Scoliosis

A spine has natural curves. It includes a top-of-the-shoulder curve and a lower back curve. These curves help the spine absorb stress from body movement and gravity. Normally, the spine should run straight down the middle of the back when viewed from the back. When abnormalities of the spine occur, the natural curvatures of the spine are misaligned or exaggerated in certain areas. If the spine is curved from side to side or in an “S” or “C” shape, the person probably has scoliosis. Scoliosis can make the person’s shoulders or waist appear uneven. Some of the bones may also be rotated slightly, making one shoulder blade more prominent than the other.

 

What causes scoliosis?

In most cases, the cause behind scoliosis is not identifiable. This is known as idiopathic scoliosis, meaning “of undetermined cause.”

Idiopathic scoliosis is broken down by age group:

  • infant (0 to 3 years).
  • juvenile (4 to 10 years).
  • adolescent (11 to 18 years).
  • adult (18+ years).

In cases where the cause of scoliosis can be determined, the most common are:

  • cerebral palsy, a group of nervous system disorders that affect movement, learning, hearing, seeing, and thinking.
  • muscular dystrophy, a group of genetic disorders that leads to muscle weakness.
  • birth defects that affect an infant’s spinal bones, such as spina bifida.
  • spinal injuries or infections.

People who have a family history of scoliosis are more likely to develop the condition. Girls are more likely to have scoliosis than boys.

 

Symptoms of scoliosis

The commonly noted symptoms of scoliosis include:

  • Uneven shoulders.
  • Uneven hips.
  • One shoulder blade sticking out more than the other.
  • Leaning slightly to one side.
  • A hump on one side of the back.
  • Back pain.
  • Breathing problems due to the reduction in the chest area for the lungs to expand.

 

Diagnosis of scoliosis

Since scoliosis is a structural deformity, a physical examination is the first step. The examination is done with you standing in a relaxed position with your arms at your sides. A doctor will observe your back looking for the curvature of the spine, shoulder blade asymmetry, waistline asymmetry and any trunk shift. Next, your doctor will ask you to bend forward and observe your back from this angle. This time he or she will look for curvature in your upper and lower back. In addition, some form of imaging test will be used to get a closer look at your skeleton. Tests such as X-ray, MRI, CT scan or a bone scan are conducted to evaluate the magnitude of the curve.

 

Reasons for the procedure

There are several reasons to treat scoliosis:

  • Appearance is a major concern.
  • Scoliosis often causes back pain.
  • If the curve is severe enough, scoliosis affects the patient’s breathing.

 

Treatment options for scoliosis

The type of treatment for scoliosis depends on several factors, the degree of spine curvature being a major factor. Your doctor will also take into consideration your age, whether you are likely to continue growing, the amount and type of curvature, and the type of scoliosis.
The primary treatment options are bracing and surgery.
Braces are often tried first to keep the curve from getting worse. It is the usual choice of treatment for adolescents who have a spinal curve between 25 and 40 degrees — particularly if their bones are still maturing and if they have at least two years of growth remaining.
The purpose of bracing is to halt worsening of the curve during a growth spurt. There are many brace varieties and depending on the condition the most appropriate brace will be prescribed and the duration of usage and wearing time will be determined. It may provide a temporary correction, but usually, the curve will assume its original magnitude when bracing is eliminated.
Most braces are worn 24 hours a day for maximum effectiveness. Children who wear braces can usually participate in most activities, with a few restrictions. If necessary, kids can remove the brace to participate in sports or other activities. As the child grows, new braces will need to be fabricated, approximately every 12-18 months. Braces are discontinued after the bones stop growing.

There are two main types of braces:

  • Underarm: This is used to treat lower spine curves, as it fits under the arms and around the rib cage, lower back and hips. Made of plastic, it is almost transparent and fits close to the body.
  • Milwaukee: This race starts at the neck, and covers the entire torso, with the exception of the legs and arms. This brace is for curves that the underarm brace cannot address.

Surgery is usually recommended for the following children and adolescents:

  • All young people whose skeletons have matured, and who have a curve greater than 45 degrees.
  • Growing children whose curve has gone beyond 40 degrees. (Not all doctors agree on whether all children with curves of 40 degrees should have surgery).

The choice of when to have surgery will vary.

  • After the bones of the skeleton stop growing, the curve should not get much worse. Because of this, the surgeon may wait until your
    child’s bones stop growing.
  • Your child may need surgery before this if the curve in the spine is severe or is getting worse quickly.

Spinal fusion is the standard scoliosis surgery. The doctor fuses two or more of the bones in the spine (vertebrae) together using a material similar to bone, called bone graft, rods and screws. Rods are used to keep the spine in a straight position and the screws hold it in place. This is done till the bone graft and the vertebrae eventually fuse into a single bone. Surgery is usually postponed until after a child’s bones have stopped growing. If the scoliosis is observed to progress rapidly at a young age, surgeons may install a rod that can adjust in length as the child grows. This growing rod is attached to the top and bottom sections of the spinal curvature and is usually lengthened every six months.

 

Risks of the procedure (surgery)

As with any surgical procedure, complications can occur. Some complications may include, but are not limited to, the following:

  • Bleeding.
  • Infection.
  • Pain.
  • Nerve damage.
  • Failure to heal.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

 

Before the procedure

  • Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the surgery.
  • You may be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.
  • In addition to a complete medical history, your doctor may perform a complete physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood tests or other diagnostic tests.
  • Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, and anaesthetic agents (local and general).
  • Notify your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
  • Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
  • You will be taught how to do special breathing exercises to help the lungs recover after surgery.
  • You will be taught special ways to do everyday things after surgery to protect the spine. This includes learning how to move properly, changing from one position to another, and sitting, standing, and walking.
  • Your doctor will suggest pre-donation of blood, i.e. store some of your blood about a month before the surgery. This is so that your own blood can be used if a transfusion is needed during surgery.
  • If you smoke, you will be asked to stop it. People who have spine fusion and keep smoking do not heal as well. Ask the doctor for help.
  • Let the doctor know right away if you have any cold, flu, fever, herpes breakout, or other illness before the surgery.
  • On the day of the surgery, you will likely be asked not to eat or drink 6 – 12 hours before the procedure.
  • Take any medicines the doctor told you with a small sip of water.

 

During the procedure

Scoliosis surgery requires a stay in the hospital. Procedures may vary depending on your condition and your doctor’s practices.
Generally, the surgery follows this process:

  • You will be asked to remove clothing and given a gown to wear.
  • An intravenous (IV) line will be started in your arm or hand. Additional catheters may be inserted to monitor the status of your heart and blood pressure, as well as for obtaining blood samples.
  • If there is excessive hair at the surgical site, it may be clipped off.
  • A catheter will be inserted into your bladder.
  • The surgery will be performed while you are asleep under general anaesthesia. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
  • The skin over the surgical site will be cleansed with an antiseptic solution.
  • There are two types of surgeries for treating scoliosis, depending on your condition and your doctor’s choice. The surgeon may also do the procedure using a special video camera.
  • If a surgical cut is made in the back, it is called the posterior approach. This surgery usually takes several hours. In this procedure, a metal rod is attached to each side of the patient’s spine by using hooks or screws attached to the vertebral bodies. Then, the surgeon fuses the spine with a piece of bone from the patient’s hip (a bone graft). The bone grows in between the vertebrae and holds them together and straight. This process is called spinal fusion. The metal rods attached to the spine ensure that the backbone remains straight while the spinal fusion takes place.
  • If a cut is made through the chest wall, it is called a thoracotomy. The patient lies on his or her side during the surgery. During this procedure, the surgeon makes incisions in the patient’s side, deflates the lung, and removes a rib in order to reach the spine.
  • During surgery, the nerves that come from the spine are watched using special equipment to make sure no damage is done to any of the nerve roots.
  • Scoliosis surgery usually takes 4 – 6 hours. It may take longer or shorter for some children.
  • The incision will be closed with stitches or surgical staples.
  • A sterile bandage or dressing will be applied.

 

After the procedure

After the surgery, you will be taken to the recovery room for observation. Once your blood pressure, pulse, and breathing are stable and you are alert, you may be taken to the intensive care unit (ICU) or your hospital room. You will need to stay in the hospital for about 5 – 7 days after surgery. The repaired spine should be kept in its proper position to keep it aligned. If the surgery involved a surgical cut in the chest, you may have a tube in the chest to drain fluid build-up. This tube is often removed after 24 – 72 hours.
A catheter may be placed in the bladder the first few days to help your child urinate.
The patient’s stomach and bowels may not work for a few days after surgery. He or she may need to receive fluids and nutrition through an IV line.
You will receive medicine to relieve pain in the hospital. At first, the medicine may be delivered through a special catheter inserted into your back. After that, a pump may be used to control how much pain medicine you should get. You may also get shots or take pain pills.
In most cases, your surgeon will want you to get out of bed on the first or second day after your surgery. Nurses and physiotherapists will assist you with this activity until you feel comfortable enough to get up and move around on your own. You may have a body cast or a body brace.

Follow any instructions you are given on how to care for your spine at home.

Aftercare at home

Before you are discharged from the hospital, your doctor and other members of the hospital staff will give you additional self-care instructions for you to follow at home – a list of “dos and don’ts,” which you will be asked to follow for the first 6 to 8 weeks of your home recovery.
Some restrictions are as follows:

  • No lifting weights heavier than 2.5 kg.
  • No bending above the waist. It is important to bend from the hips and keep the back straight.
  • No bicycling for 1 month after surgery.
  • The patient may shower seven days after surgery.
  • No sports, running or jumping for 3 months after surgery.
  • There are no permanent restrictions after 6 months of the date of surgery.

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

Remember that it is important to follow up in clinic six weeks after the date of discharge from the hospital.

Recovery

Your spine should look much straighter after surgery. There will still be some curve. It takes at least 3 months for the spinal bones to fuse together well. It will take 1 – 2 years for them to fuse completely. Most patients are able to return to school or work in 2 to 4 weeks after the surgery.
Fusion stops growth in the spine. This is not usually a concern because most growth occurs in the long bones of the body, such as the leg bones. Children who have this surgery will probably gain height from both growth in the legs and from having a straighter spine.