Correcting The Curved Spine

Correcting the curved spine

When Laura Bradbard was 12, her mother noticed a lump on her back and was concerned it might be a tumor."It was my rib cage rotating," Bradbard says today, 38 and working as a secretary in Rockville, Md. "The lump was my shoulder blade and ribs protruding out the back. X-rays showed my spine was growing sideways, curving in the shape of an 'S.' The doctor said I should do something about it before it got worse." Sideways curvature of the spine of 11 degrees or more is known as scoliosis. Bradbard's spine was off-center 36 degrees. Bradbard has scoliosis--in her case, it's called "idiopathic," which means the cause is unknown. Some 80 percent of patients have this variety. Other cases are due to birth defects, spinal cord injuries, and nerve and muscle diseases such as muscular dystrophy.

Who Gets Scoliosis?

Showing up during the growth spurt at ages 10 to 15, scoliosis strikes 2 to 3 percent of adolescents. For unknown reasons, it affects more girls than boys--an inequality of about 3.6 to 1 overall, but 10 to 1 when curves are 30 degrees or more. Very mild scoliosis curves, under 20 degrees, are nothing to worry about, doctors say. Even 20-degree curves sometimes improve on their own, with only 1 in 5 worsening, and only 3 in 1,000 worsening enough to need treatment. When curvature gets worse, the spine twists on its center, slowly pulling the rib cage out of normal position. One side of the rib cage becomes higher at the back and sticks out. The ribs inside the curve scrunch together as those outside the curve spread apart. Although most scoliosis curves are "S" shaped like Bradbard's, some resemble a long "C." "As a curve approaches 60 degrees," says Martin Yahiro, M.D., "the distorted rib cage restricts expansion of the lungs, causing breathing problems." Yahiro is an orthopedist (specialist in bone disorders) at the Food and Drug Administration's Center for Devices and Radiological Health, which regulates scoliosis treatment devices.

Why some scoliosis curves worsen and others don't is unknown. The larger the curve and the younger the patient when it's discovered, the greater the chance it will worsen, Yahiro says. Often, the first clue that scoliosis is developing is an uneven skirt hemline or a difference in pant-leg length. Other early warning signs, which might resemble poor posture to an untrained eye, include a hip or shoulder higher than the other, protruding shoulder blade, or tilted head. After a thorough examination to rule out other problems, the orthopedist diagnoses scoliosis and orders one or more x-rays to determine the type and extent of the curve. (A person with scoliosis may also have other abnormal curvatures, which can be detected by x-ray and treated along with the scoliosis. If the normal rounding of the back is too great, the condition is called "hyperkyphosis." If the normal forward curving in the lower back is too great, the condition is called "hyperlordosis.")

The American Academy of Pediatrics recommends screening for scoliosis during routine doctor visits at ages 10, 12, 14, and 16. The American Academy of Orthopaedic Surgeons and the Scoliosis Research Society recommend screening girls at 10 and 12 and boys once at 13 or 14. Many states have scoliosis screening programs in schools.

Tailored Treatment

Decisions about scoliosis treatment depend on the person's age, gender, general health, and potential for growth, as well as severity and location of the curve. For a very mild curve, the doctor may only advise monitoring checkups, with x-rays to detect worsening, every three or foor months or maybe once a year. Even moderate curves of 25 to 40 degrees may not warrant treatment, Yahiro says. "If an 18-year-old no longer growing has a 30-degree curve," he says, "I probably would do no more than monitor it. On the other hand, I'd immediately treat such a curve, and often a slighter one, in a 12-year-old just starting the growth spurt." A severe curve of 40 to 50 degrees or more that's detected early, Yahiro says, would be expected to rapidly get much worse, so he would treat it even more aggressively. Another important factor is the patient's attitude toward treatment. For instance, Yahiro says, a worsening 35-degree curve that could have been treated with bracing may, in fact, need surgery if the young person refuses to wear a brace.

Bracing for Prevention

A nonsurgical treatment for moderate curves (24 to 40 degrees) is a body brace. Not a cure, bracing is intended to check a curve until growth is completed. It can generally straighten a moderate curve. Unfortunately, as happened with Bradbard, some curves return after the brace is no longer worn. Bradbard wore a full torso brace, formed from a cast modeled from her body. It consisted of a molded leather girdle, straps, and a neck ring to hold support bars in position. Together, these parts held Bradbard in a position that kept her rigid from chin to hips. Bolts and buckles permitted adjustments as she grew. "I wore it day and night for 23 hours from eighth grade through 10th," she says, "only taking it off for gym and showers. After a time, it was just part of me. I played neighborhood baseball and basketball and rode a bike wearing it."

But Bradbard's inability to bend meant she couldn't look down, and she had to adjust for this. "I couldn't see the stairs when I was walking," she says, "and I had to carry a desk frame from class to class to hold my books up where I could see them. I had several frames that had belonged to an older girl in school who didn't need her brace anymore." Today, molded braces are available that generally don't show under clothing because they fit close and only come up to the underarms. Although underarm braces are effective for lower chest and lower back curves, a full torso brace works best for a high chest curve. Getting a young person to wear a full brace continuously isn't always successful, says Yahiro, "so it's not used as much as it could be." An alternative treatment is stimulation of muscles alongside the spine during sleep with an electrical muscle stimulator, attached by electrodes placed on the skin. FDA approved stimulators for scoliosis in 1986. But doctors may not want to use this alternative. One study, sponsored by the Scoliosis Research Society, reported success with bracing, but not stimulation. The study was summarized in the fall-winter 1993 newsletter of the National Scoliosis Foundation, Inc.

Surgery

Of the 30,000 to 70,000 spinal surgery procedures done each year, "about a third are probably for severe scoliosis," says Mark Melkerson, who reviews the medical devices used in these procedures for FDA's orthopedic devices branch. "Depending on the patient's age," he says, "doctors usually start considering surgery when a curve exceeds 40 to 50 degrees, to prevent breathing problems." The surgeon attaches steel rods to vertebrae at the top and bottom of the curve with hooks, screws or wires, fusing the vertebrae with bone fragments taken from the hips, ribs, or the spine itself. The healed fusions harden in a straightened position, leaving the rest of the spine flexible. Afterwards, most patients need a brace for about six weeks. "It usually takes three months for everything to fuse," Yahiro says. "Still, we don't say a fusion has failed until after a year." Bradbard had corrective surgery five years ago. She'd gone back to the doctor complaining of back pain, and x-rays showed her curve had progressed to 52 degrees. Since someone past adolescence is no longer growing, why would a scoliosis curve worsen?

Yahiro says that doctors don't yet have a complete answer, but they do know that when the spine is already severely curved, the person's weight is distributed across the abnormal curve. Over time, this stress may make the curve worse. Before Bradbard's surgery, her right hip and ribs practically sat on each other, she says, so that she essentially had no waist. Afterwards, she suddenly was 2 inches taller, thanks to straightening with 8 inches of rods and a fused spine. "For the longest time," she says, "I kept hitting my head when I'd get in or out of the car." When corrective surgery is done before growth is completed, Yahiro says, the patient both gains height from the straightening and loses height from the fusions, which stop growth. The gain and loss tend to cancel each other out, he says. Bradbard's recovery required two weeks in the hospital. But with help, she was sitting for short periods by the second day, and standing for short periods by the third. Unlike patients undergoing scoliosis surgery 15 years ago, Bradbard didn't have to lie in a body cast for months. She didn't even have to wear a brace, though it took a full year before muscle strength returned. The lower end of her curve couldn't be corrected, or she wouldn't be able to bend at all. As a result, one leg is a quarter of an inch shorter, which she compensates for by wearing a heel lift in her shoe. The corrective method her surgeon used is called Cotrel-Dubousset, one of several newer systems for attaching rods to the spine with hooks and screws. Researchers report Cotrel-Dubousset has less than 2 percent loss of correction, compared with 10 to 25 percent loss from the older (Harrington Rod) system. The older system allowed the hooks to rotate, so a body cast was needed to prevent their movement until fusion. "With many of the newer systems," Melkerson says, "the hooks are rigidly fixed to resist rotation." Like any surgery, a scoliosis operation can have complications, such as infection or a bad reaction to anesthesia. Additional risks, though rare, are possibly dislodging a hook, fracturing a fused vertebra, or damaging the spinal cord. Someone facing possible scoliosis surgery should ask the doctor to explain how it will help and how it poses risks, which vary with the patient and method of surgery.

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