When the Spine Curves: Treatments for Scoliosis

The Treatment of Scoliosis

Why Surgery?

Surgery as a treatment for scoliosis was first performed in 1911 by Dr. Russel Hibbs. He performed the first spinal fusion in the New York Orthopedic Hospital. Bone grafts from the hip were placed between each vertebra and fused into place. Patients endured a long period of postoperative casting, which immobilized them and provided stability while the spine healed. Surgical techniques have improved since Hibbs' time; it was found that the placement of metal rods on either side of the spine speeded recovery and stabilized the bones, without the use of casts.

As in bracing, the goal of surgery is to halt the progression of a scoliotic curve. Stabilizing the pelvis and aligning it with the neck is also important in preventing progression. This, and stabilizing the spine itself, are two of the aims of surgery. The third, but less important focus, is straightening the spine as much as its curvature will allow.

Surgery may be recommended for patients who have a progressive curve of 50 degrees or greater, or whose spines remained untreated into adulthood. Many untreated adults have surgery only to decrease back pain that has not responded to medication. Preventing loss of heart and lung function, seen in severe thoracic curves only may also be a reason to recommend surgery. Halting the progression of the curve is considered the primary goal in all cases.

18. X-ray of scoliotic spine before surgery Thoracic curve of 40 degrees circa 1997 Courtesy of Stuart Weinstein, MD, UIHC Department of Orthopaedics

19. X-ray of spine with Luque instrumentation circa 1998 Courtesy of Stuart Weinstein, MD, UIHC Department of Orthopaedics

For some patients, such as those with congenital scoliosis, no treatment other than surgery is recommended. Braces may fail or the degree of curvature may be too great for other treatment to work. A curve must be 40 degrees or more for surgery to be performed with no prior treatment. Surgery will also be the first option to a skeletally mature patient with a curve of 50 degrees or more. In this case, the curve has become so deforming and debilitating that surgery is required. Adults who have scoliosis accompanied by severe pain may also require surgery.

Surgical Procedures for Scoliosis

Pre-operative
When planning a surgery for scoliosis, a physician measures the patient's spine flexibility, postural abnormalities and difference in leg lengths caused by curvature. Muscle strength, neurological status and respiratory abilities establish a baseline to maintain after surgery.

Spinal Fusion
Posterior and anterior spinal fusion use metal rods placed on both sides of the spine to stabilize and correct scoliotic curves. Hooks and wires attach the pre-bent rods to the spine, pulling the spine into a straighter position and supporting the bone grafts. The rods are removed only if complications or pain arise.

Post-operative
A decrease in lung volume is common among patients with congenital scoliosis, making observation of pulmonary function necessary. Patients with infantile or juvenile scoliosis may develop the "crankshaft phenomenon" after surgery. In these cases, one side of the spine continues to grow while the other has been fused and can no longer grow. This can be easily prevented by fusing both the posterior and anterior sides of the spine.

Immediately after surgery, the patient is usually confined to bed with regular doses of pain medication and rolling exercises to stimulate back muscles. On the second day of recovery, most patients sit up in a chair. Walking begins on the third day with few problems. After seven days in the hospital, the patient usually returns home with mild medication. Children and adolescents can return to school, and adults can return to work after 2 to 3 weeks. Most other activities can be resumed at this point without the complications or restrictions of bracing and casting, which are generally not necessary after surgery.

20. Patient before surgery 1997 Courtesy of Stuart Weinstein, MD, UIHC Department of Orthopaedics

21. Patient after surgery 1998 Courtesy of Stuart Weinstein, MD, UIHC Department of Orthopaedics