Emily Stankoski, MSPA, PA-C
Physician Assistant, Orthopaedics and Spine, Shriners Hospitals for Children-Philadelphia
Philadelphia, PA
Curvature of the spine, otherwise known as scoliosis, was defined by Hippocrates as a concern dating back to ancient Greece, 400 BCE. Despite significant advances in public health and medical care, thousands of years later scoliosis is still present in approximately two-four percent of the population. Of these, more than half (65 percent) are of idiopathic etiology or have “a disease of its own kind.”2 Early detection is key in preventing progression of scoliotic curvatures which can lead to significant medical problems and disability. Bracing, the most common initial non-operative treatment, is effective and very low risk. Recent studies have shown that appropriate initiation of bracing can prevent moderate scoliosis from reaching a surgical threshold. An article published in the New England Journal of Medicine titled Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST), demonstrated 72 percent of adolescent idiopathic scoliosis (AIS) patients who were braced 13+ hours per day avoided the need for surgery (less than 50 degrees).4
With routine screenings for scoliosis regularly performed in schools and pediatrician offices in the United States, patients with scoliosis should be found early; thus avoiding disability and often the need for surgical intervention. However, without good screening programs, our children suffer like many foreign patients who have limited access to these resources and are undertreated as a result. At Shriners Hospital for Children in Philadelphia, we treat many international patients for scoliosis, the majority of which have severe deformity that has been left undertreated or undiagnosed.
Recently, for example, a 12-year-old patient from the Philippines initially presented to our clinic with a 140 degree right thoracic and 69 degree left lumbar curvature. She had been diagnosed with juvenile idiopathic scoliosis as a young child, but due to lack of close follow-up and bracing, her curvature progressed significantly. Due to the magnitude of her scoliosis, we proposed a staged procedure that included:
- A specialized form of traction (Halo gravity traction) for six weeks; and
- A 2-stage posterior spinal fusion from T3 to L4.
The surgery was successful with full recovery, and she has since returned to her home in the Philippines.
Untreated or undertreated scoliosis may not only lead to severe cosmetic deformity but also compromise cardiac and pulmonary function when curves exceed 90 degrees. Although early detection and bracing may not prevent surgery in all cases, it may help preserve functional levels when planning for posterior spinal fusion. A review by the Scoliosis Research Society International Task Force in 2013 showed moderate evidence that screening leads to referral and detection at an earlier stage.1 However, a recent study of a Minnesota county that had stopped the comprehensive school screening program resulted in mean curve magnitude and rates of bracing at presentation statistically increased at new evaluations of scoliosis.3 Unfortunately, here in the United States, many school screening programs continue to be disbanded in favor of cost-effectiveness. The clinical outcomes of this trend are yet to be determined but may place more emphasis on the role of parents and primary care physicians in the future screening processes. Clearly, scoliosis prevention through early detection and intervention is a sound investment.
Innovations have pushed forward in several areas for these patients. New brace technology, including specialized night braces, are trying to increase compliance with bracing and diminish the impact on quality of life. Surgical interventions have become safer and faster, using stereotactic guidance systems along with 3-D printing for surgical planning. Post-operative collaborative care has reduced the length of hospitalization, the use of opioid narcotics and negative impact on school work. While there is still much room for progress, pediatric neurosurgeons continue to work on behalf of scoliosis patients and their families to provide them with the best treatment possible.
References:
- Labelle H, Richards SB, De Kleuver M, et al. Screening for adolescent idiopathic scoliosis: an information statement by the scoliosis research society international task force. Scoliosis 2013;8:17
- Nachemson AL, Lonstein JE, Weinstein SL. Report of the Prevalence and Natural History Committee of the Scoliosis Research Society. Denver: Scoliosis Research Society, 1982
- Thomas JJ, Stans AA, Milbrandt TA. Does School Screening Affect Scoliosis Curve Magnitude at Presentation to a Pediatric Orthopedic Spine Deformity 2017;6:403-408
- Weinstein SL, Dolan LA, Wright JG, Dobbs MB. Effects of bracing in adolescents with idiopathic scoliosis. N Engl J Med 2013;369:1512-21
