Adolescent Idiopathic Scoliosis

How is adolescent idiopathic scoliosis diagnosed?

Typically, adolescent idiopathic scoliosis is first noticed by the child’s pediatrician, family member or school nurse. As an initial screening method, healthcare professionals use the Adams forward-bending test to look for the presence of any asymmetry of the torso or shoulder blades, or for protrusion of the shoulder blades.

A scoliometer is used to measure the amount of trunk inclination (the curve) or rotation (twisting of the spine). Adolescents with a measurement of 7 degrees or greater are referred to an orthopedist for further evaluation. Adolescent idiopathic scoliosis rarely causes pain. For this reason, back pain symptoms in a young person with scoliosis may be a sign of an additional condition.

 

Radiological imaging

To assess the curve further, X-ray images or low-dose radiation EOS images are taken from the front and side views. Side-bending X-rays may also be taken to assess the flexibility of the curve or curves. Sometimes these images reveal two curves: the first curve to appear in the spine (the primary curve) and the compensatory curve that the patient develops through his or her effort to maintain an erect posture.
 

How is adolescent idiopathic scoliosis treated?

Treatment for adolescent idiopathic scoliosis determined by the degree of the spinal curve at the time of diagnosis and by the anticipated progression of that curve. Mild cases may not require any treatment at all. More significant cases of this type of scoliosis may be treated nonsurgically, using braces, or with spine surgery, depending on the individual patient.
 

Non-operative treatment

For curves measuring less than 25 degrees, the orthopedist may recommend frequent monitoring to see if additional intervention becomes necessary.
Young people with curves between 25 and 45 degrees may be candidates for treatment with bracing. While bracing does not correct the curve, it has been shown to stop progression in up to 75% of patients. Bracing is considered a success when progression is halted and maintained within 6 degrees of the original measurement of the curve.
Candidates for bracing are generally younger patients – prepubescent and skeletally immature as measured on the Risser test (a staging system that measures maturation of the hip bone). A measurement of 0 to 2 indicates that the growth is expected to continue. Skeletal maturity is achieved in female patients who reach a level of 4 and in male patients who have reached a level of 5. The absence of any change in height over a period of 6 to 12 months is another indicator of skeletal maturity.
In most cases, patients wear a brace for 22 to 23 hours a day, removing it only for hygiene and sports activities. However, some patients may only require the use of a brace at night.
A variety of braces are available and selection is based on how many curves are present and where on the spine the curve or curves are. Some models provide support at the pelvis, front, back, and neck, where others provide support throughout the torso and underarms.
While many braces are rigid, flexible braces have been developed in recent years. This type of brace, which is only appropriate in patients with single curves, is worn as a vest and allows the patient to participate in some sports activities.
Patients continue to wear the brace until skeletal maturity is reached. A weaning process follows in which the number of hours the brace is worn per day is gradually reduced over a period of six months to a year. This allows the supportive muscles in the back and trunk to become stronger after a period of inactivity. Physical therapy is also recommended, both during bracing and weaning.

 

Surgical treatment

Patients with curves that continue to progress beyond 50 degrees, either with or without bracing, generally require surgical intervention.

How does surgery for adolescent idiopathic scoliosis work?

There are different surgical methods, but the most common type of surgery is a posterior spinal fusion with instrumentation (artificial implants). In this procedure, the orthopedic surgeon makes an incision from the back and essentially "welds" the vertebrae together using bone chips.

These bone chips may be:

• Autografts: taken from elsewhere in the patient's own body
• Allografts: sourced from donors through a bone bank

During the healing process, which takes 6 to 12 months in an adolescent, the spine is held in alignment by hooks, screws or other instrumentation. Once the fusion is complete, the implants no longer serve a function but are left in place to avoid the need for additional surgery.
 

Posterior, anterior and thorascopic surgical approaches

Depending on the nature of the curve and its location, the orthopedic surgeon may need to perform a fusion from the front (anterior), the back (posterior) or both. When both approaches are needed, the procedure may be performed either as a single operation or in stages. Currently, however, this surgery is most commonly performed using a posterior-only procedure.
 

Vertebral body tethering

A newer approach to treat adolescent idiopathic scoliosis is a non-fusion procedure termed the "tethering" procedure. In Vertebral body tethering (sometimes also called "spinal tethering"), a thoracoscopic approach as described above is performed, and screws are placed within the specific vertebrae. Then, instead of using rods, a thick cord is placed to connect the screws, functioning as a tether. Tension is applied to help a growing child's spine develop with a straighter orientation. Not all patients are candidates for this procedure. Usually, candidacy is dependent on a patient's curve magnitude, age, skeletal maturity and curve type. The results of this procedure have not been researched as extensively as fusion procedures, however, short-term studies demonstrate that it can be successful in selective cases.
 

What are the results of spinal fusion surgery?

The surgery provides significant spine curvature correction, cosmetic and posture benefits, but does cause some inflexibility in the spine.
Curvature correction

Fusion surgery generally yields very good results, with a correction rate of between 60% to 100%, depending on curve flexibility and location. 
The extent of that varies depending on the section of spine corrected and the number of vertebrae fused.
 

Cosmetic results

• A balanced spine
• Leveled shoulders
• reduction or elimination of any rib hump
   

Complications

Rare complications can include infection and spinal cord abnormalities or injury. 
 

What is the expected scoliosis surgery recovery time?

Following surgery, most patients remain in the hospital for 3 to 5 days (slightly longer for those who undergo combined anterior/posterior procedures) and are on their feet in two days. Pain medication is continued for a few weeks and the majority of young people are back in school within 4 to 6 weeks. Some exercise, such as swimming and low-impact aerobic exercise, may be resumed within three months and patients may return to full activity within six months. Different Surgeons have different specified approaches to post-operative management.