Tag: scoliosis surgery

Wait and see, wait for treatment, wait for surgery…

Posted on January 8, 2020 by - Blog

The UK Scoliosis clinic blog isn’t a political platform, but it’s clear for anyone in the UK to see that in many areas, NHS waiting times are a real problem. What’s perhaps even more of a problem are waiting times to see specialists (and therefore the time to access proactive treatment)  – or indeed, time wasted on a “wait and see” approach to scoliosis progression. The problem is that scoliosis is a progressive condition – if caught early it can often be treated without surgery, but if you wait too long, your options can narrow.

 

Scoliosis, its progressive condition.

In most cases, scoliosis is a progressive condition – to be sure, there are some cases (mainly adult cases) where the risk of progression may be lower, but certainly, in children and young people, the rate of progression can be rapid.

Whereas cases of adult scoliosis (that is to say scoliosis which began in childhood and was carried into adulthood) increase in curvature by approximately 0.82° per year, the rate at which scoliosis increases in young patients depends upon risk factors such as the severity of scoliosis considering age, rigidity of curve, and family history. Research has demonstrated that Juvenile scoliosis greater than 30 degrees increases rapidly and left untreated presents a 100% prognosis for surgery, whereas curves from 21 to 30 degrees are more difficult to predict but can frequently end up requiring surgery, or at least causing significant disability.[1]

With scoliosis, there is, therefore, a very real need to act quickly and proactively if the condition is to be halted and the curvature corrected before either surgery is required, or full correction is no longer possible.

 

Wait to see your GP

For most of us, the GP is the first port of call for all things medical – this is exactly how it’s supposed to be, and while we’re certainly not looking to criticise GP’s, there are a couple of points to keep in mind. Firstly, if you suspect scoliosis, consider the waiting time for a non-urgent appointment at your local doctor’s surgery – scoliosis suspected in younger patients can develop even over a few weeks, so no time should be spared in seeking an evaluation.

Secondly, it’s true that most GP’s do not have specialist training in Scoliosis – and where training is given, the message often reflects out of date attitudes to the condition – specifically, the outdated notion that scoliosis can only be effectively treated with surgery. Because of this, GP’s often lack the specialist training, time and knowledge of the treatments available to do anything other than refer you to a specialist, or, simply ask you to “wait and see”.

 

Wait to see a specialist

With any luck, a visit to your GP will net you an appointment to see a spinal specialist, who, when you finally do get an appointment, will certainly be able to diagnose scoliosis. The problem again is that you may wait many months for such an appointment, during which time scoliosis can continue to progress. Even once scoliosis has been diagnosed, many specialists will still recommend a further “wait and see” approach (which can sometimes last for years) in the hope that the scoliosis may resolve on its own. While this can happen in a very small number of cases, it is incredibly uncommon.

Some specialists are more sympathetic to scoliosis cases, and through training and awareness more and more health professionals are becoming aware of the non-surgical treatments available. You may be offered a brace to help stop scoliosis progressing at this point – but the options available through the NHS are currently limited.

 

Wait for surgery

Some specialists still take the view that scoliosis can only be treated surgically (this is false!) and other times you may be seen by a specialist once scoliosis has developed beyond 45 degrees, which is typically considered the threshold for surgery. Bracing and other non-surgical methods are certainly still possible up to 60 degrees however, and should still be considered.

Recent research by the British scoliosis society[2] has shown that even at this stage, most patients face another long wait for treatment during which scoliosis tends to progress. This 2018 study specifically looked at scoliosis progression whilst waiting for a consultation and eventual surgery. In the study, 41 females and 20 males with a mean age of 11.8 years with a mean Cobb angle (curvature) of 58° were followed –  Average waiting time to be seen in the clinic for an initial consultation was 16 months – thereafter, the average waiting time for surgery was 10 months. Rapid curve progression was seen in twelve patients, of which 10 required more extensive surgery than originally planned. Their mean Cobb angle at presentation was 48° which increased to a mean of 58° at surgery.

 

Scoliosis – DON’T WAIT!

The “wait and see” approach to scoliosis was once prevalent – based on the idea that scoliosis could only be treated with surgery, doctors justifiably took the view that it was better to hope that scoliosis would not progress too much, and would put off the decision to undertake surgery for as long as possible. Today, however, the choice is very different – modern clinics, like the UK Scoliosis clinic, specialise in the non-surgical treatment of scoliosis and can reduce and often totally eliminate scoliotic curves through non-invasive techniques such as active bracing and scoliosis specific exercise.

While we certainly would not discourage you from seeking an opinion from your GP if you have concerns about scoliosis, we strongly recommend that parents of children or teenagers with potential scoliosis also make an appointment with a scoliosis specialist. Rather than waiting months, perhaps years, a scoliosis specialist appointment can usually be arranged with a few weeks, and non-surgical treatment can begin almost immediately.

Perhaps the saddest part about the study from the British scoliosis society was the specific data on the curves of the participants at the beginning of the research. The range of curves studied was between 17°–90°[3], and while a 90-degree curve would certainly be likely to require surgery, a 17-degree curve would almost certainly have not – indeed, a 17 degree curve would be an excellent candidate for the kind of conservative, non surgical treatment we offer at the UK scoliosis clinic.

By the end of the study, the smallest curve was  30°and the largest was 120°. While it is certainly easier to treat a smaller curve,  a 30-degree curve still has a good prognosis with modern conservative treatment through active bracing, such as scolibrace.  This study goes to show that the right information at the right time makes a significant difference in scoliosis cases.  Indeed –  in stark contrast to the above – one recent study of 113 scoliosis patients treated with non-surgical approaches showed that vast majority achieved a significant curve correction and only  4.9% of patients needed surgery.[4]

If you have Scoliosis, or have a child with scoliosis – consider getting a second (or first) opinion from a scoliosis professional, whichever stage of the process you are at!

 

[1] Progression risk of idiopathic juvenile scoliosis during pubertal growth, Charles YP, Daures JP, de Rosa V, Diméglio A. Spine 2006 Aug 1;31(17):1933-42.

[2] H V Dabke, A Jones, S Ahuja, J Howes, P R Davies, SHOULD PATIENTS WAIT FOR SCOLIOSIS SURGERY?  Orthopaedic ProceedingsVol. 88-B, No. SUPP_II

[3] H V Dabke, A Jones, S Ahuja, J Howes, P R Davies, SHOULD PATIENTS WAIT FOR SCOLIOSIS SURGERY?  Orthopaedic ProceedingsVol. 88-B, No. SUPP_II

[4] ‘Brace treatment in juvenile idiopathic scoliosis: a prospective study in accordance with the SRS criteria for bracing studies –SOSORT award 2013 winner‘ Angelo G Aulisa, Vincenzo Guzzanti, Emanuele Marzetti,Marco Giordano, Francesco Falciglia and Lorenzo Aulisa, Scoliosis 2014 9:3 DOI: 10.1186/1748-7161-9-3

Spinal surgery for scoliosis and degenerative disc disease

Posted on September 21, 2019 by - Blog

Scoliosis, if left untreated, tends to progress in most cases – and where this progression is significant enough it can result in significant disability and reduction in quality of life. For this reason, scoliosis is a condition which the medical profession has been keen to treat and treat as early as possible in affected individuals. Stopping scoliosis is the primary objective of any surgical procedure, but unlike non-surgical approaches, there are known complications with surgical interventions. One of the most common is Degenerative Disc Disease (DDD).

 

Treatment options for scoliosis

Today, the treatment options for Adolescent Idiopathic scoliosis include observation, bracing, exercise approaches and surgery, and the general goal is to keep curves under 50° at maturity[1]. Observation, while still recommended by some medical practitioners not specially trained in scoliosis management, is not truly a treatment for scoliosis, and instead simply allows the condition to progress. Non-surgical options, such as bracing and exercise are fast becoming the treatment of choice, with surgery usually preferred as a last resort.

There are three main approaches to scoliosis surgery – these are posterior spinal fusion (PSF), anterior spinal fusion (ASF), or a combination of both. In each case, the goal is to fuse the affected vertebra into the correct position – this results in the targeted vertebra being unable to move, instead fusing into a single unit, but also eliminates scoliosis. PSF remains as the gold standard for the treatment of thoracic and double major curves, which make up most scoliosis cases. ASF is indicated for thoracolumbar and lumbar cases having a normal sagittal profile. A combination of ASF and PSF could also be used for the management of large curves (> 75°) or stiff curves, young age, and to prevent the “crankshaft phenomenon” – a condition in which the posterior fusion of the spine cases a secondary curvature to form as the bones grow.[2]

Although the safety and efficacy of both techniques have been demonstrated[3], many patients and surgeons are increasingly concerned about the long-term outcome of an extensive fusion in terms of spinal function, the development of degenerative disc disease and pain[4]. Weiss et al. reviewed the long-term risks of fusion spinal surgery with respect to scoliosis to enable establishing a cost/benefit relation of this intervention. According to their study, average rate of complications was as high as 44% in adolescent cases, ranging from 10 to 78%. They concluded that long-term complications have not yet been fully evaluated and further studies are needed to address this concern adequately[5].

 

Post-operative complications – new research

Corrective surgery of AIS can result in several benefits for the affected patients including improvements in aesthetics, quality of life, disability, back pain, psychological well-being, and breathing function. This is especially the case for patients whose scoliosis has progressed beyond the range likely to be positively impacted by non-surgical approaches, such as bracing.

These points notwithstanding, surgery is also associated with a variety of complications whose long-term impact is currently poorly understood – these may include  neurological damage, loss of normal spinal function, strain on unfused vertebrae, curvature progression, decompensation and increased sagittal deformity, increased torso deformity, delayed paraparesis, and pseudarthrosis.[6] Degenerative disc disease is however considered one of the most common results of surgery (although it is also associated with scoliosis progression)  and its association with the severity of pain has been reported.[7]

The most recent study looking at this connection was published in 2018[8] and followed a total of 42 AIS patients who underwent PSF surgery. The participants were examined for a range of post-operative complications. The mean age of the surgery was 14.4 ± 5.1 years. The mean follow-up of the patients was 5.6 ± 3.2 years.

On the positive side, the study confirmed that complete fusion of the vertebra was observed in all cases, and no cases of failure of surgical implants were noticed – in this sense, the patient’s scoliosis cases were therefore addressed and halted, which was of course the primary objective. However, according to the most recent study, degenerative disc disease had developed in 6 out of 37 (16%) of the patients. This finding was roughly in line with previous research, which has suggested rates on average of 7%, although rates varied by study.[9]

More concerning however, was the fact that the observed post-operative disability tended to increase over time, a similar study by Upasani et al. also showed an increased pain at 5 years compared with 2 years after AIS surgical treatment[10], and with this in mind the study investigators suggest that possible progression of DDD and associated increases in pain be carefully considered before opting for a surgical procedure.

 

Treating scoliosis without surgery

While it’s clear that for some patient’s surgical intervention may be the best option, even if there is a risk of postoperative complications, recent advances in non-surgical approaches to scoliosis treatment mean that other options exist for far larger numbers of patients then ever before. Scoliosis bracing, for example, is not associated with any long-term complications, save for the possibility of a loss of muscle strength, which is easily mitigated with targeted exercises. While such approaches are necessarily slower to show results than a surgical procedure, the most modern “over corrective” braces (such as the ScoliBrace we offer at the UK Scoliosis clinic) can nonetheless offer a substantial correction, typically over a period of 6 to 12 months.

 

 

[1] Janicki JA, Alman B. Scoliosis: review of diagnosis and treatment. Paediatr Child Health. 2007;12:771–6.

Tari SHV, Mahabadi EA, Ghandehari H, Nikouei F, Javaheri R, Safdari F. Spinopelvic sagittal alignment in patients with adolescent idiopathic scoliosis. Shafa Orthop J. 2015;2(3):e739.

[2] Hasan Ghandhari, Ebrahim Ameri, Farshad Nikouei, Milad Haji Agha Bozorgi, Shoeib Majdi & Mostafa Salehpour  ,Long-term outcome of posterior spinal fusion for the correction of adolescent idiopathic scoliosis Scoliosis and Spinal Disordersvolume 13, Article number: 14 (2018)

[3] Wang Y, Fei Q, Qiu G, Lee CI, Shen J, Zhang J, Zhao H, Zhao Y, Wang H, Yuan S. Anterior spinal fusion versus posterior spinal fusion for moderate lumbar/thoracolumbar adolescent idiopathic scoliosis: a prospective study. Spine. 2008;33:2166–72.

[4] Bridwell KH, Shufflebarger HL, Lenke LG, Lowe TG, Betz RR, Bassett GS. Parents’ and patients’ preferences and concerns in idiopathic adolescent scoliosis: a cross-sectional preoperative analysis. Spine. 2000;25:2392–9.

[5] Weiss H-R, Goodall D. Rate of complications in scoliosis surgery—a systematic review of the Pub Med literature. Scoliosis. 2008;3:9.

[6] Weiss H-R, Goodall D. Rate of complications in scoliosis surgery—a systematic review of the Pub Med literature. Scoliosis. 2008;3:9.

[7] Buttermann GR, Mullin WJ. Pain and disability correlated with disc degeneration via magnetic resonance imaging in scoliosis patients. Euro Spine J. 2008;17:240–9.

[8] Hasan Ghandhari, Ebrahim Ameri, Farshad Nikouei, Milad Haji Agha Bozorgi, Shoeib Majdi & Mostafa Salehpour  ,Long-term outcome of posterior spinal fusion for the correction of adolescent idiopathic scoliosis Scoliosis and Spinal Disordersvolume 13, Article number: 14 (2018)

[9] Jones M, Badreddine I, Mehta J, Ede MN, Gardner A, Spilsbury J, Marks D. The rate of disc degeneration on MRI in preoperative adolescent idiopathic scoliosis. Spine J. 2017;17:S332.

[10] Upasani VV, Caltoum C, Petcharaporn M, Bastrom TP, Pawelek JB, Betz RR, Clements DH, Lenke LG, Lowe TG, Newton PO. Adolescent idiopathic scoliosis patients report increased pain at five years compared with two years after surgical treatment. Spine. 2008;33:1107–12.