eMedicine Specialties > Orthopedic Surgery > Spine

Idiopathic Scoliosis: Treatment

Author: Charles T Mehlman, DO, MPH, Director, Musculoskeletal Outcomes Research, Associate Professor, Division of Pediatric Orthopedic Surgery, Cincinnati Children's Hospital Medical Center
Contributor Information and Disclosures

Updated: Oct 20, 2009

Treatment

Medical Therapy

Nonoperative management consists of either mere observation or orthosis use. Observation is watchful waiting with appropriate intermittent radiographs to check for the presence or absence of curve progression. Orthosis use for scoliosis is discussed extensively below. No other treatments, including electrical muscle stimulation, physical therapy, spinal manipulation, and nutritional therapies, have been shown to be effective for managing the spinal deformity associated with idiopathic scoliosis. The lack of demonstrated effectiveness in this context means that scientifically valid studies have either been done that do not support the treatment or no such studies have yet been published that would allow an evidence-based evaluation.

The first widely used scoliosis brace with proven effectiveness was the Milwaukee brace. This brace was developed by Walter Blount and Albert Schmitt and introduced at a meeting of the American Academy of Orthopaedic Surgeons in 1946.96 The brace was originally designed to be used as part of the surgical treatment of scoliosis and only later evolved into a stand-alone nonoperative treatment.

Lonstein and Winter studied 1020 patients with adolescent idiopathic scoliosis treated with the Milwaukee brace. They reported that this orthosis was effective in preventing significant curve progression in patients with 20-39° curves.97 These same authors recommended that adolescents with a curve of 25° and a Risser sign of 0 be braced immediately and not wait for evidence of curve progression.97 Other authors have shown that an average curve correction of 20% in the brace (Milwaukee brace) is associated with bracing success.98,99

Rowe and his colleagues performed a meta-analysis aimed at evaluating the efficacy of nonoperative treatments for idiopathic scoliosis.100 They calculated the weighted mean proportion of success for 3 nonoperative treatments: observation, electrical stimulation, and bracing. They were able to successfully combine data on 1910 patients from 20 different studies for purposes of meta-analysis. Their main results are as follows (treatment, success rate):

  • Observation, 49%
  • Electrical stimulation, 39%
  • Bracing 8 hours per day, 60%
  • Bracing 16 hours per day, 62%
  • Bracing 23 hours per day, 93%

In a prospective, multicenter study from the Scoliosis Research Society, Nachemson and his coworkers found brace treatment (an underarm plastic brace worn for at least 16 h/d) to be successful 74% of the time (95% confidence interval [CI], 52-84%).101 Some authors have not been able to identify a major difference between full-time bracing (23 h/d) and part-time bracing (12-16 h/d).102

The psychological stress associated with scoliosis has been documented,103 and this does not improve compliance with brace wear. MacLean and his coauthors from Vanderbilt studied 31 adolescent and preadolescent females who were undergoing part-time brace treatment for their idiopathic scoliosis.104 Part-time bracing was defined as 13-16 hours per day. Eighty-four percent of their patients described the initial period of bracing in "stressful terms" and experienced lower levels of self-esteem.104 A reassuring finding is that overt psychopathology was not identified in MacLean's study.

Compliance with prescribed brace-wear regimens has been shown to be poor. DiRaimondo and Green found that, on average, patients only wore their braces 65% of the prescribed amount of time.105 Patients prescribed part-time bracing (16 h/d) actually demonstrated worse compliance (58%) than those prescribed full-time (24 h/d) bracing (71%).105 Overall, only 15% of patients demonstrated a highly compliant (>90%) brace-wear routine.105

Questions have also been raised regarding the consistency of strap tension in thoracolumbosacral orthosis (TLSO) bracing.106 Using an instrumented load cell to measure strap tension, Aubin et al studied 34 of their patients with braces in Quebec. They found marked variability in tension, with the greatest change occurring while patients were recumbent.106

In part due to the aforementioned psychological and brace-wear compliance issues, new approaches to bracing are being developed.107,108 One such approach is that developed by Dr. Christine Coillard and Dr. Charles Rivard of the St. Justine Hospital in Montreal, Canada. Their dynamic bracing approach is referred to as the SpineCor Brace or as the St. Justine Brace.109 It involves elastic straps that are anchored on a pelvic corset, and based on curve morphology, these straps are tensioned to exert corrective forces. The brace is a radical departure from traditional plastic and metal orthoses. Early results with the St. Justine Brace are rather encouraging, with success rates comparable to those of traditional bracing. Continued follow-up of their growing international cohort of patients is necessary.

Surgical Therapy

Even in the setting of adequate correction and solid fusion, up to 38% of patients still have occasional back pain.80,110

The primary goal of scoliosis surgery is to achieve a solid bony fusion. The surgical technique used to achieve such an arthrodesis is vastly more important than the instrumentation system that the surgeon needs to use, if any.21,111

Modern instrumentation systems have been shown to allow for adequate curve correction but with little or no ability to diminish associated rib humps.112 Despite claims of certain instrumentation systems to derotate the spine, little actual derotation has been documented. Derotation of the instrumented curve also has been shown to possibly occur at the expense of creation of new rotation in uninstrumented portions of the spine.113

Previously, much attention was paid to the ability of certain spinal instrumentation systems (eg, Cotrel-Dubousset to derotate the spine during scoliosis correction. Jarvis and Greene showed that use of the Wisconsin segmental spinal instrumentation (a system traditionally thought to not be associated with significant spinal derotation) was associated with spinal derotation equal to or greater than that of the Cotrel-Dubousset–type systems.114

Since 1993, VATS has been used in the anterior treatment of pediatric spinal deformity at Cincinnati Children's Hospital Medical Center.115 This minimally invasive surgical technique is aimed at decreasing operative morbidity and optimizing patient recovery from surgery. Over 100 of these procedures have been performed at this institution. Initial biomechanical studies in animal models have correctly predicted what clinical practice has now borne out—that endoscopic anterior release and diskectomy is as effective as the open version of the operation.74,101,116,117 Endoscopic spinal instrumentation techniques have also been introduced and continue to evolve.118

Preoperative Details

Preoperative evaluation focuses on specifics of curve location, magnitude, and flexibility. These parameters are used in conjunction with patient maturity factors to determine optimal treatment choice, but definitive studies are not yet available that dictate specific surgical tactics. However, the scoliosis surgeon is aided by commonly applied clinical guidelines that have evolved over time. The goal is always to fuse as little of the spine as possible while adequately treating existing major curvature.

For a thoracic curve (with adequate flexibility) without any significant associated lumbar curvature, the most common surgical approach has not changed since the days of Paul Harrington: posterior spinal fusion with instrumentation. Surgeons may choose from a diverse array of anchors to secure large-diameter rods (usually in the 0.25-in range) to the spine. These anchors include sublaminar hooks, pedicle hooks, transverse process hooks, sublaminar wires (Luque wires), spinous process wires (Drummond wires), and pedicle screws. Some surgeons have advocated anterior spinal fusion and instrumentation for such isolated thoracic curves. These have included both open (thoracotomy) and limited-incision (thoracoscopic) techniques.

When the primary problem is a large, stiff thoracic curve (usually not bending less than 50°), a different surgical tactic is usually undertaken in which an anterior release (usually including diskectomy and bone grafting) is performed prior to posterior spinal fusion and instrumentation. Anterior spinal fusion and instrumentation has also been advocated in this situation, provided the patient does not have excessive kyphosis associated with a large thoracic curve.

Large curve patterns that include both thoracic and lumbar deformity continue to challenge scoliosis surgeons. If adequate flexibility and balancing of the lumbar spine is possible, then selective fusion of the thoracic curve is possible. When this is not the case, extensive fusion (at times down to the fourth lumbar segment) may become necessary.

The Scoliosis Research Society has a rather specific definition of thoracolumbar scoliosis: a curve whose apex lies at the body of T-12 or L-1 or at the T12-L1 interspace. These curves are most commonly left-sided curves and they present one of the most common scenarios in which anterior spinal fusion and instrumentation is utilized. Anterior approaches to this area of the spine were pioneered by Hodgson (Hong Kong), Dwyer (Australia), and Zielke (Germany). Current approaches represent further refinement of these original techniques, such as modern large rod-and-screw systems and the John Hall short anterior segment overcorrection technique. The value of such techniques lies in their ability to powerfully correct large thoracolumbar curvatures while minimizing fused segments within the lumbar spine.

There is little debate regarding the fixation of the rods used for anterior instrumentation. Large bone screws are almost always the anchor of choice. For posterior instrumentation procedures, the surgeon has more options. Multiple hooks are the most commonly used anchors. They offer simplicity, strength, and near complete visualization during insertion. Their main drawbacks relate to size mismatch between hooks and associated bony elements, as well as the absence of appropriate hook sites (such as might be the case in myelomeningocele, tumor cases, or revision surgeries).

Sublaminar wires offer the power of segmental fixation and firm bony purchase, but with the drawback of possible dural and/or spinal cord trauma. As a result, either very selective use of or no use at all of sublaminar wires is usually the case in the setting of idiopathic scoliosis. A reasonable compromise was achieved when Denis Drummond introduced his spinous process wires (also known as Wisconsin wires). These devices still offer the power of segmental fixation with virtually none of the nerve injury risks of sublaminar wires.

Pedicle screws have also become a popular anchor for the rods used in posterior scoliosis fusion procedures.119 They offer the potential advantage of increased strength (and possibly power of correction) while at the same time introducing added insertion-technique complexity and different neurologic complication risks. A very real and major increase in the overall cost of instrumentation constructs that include many pedicle screws is the case when comparing them to similar constructs that may include hooks and wires. At this time, evidence is not conclusive to support a commensurate improvement in clinical outcomes to support the routine use of such pedicle screw constructs in the treatment of idiopathic scoliosis.

Pulmonary function testing is commonly used in the preoperative evaluation of patients with idiopathic scoliosis who are slated to undergo surgery. Such testing may influence the surgeon's enthusiasm for related procedures, such as costoplasty (thoracoplasty). Pulmonary function testing may also uncover previously unrecognized tobacco use (an independent risk factor for pseudarthrosis) or undiagnosed (subclinical) pulmonary disease.

Predonation of several units of donor-directed blood is considered standard for most patients. Certain commercially available intraoperative blood recovery devices may also be used at times.

Intraoperative Details

Hoppenfeld described an ankle clonus test for intraoperative assessment of the integrity of the spinal cord during scoliosis surgery. In more than 1000 patients, the test was noted to have no false-negative results and 3 false-positive results. This translated into 100% sensitivity and 99.7% specificity.120

Postoperative Details

Postoperative patient management involves close monitoring, which often occurs initially in an intensive care unit setting. Patients have monitoring devices, such as arterial lines, and closed suction devices, such as chest tubes, that also require special nursing attention. The use of certain special spine-specific hospital beds, such as the Stryker frame, may also aid in patient care and comfort (change from supine to prone position) during the initial postoperative period.

The use of postoperative bracing varies from surgeon to surgeon. As outlined in History of the Procedure, the roots of scoliosis surgery involved immobilization in a body cast. Following the development of initial instrumentation systems (eg, Harrington instrumentation), external immobilization was still used routinely. With the advent of large-rod multiple-hook constructs, such as the Cotrel-Dubousset system and its direct decendents, bracing has been deemphasized a bit. Thus, it is almost as likely that a patient will not receive a postoperative brace as receive one, whereas, previously, bracing was much more widespread. In certain specific circumstances, postoperative bracing is still almost always used, such as anterior thoracic or thoracolumbar instrumentation procedures or surprisingly weak bone stock.

When a brace is used, it is typically to be worn full-time for at least 6 weeks, followed by a period in which the brace may be taken off for bathing, with subsequent progressive weaning. As a rule of thumb, patients may also miss up to 6 weeks of school (if their procedure is done at such time of the year), and up to 6 months may be required before they resume most of their normal activities. Vigorous sports may be restricted for at least a year or, in some instances, permanently (based on risk-versus-benefit discussions between patients, families, and their surgeons).

Follow-up

At an average of 21 years following posterior spinal fusion with Harrington instrumentation (performed by Paul Harrington himself), about 21% of patients experienced significant interscapular pain.121

Complications

Complications are of great concern to parents, patients, and surgeons. Thankfully, complications are rare with modern scoliosis surgery, despite the magnitude of these spinal deformity procedures.4 Several important intraoperative, early postoperative, and late postoperative complications are discussed here.

McKie and Herzenberg described coagulopathy as a complication of intraoperative blood salvage during scoliosis surgery.122 These authors suggested that thrombin and Gelfoam that may have been aspirated along with salvaged blood may have contributed to the disseminated intravascular coagulation experienced by their 17-year-old patient. This effect of the thrombin and Gelfoam would have been in addition to that of hemodilution (hemodilution-induced platelet and leukocyte activation syndrome).122

The importance of appropriate intraoperative spinal cord monitoring during scoliosis surgery is hardly debatable. Such monitoring can allow early recognition and treatment of spinal cord dysfunction.123 Somatosensory and motor evoked potentials are commonly used to monitor spinal cord function. A Stagnara wake-up test may also still be employed if the surgeon desires. Current efforts at monitoring have helped achieve and maintain a very low rate of spinal cord injury (less than one half of one percent).

Some concern exists regarding postoperative activity level and the possible hazards of trauma. Neyt and Weinstein have reported a case of lumbar spine fracture dislocation in a teenage boy 3 years after successful scoliosis surgery.124 The boy's fusion extended from the second thoracic vertebra to the first lumbar vertebra, and his subsequent fracture dislocation occurred at the L2-3 level.124

Delayed infections following posterior spinal fusion with Texas Scottish Rite Hospital instrumentation has been reported. Richards reported on 10 such patients who presented with infections at an average of about 2 years following successful spinal fusion.125 Low-virulence organisms such as Propionibacterium acnes were the main cause, and instrumentation removal was successful in eradicating the infections. Richards hypothesized that the infections might be related to the amount of hardware (eg, hooks, rods) used and suggested that efforts at minimizing such hardware might help prevent such infections.125

Much has been written regarding a particular complication called crankshaft phenomenon. It may occur following posterior spinal fusion of idiopathic scoliosis in patients who have significant anterior spinal growth remaining. Sanders and coauthors reported that the risk of the crankshaft phenomenon was highest in patients younger than 10 years and in patients with a Risser sign of 0 with an open triradiate cartilage.126

Significant concern exists regarding the inferior (caudad) extent of a patient's spinal fusion and its potential relationship with future low back pain.127 Connolly led a group of researchers at the Toronto Hospital for Sick Children who studied this question in 83 patients fused with Harrington instrumentation to the second, third, fourth, or fifth lumbar vertebra. At an average of 12 years (range 10-16 y) following their surgery, these patients were found to have a statistically higher rate (76%) of low back pain than a control group (50%). Connolly's patients were from an era in which the predominant instrumentation system was noncontoured Harrington rods, which were notoriously associated with low back pain when applied to the lumbar spine.127 The results of this study almost certainly cannot be generalized to current scoliosis patients, who are treated with very different instrumentation systems.

Some complications have been associated with particular surgical approaches to scoliosis. For instance, chylothorax and tension pneumothorax have both been reported in association with video-assisted thoracoscopic surgery (VATS) procedures.128,129

Pseudarthrosis is a complication that represents a basic failure of the central intention of scoliosis surgery: bone fusion. Luckily, pseudarthrosis is very rare in modern scoliosis surgery. This is in small part due to excellent stable internal fixation (scoliosis instrumentation systems) and in large part due to proper attention to fusion technique. Pseudarthrosis may be suggested by persistent pain, progressive deformity, or broken hardware. Previously tomographic plain x-rays (tomograms) were commonly used to image suspected pseudarthrosis. This is no longer the case, as such tomography equipment is on the endangered species list of imaging devices. As such, computed tomography may be helpful, but clinical suspicion and fusion mass exploration (a rare case for modern-day exploratory surgery) remain the cornerstones of pseudarthrosis diagnosis and treatment.

More on Idiopathic Scoliosis

Overview: Idiopathic Scoliosis
Workup: Idiopathic Scoliosis
Treatment: Idiopathic Scoliosis
Follow-up: Idiopathic Scoliosis
References
Further Reading
[ CLOSE WINDOW ]

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Further Reading

Related eMedicine topics

Adolescent Idiopathic Scoliosis

Infantile Scoliosis

Juvenile Idiopathic Scoliosis

Neuromuscular Scoliosis

Scoliosis, Idiopathic (Radiology)

Clinical guidelines

Screening for idiopathic scoliosis in adolescents: recommendation statement. U.S. Preventive Services Task Force (USPSTF). Screening for idiopathic scoliosis in adolescents: recommendation statement. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2004 Jun. 4 p. [4 references]

Clinical trials

Phase IV Comparing Rods of Yield Strengths to Correct Adolescent Idiopathic Scoliosis.

Surgical Outcomes Using Variable Rod Diameters in the Treatment of Idiopathic Scoliosis

Risk Factors for Psychiatric Disorders Associated With Adolescent Idiopathic Scoliosis

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Keywords

adolescent idiopathic scoliosis, adolescent scoliosis, early onset idiopathic scoliosis, early onset scoliosis, idiopathic scoliosis, infantile idiopathic scoliosis, infantile scoliosis,  juvenile idiopathic scoliosis, juvenile scoliosis, kyphoscoliosis, late onset scoliosis, late onset idiopathic scoliosis, lumbar scoliosis, neuromuscular scoliosis, rotoscoliosis, spinal deformity, thoracic scoliosis, thoracolumbar scoliosis

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Contributor Information and Disclosures

Author

Charles T Mehlman, DO, MPH, Director, Musculoskeletal Outcomes Research, Associate Professor, Division of Pediatric Orthopedic Surgery, Cincinnati Children's Hospital Medical Center
Charles T Mehlman, DO, MPH is a member of the following medical societies: American Academy of Pediatrics, American Fracture Association, American Medical Association, American Orthopaedic Foot and Ankle Society, American Osteopathic Association, Arthroscopy Association of North America, North American Spine Society, Ohio State Medical Association, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society
Disclosure: Nothing to disclose.

Medical Editor

K Daniel Riew, MD, Mildred B Simon Distinguished Professor of Orthopedic Surgery, Professor of Neurologic Surgery, Washington University School of Medicine; Chief, Cervical Spine Surgery, Department of Orthopedic Surgery, Barnes-Jewish Hospital
K Daniel Riew, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, AO Foundation, Cervical Spine Research Society, North American Spine Society, and Scoliosis Research Society
Disclosure: Medtronic Grant/research funds None; Medtronic Royalty Medtronic Vertex; Biomet Royalty Maxan anterior cervical plate; Osprey Royalty Interbody Graft; Osprey Ownership interest Consulting; SpineMedica Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

William O Shaffer, MD, Professor, Vice-Chairman and Residency Program Director, Department of Orthopedic Surgery, University of Kentucky at Lexington
William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, International Society for the Study of the Lumbar Spine, Kentucky Medical Association, Kentucky Orthopaedic Society, North American Spine Society, Southern Medical Association, and Southern Orthopaedic Association
Disclosure: DePuySpine 1997-2007 (not presently) Royalty Consulting; DePuySpine 2002-2007 (closed) Grant/research funds SacroPelvic Instrumentation Biomechanical Study; DePuyBiologics 2005-2008 (closed) Grant/research funds Healos study just closed; No present Industry grants or funds. None None

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania
Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association
Disclosure: Nothing to disclose.

 
 
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