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The curvature progressed
despite the Harrington Rods. Correction was achieved
by the use of thoracic pedicle screws.To view his
case, click here.
To read a post-surgery interview about his surgery,
click here |
Once skeletal maturity or growth is completed,
a patient with adolescent idiopathic scoliosis is now
said to have adult idiopathic scoliosis. The distinction
is important for while a patient with Adult Idiopathic
Scoliosis may still need treatment for progression, pain
is a much more common indication for treatment. Normal
degenerative changes of the spine may be accelerated
by curvature and the patient with adult idiopathic scoliosis
may be at higher risk for skeletal pain or extremity
pain due to nerve compression. If treated, adult idiopathic
scoliosis should never lead to neurologic (paralysis)
or cardiopulmonary (heart or lung failure) deterioration.
The goal of treatment in patients with adolescent idiopathic
scoliosis is to prevent the curve from progressing past
40 degrees. The importance of the 40 degree mark is that
bracing becomes ineffective at this curvature for mechanical
reasons. Of secondary importance though is the statistical
finding that in adults, curves less than 40 degrees rarely
progress and when they reach 50 degrees, they may increase
at mean rate of 1degree/year. Studies have also shown
that at 60 degrees, pulmonary function (breathing health)
may deteriorate and at 100 degrees, severe cardiopulmonary
dysfunction is seen. The orthopedic spine surgeon will
commonly use these curve measurements as parameters for
treatment.
Evaluation of the adult with scoliosis always starts
with a careful history and physical examination. Documentation
of pain location and duration are critical for individualizing
treatment. A patient with a gray area curve measuring
49 degrees may be complaining of radiculopathy or nerve
pain in the leg or arm which may be amenable to local
treatments such as steroid blocks. In these cases, treatment
of the curve may take on secondary importance. The physical
examination may reveal decompensation of the trunk. As
the spine ages, it becomes less flexible. Compensatory
curves in a child may not be able to balance the curves
as that child becomes an adult leading to decompensation
or imbalance of the head relative to the pelvis. For
example the patient may find herself leaning to the left
or right or leaning forward when standing or walking.
Decompensation can cause pain due to the fatiguing of
muscle as it attempts to "right" the imbalanced
spine (for further discussion, see Flatback section.)
Scoliosis x-rays in the standing position are critical
in evaluating the patient. Size, location, and balance
of the curves help determine the best treatment for the
individual. CT and MRI scans sometimes are necessary
to better evaluate points of nerve compression. If pain
is the major complaint by the patient, treatment similar
to patients with non-scoliotic spine pain may be attempted.
These consist of anti-inflammatory medications, physical
therapy, professional spinal manipulation, steroid blocks,
and cardiopulmonary rehabilitation. A course of bracing
may be helpful to alleviate symptoms temporarily, although
it should be kept in mind that all bracing tends to produce
muscle weakness from disuse atrophy. Antidepressant medications
have been shown in select individuals to allow the more
effective implementation of conservative measures through
behavioral mediated pain reduction. Surgery is reserved
for progressive curves over 50 degrees or painful curves
refractory to conservative treatment. Cosmesis is a rare
indication for surgery due to the unpredictability of
esthetic results. |
A patient should understand the risks/benefits of any surgical procedure and
surgical decision-making should be individualized to the patient. Expected
results should include 70-95% pain reduction although the frequency of
painful intervals may not change. Curves can routinely be corrected to
40% of there original size, but the surgical goal should more importantly
be viewed as producing a fused spine that leaves the patient balanced (for
a complete discussion of the importance of balance in spinal fusion surgery
see spinal balance).
Surgical strategy will depend on the location of the
curve, the size of the curve, whether the patient presents
with or without a balanced spine, and whether spine pain
or nerve root compression are the presenting complaints.
In general, thoracic curves that are stiff, unbalanced
or greater than 60 degrees will require an anterior disc
removal and fusion, followed by a posterior fusion with
instrumentation. Almost complete correction of the curves
can be achieved by the use of thoracic pedicle screws. See
examples of Scoliosis cases Dr. Pashman has perfomed.
Commonly, the anterior surgery can be accomplished by
thoracoscopic, or video assisted techniques. In limited
cases, anterior only fusion with instrumentation can
be attempted. Smaller, balanced thoracic curves with
associated flexible compensatory lumbar curves can be
approached posteriorly with fusion and instrumentation.
To view video of pedicle screw insertion, click on the
picture below. This is video of a surgical procedure,
and may not be suitable for all audiences |
In my hands, lumbar curves that don't
involve L5 or the sacrum are best corrected with anterior
fusion and instrumentation. In the lumbar spine,
nerve pain may require decompression by standard laminotomy
techniques (see microdecompression).
Because of the specialized nature and infrequent, but
not rare complications of these types of procedures,
the patient considering surgery should chose a surgeon
with specialized training and experience in treating
the patient with adult idiopathic scoliosis.
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