Sunday, November 18, 2007

"A Stitch In Time Saves 9": Why adult as well as adolescent patients should be followed regularly for evidence of scoliosis and kyphosis progression

This past week, as always,  we saw several younger and older adult patients with scoliosis, as well as adolescents and younger children with scoliosis.
There were a couple of adult patients, however, that were quite memorable.
This patient pictured above had a Harrington Rod fusion done many years ago, and did very well until about 10 years ago when she had some increasing pain.
Over past 4-5 years, she has noticed some changes in her posture, with the most significant change being during past year or 2.
She was not followed routinely for her scoliosis and kyphosis.
She then saught several opinions, who told her that she was not treatable, and put her in a molded brace only.
Her posture continues to fall over the right side, and forward into kyphosis, and her walking ability and pain continue to worsen.

You can see the dramatic change in her X-Rays over just a 5 year period.

LESSON #1: Adult scoliosis curves can be very stable over many years, or progress very slowly, but due to ongoing wear and tear on the discs and facet joints with the asymmetric loading of the curves, the spine can develop segments that become unstable, and begin to collapse and loosen, allowing the curves and slippages (spondylolisthesis) to progress, sometimes dramatically.

LESSON #2: All adults, as well as children and adolescents require follow-up examinations and X-Rays on a regular basis, even if the scoliosis has been “fixed”, as in this case, since the levels above and/or below the fused/instrumented levels can collapse.

LESSON #3: Once progression of the adult curve has been documented, it is better to fix the curves early with surgery, rather than waiting until later.  As you can tell from this woman’s standing posture and current X-Ray, her scolioisis will be difficult to fix, requiring pedicle subtraction osteotomies, cages, and multilevel instrumentation with some removal of her old hardware. Adult scoliosis surgery is always easier when caught earlier since:
  1. Curves are smaller.
  2. Patients are less debilitated, so they recover quicker.
  3. Medically their hearts and lungs are younger, and more able to handle big surgeries.
  4. Patients suffer for fewer months, and are able to get back to decent quality of life.
  5. Patients also have longer to enjoy their new posture and self image / appearance
  6. Bone quality is better with less osteoporosis which allows hardware to hold better to bone, and also decreases chances of fractures at adjacent vertebral levels.
  7. Bones/Fusions tend to heal better.

LESSON #4: If your orthopaedic or neurosurgical spine surgeon tell you that your scoliosis and/or kyphosis is “NOT FIXABLE”, do further research and get second and third opinions from surgeons that have significant experience in adult spinal deformity.  The Scoliosis Research Society (SRS) website is a good place to look here.  You can also ask your local doctors and search the web for your regional scoliosis centers.   I have seen many patients like this one above who have had their treatment delayed because they were told that “NOTHING COULD BE DONE,” which then causes problems with Lesson #3 above.

Lloyd A. Hey, MD MS
Hey Clinic for Scoliosis and Spine Surgery
Raleigh, NC  USA

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