Adolescent Idiopathic Scoliosis
Adolescent Idiopathic Scoliosis (AIS) is a lateral (side) curvature of the spine that can occur in children aged 10 to maturity. The spine may curve to the left or right. Sometimes AIS may start at puberty or during an adolescent growth spurt.
Symptoms of scoliosis include back pain, leg length discrepancy, an abnormal gait, and uneven hips. Patients with AIS may have one shoulder higher than the other, a "prominent" shoulder blade and rib cage when bending forward, and visible curving of the spine to one side. Often the first indication of AIS is when an adolescent or parent notices that clothes no longer fit correctly (for example, the legs of pants may seem uneven). It is important to seek treatment for AIS because progressive scoliosis, left untreated, can result in significant deformity. The deformity can cause marked psychological distress and physical disability, especially among adolescent patients. Additionally, the deformity can have serious physical consequences. As the vertebrae (spinal bones) rotate, the rib cage is affected, which in turn can cause heart and lung compromise (i.e. shortness of breath). When progressive scoliosis affects the lumbar spine the pain can be debilitating.
Dr. Lonner’s assessment of the child’s condition will include medical history, physical and neurological exam, and diagnostic tests. Medical history may include questions about the parent’s genealogy. Are there other family members with scoliosis? If so, how did the scoliosis progress and what treatment was provided? Dr. Lonner will check for any underlying medical condition that might otherwise be causing the scoliosis. In addition, the patient’s age, onset of puberty, and age at which a young woman has her first period, will help us to determine the number of years that remain before the child reaches skeletal maturity. At skeletal maturity curve progression may stop as long as the curve is less than 40-45 degrees. The curve may continue to progress throughout adulthood, if the curve exceeds 40-45 degrees.
Non-Surgical Treatment Some cases of AIS can be treated non-surgically and others require surgical intervention. Small curves (those less than 15-20 degrees) are observed for possible progression over a period of time. At this stage, no specific treatment is needed. Larger curves (those between 20-40 degrees) will require bracing to prevent further progression of the curve. Some adolescents find wearing the brace 16 to 23 hours every day difficult. Braces can be uncomfortable, unattractive, hot, and can make a child self-conscious even though well disguised under clothing. However, when bracing works and surgery is avoided, the commitment required is worthwhile. At this point a carefully designed exercise program may also be recommended. Unfortunately, some curves do not respond to bracing. Cervicothoracic curves (from the middle of the back up into the neck) and curves greater than 40 degrees tend not to respond well to bracing. Also, older patients who are closer to skeletal maturity may not respond to bracing. Surgical Treatment Surgery may be recommended for curves in excess of 40 degrees. Surgery for scoliosis involves special surgical implants such as rods, hooks, screws, and wires. The goal is to straighten and balance the spine and secure it in place (fusion) so curve progression stops while skeletal maturity is reached. Surgery does not cure scoliosis; it is simply a way to correct the curve and manage the progression of the disease to avoid greater deformity. Spine surgeons utilize various surgical procedures to treat AIS. The overall goals are always the same, but the techniques and instrumentation used will vary from case to case. Dr. Lonner may perform the procedure from the front (anterior) or from the back (posterior). He may even make extensive use of minimally invasive techniques. For those patients who are surgical candidates, a number of approaches are available. The approach best suited for the individual is chosen by Dr. Lonner based on the size of the curvature, the extent of the curvature (number of levels of the spine involved), the specific location of the curvature, as well as the age of the patient. Each approach has its distinct advantages that make it suited for the individual patient. The thoracoscopic approach allows for correction of thoracic curvature in the adolescent patient. This is done through the side of the chest cavity with very small incisions. The advantage of this approach is that minimal scarring occurs and the pain after surgery is less than with traditional approaches. In addition, this technique is associated with less blood loss and fewer levels of the spine being fused than with other techniques. This approach is not for all patients and Dr. Lonner will discuss the application of this technique when appropriate (see article on thoracoscopic surgery).