Rudolph F. Taddonio, M.D.
Scoliosis and Spinal Surgery

What Are Spinal Deformities?

When the body is viewed from behind, a normal spine appears straight. (Fig. la) However, when a spine with scoliosis is viewed from behind, a lateral or side-to-side curvature may be apparent. This gives the appearance of leaning to one side and should not be confused with poor posture.

When the trunk is viewed from the side, the spine will demonstrate normal curves. The upper chest area has a normal roundback, or kyphosis, while in the lower spine there is a swayback, or lordosis. (Fig. 2a) Increased roundback in the chest area is correctly called hyperkyphosis while increased swayback is termed hyperlordosis. (Fig. 2b) Changes from normal on a side view frequently accompany scoliosis changes.

What Are the Signs of Scoliosis?

1. One shoulder may be higher than the other.
2. One scapula (shoulder blade) may be higher or more prominent than the other.
3. With the arms hanging loosely at the side, there may be more space between the arm and the body on one side.
4. One hip may appear to be higher or more prominent than the other.
5. The head is not centered over the pelvis. (Fig. 3)
6. When the patient is examined from the rear and asked to bend forward until the spine is horizontal, one side of the back appears higher than the other.

What Causes Scoliosis?

Eighty-five percent of people with scoliosis have the "idiopathic" type. "Idiopathic" means "no known cause." It commonly affects adolescents as they complete the last major growth spurt. Idiopathic scoliosis frequently runs in families and may be due to genetic or hereditary influences. Idiopathic scoliosis may appear at any age but most often appears in early adolescence. At this age young people are reluctant to allow their bodies to be seen by parents and other adults. As a result, the Scoliosis Research Society and the American Academy of Orthopaedic Surgeons have endorsed school screening programs to detect scoliosis curves before they may become advanced. In contrast to idiopathic scoliosis, there are several less common types of scoliosis which do have a known cause. These curves may be due to defects of spinal vertebrae already present at birth ("congenital scoliosis"), disorders of the central nervous system such as cerebral palsy, muscle diseases (muscular dystrophy), disorders of connective tissue (Marfan's syndrome), and chromosome abnormalities (Down's syndrome).

Who Gets Scoliosis?

In childhood, idiopathic scoliosis occurs in both girls and boys. However, as children enter adolescence, girls are five to eight times more likely to have their curves increase in size and require treatment.

What Should Be Done?

In ninety percent of cases, scoliotic curves are mild and do not require active treatment. In the growing adolescent, it is very important that the curves be monitored for change by periodic examination and standing X-rays as needed. Increases in spinal deformity require evaluation by an orthopaedic surgeon to determine if brace treatment is required. In a small number of patients, surgical treatment may be needed.

What Factors Determine Treatment?

1. Age in years.
2. Bone age (the maturation of bone is not always the same as the chronological age).
3. Degree of curvature.
4. Location of curve in the spine.
5. Status of menses/puberty.
6. Sex of the patient.
7. Worsening of curve

What Causes Abnormal Kyphosis?

Kyphosis (roundback) is commonly used to refer to excessive curvature of the thoracic spine when viewed from the side. (Fig.5a-b) Excessive roundback deformity may simply be postural and can often be corrected with exercises and proper posture. A small percentage of patients with kyphosis have more rigid deformities than the postural type, which are associated with wedged vertebrae. This type is called Scheuermann's kyphosis and is much more difficult to treat than postural kyphosis. Its cause is unknown. Bracing may be recommended for the immature adolescent with Scheuermann's kyphosis.

Brace Treatment for Spinal Deformity

Brace treatment (orthosis) is recommended for increasing scoliosis or kyphosis in the skeletally immature patient. Bracing is recommended for moderate scoliosis or abnormal kyphosis. There are many types of braces, all designed to prevent curves from increasing as the adolescent grows. The orthosis acts as a buttress for the spine to prevent the curve from increasing during active skeletal growth. Braces will not make the spine straight, and cannot always keep a curve from increasing. However, bracing is effective in halting curve progression in a significant percentage of skeletally immature adolescents.

What Does Successful Brace Treatment Require?

1. Early detection while the patient is still growing.
2. Mild to moderate curvature.
3. Regular examination by the orthopaedic surgeon.
4. A well-fitted brace.
5. A cooperative patient and supportive family.
6. Maintenance of normal activities, including exercise, dance training, and athletics, with elective time out of the brace for these activities as supervised by the physician.

What Happens if the Curve Requires Surgery?

When a young person exhibits a worsening spinal deformity, surgical treatment is indicated to improve the deformity and to prevent increasing deformity in the future. The most common surgical procedure is a posterior spinal fusion with instrumentation and bone graft. The term "instrumentation" refers to a variety of devices such as rods, hooks, wires and screws, which are used to hold the correction of the spine in as normal an alignment as possible while the bone fusion heals. The instrumentation is rarely removed. A number of factors influence the recommendation for surgery:

1. The area of the spine involved
2. Severity of scoliosis
3. Presence of increased or decreased kyphosis
4. Pain (rare in adolescents, more common in adults)
5. Growth remaining
6. Personal factors.

Operative Considerations

The goal of surgery is to fuse the spine at the optimum degree of safe correction of the deformity. There are always risks that accompany any surgical procedure. These should be discussed with your orthopaedic surgeon. Some important points in planning your surgery are:

1. A comprehensive preoperative conference
2. Donating your own blood (if possible)
3. Good nutritional status before and after surgery
4. Exercise program before and after surgery
5. Positive mental attitude

The Scoliosis Research Society has prepared this booklet to provide patients, and in the case of children, their parents, with a better understanding of scoliosis, its diagnosis and management, using idiopathic scoliosis-the most common type-as a model. This information is intended as a supplement to the information your physician will provide you. Just as no two individuals are exactly alike, no two patients with a spinal deformity are the same. Therefore, your orthopaedic surgeon will be the most important source of information about the management of your particular spinal problem.

It is beyond the scope of this booklet to discuss technical details concerning the surgical correction of scoliosis and kyphosis. Therefore, only a general review of these procedures has been included in the section dealing with surgery.