? Dr.Jamil explains, “In very advanced cases you have respiratory symptoms and even cardiac failure if the Scoliosis is in the thoracic or chest region which is the commonest site of the condition and also the most difficult to treat because the thoracic spine is not as immobile as the lumbar region. But having said that, screening and treatment modalities have advanced to such an extent that the problem does not reach this kind of a magnitude where the lungs and heart are threatened.”

Dr.Madhusudan adds, “Left untreated, the convex part of the curve squeezes the lung to one side and the patient is practically breathing on one lung. Because adults may experience breathlessness, we perform surgery. More than the cosmetic appearance, it is for this reason that surgery is mainly done.”

What are the investigations required to diagnose Scoliosis? Dr.Chandy explains, “In the USA, it is compulsory for schools to screen every kid when it joins school. This screening should be done every year because it is possible you don’t find it in a child this year, but do find scoliosis when you screen the child the next year!”

Dr.Jamil adds, “Any spinal problem would be dominated by pain as a symptom. So it’s a physical examination which will determine what is causing the pain. Once you determine this, X Ray is the next step to confirm diagnosis.”

The surgeons add that in some instances, MRI Scan may be needed to evaluate the spinal cord and to rule out neurological anomalies at the base of the skull if there is reason to suspect neurological problem.

Once diagnosed, what is the treatment modality? The first choice of treatment is the brace, made of plastic, worn under the clothing, is contoured specifically for each patient in order to give the straightest possible shape. Individuals with a brace lead very normal lives, and participate in various physical and sports activities.

The surgeons explain that in Congenital and Infantile Scoliosis, surgery is the best option even if the Scoliosis is mild but of a progressive nature. These children might require yet again another surgery when they grow up to the teen years. Dr.Madhusudan explains, “Usually in Idiopathic Scoliosis, you can wait till the children stop growing. But if the curve is growing rapidly as happen in Congenital Scoliosis, surgery is a must.”

In early onset scoliosis where the children might have congenital malformation of the spinal cord or vertebral column or have a tumour, treatment is necessary at that stage since it could compromise the lung function, explain the surgeons. Dr.Madhusudan explains, “Initially we try plaster jackets. A vast majority of children who do not have any structural deformity but who have Scoliosis, get better with this. Plaster jackets are used with great effect right from the age of 4 months. If they don’t respond to this treatment, then we have to operate at an appropriate time. That is, we allow them to achieve as much length as possible. But if the deformity is worsening rapidly, we then trade in: if the growth is not there, at least the kid will have a straight back. In such situations, even though the kids are short in terms of spinal length, once you straighten the spine, they become taller. When we operate on these cases, we put “growing rods” and don’t do fusion. We just put an implant which we keep stretching every six months as the child is growing. These 6 monthly procedures take 15-20 minutes and are done under a short general anesthesia since children don’t normally tolerate a local anesthesia.”

What is the aim of spinal fusion surgery and what does it involve? Surgery is usually done to prevent decreased lung function, back pain and poor appearance. The safest period for surgical treatment is before these problems are expected to develop. Spinal fusion surgery to treat Scoliosis is done to prevent the spine from curving further and is augmented with a bone graft harvested either from the patient’s pelvis or taken from the bone bank, each having its own merits and demerits. The process involves two aspects: straightening the spine with rigid rods and, adding bone graft to the curved area of the spine to fuse it in the correct position as secured by the rods. Metal implants including rods, screws, hooks or wires are used to hold the spine still while the vertebrae fuse, the surgeons explain.

Drs.Madhusudan and Lakshmikanth explain, “During the growth period of adolescents if the curve keeps on increasing or if it increases to beyond 50 degrees, we advice surgery. We do a spinal fusion and put a rod to straighten it to the extent possible. For instance, a 50 degree curve, we may bring it down to 20 degrees and from 70 degrees to 30 degrees. We can’t bring it to zero degree because this may put pressure on the spine.”

What are the complications of the surgery? A very good anesthesia specialist and neurospine surgeon are a must for the procedure since the procedure may cause pressure on the spinal cord. Dr.Madhusudan explains, “When a patient’s body is used to a curve and you suddenly straighten it, sometimes there can be pressure on the spinal cord. This may be seen if the patient is unable to move his toes. We then immediately release the rod and accept a slightly bigger curve and again check the toes for movement. The other complications from surgery include bleeding, infection, nerve injury and failure of fusion to happen and the implants failing. But again, these risks though possible, occur very rarely because of modern treatment techniques and sterile operating conditions.”


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