Your twelve year old just came home from school with a note from her school nurse. She has scoliosis, a crooked back, and needs to see a doctor. You panic, envisioning your beautiful daughter as a female version of the Hunchback of Notre Dame, and you call your Family doctor or pediatrician for this emergency, only to have the receptionist laugh and say you are the fifth parent who called today after the “routine” screening was done, and don’t worry. The doctor can see you in three weeks…
Well, here is a short summary. I’m just a Family doc, so don’t sue me if I don’t have all the details, but the links will be a help if you have questions about the problem.
Scoliosis is a crooked spine. There are many causes, but the type I am talking about in this essay is the “idiopathic” type. Idiopathic means “who know?”. It usually is in girls, and usually starts in early puberty, and gets worse until the kid stops growing, then remains “stable” (doesn’t get worse for the rest of your life).
Severe scoliosis is a problem, not just because you sort of hunch over, but because the rib cage is crooked, so the bellow action of the rib cage isn’t as good, so there is a danger if you get pneumonia. And when you are older, you get arthritis. But nowadays, few docs see bad cases under age 50. That is because the treatments discussed below became common since the 1950′s. But I’ve seen severe cases in the elderly, and of course in Africa and here in the Philippines.
Scoliosis has been around a long time. According to this article : “…Ancient Hindu religious literature (circa 3500-1800 BC) describes the treatment of spinal deformity rather clearly. The story is told of a woman who was “deformed in three places” and how Lord Krishna straightened her back (Kumar, 1996). This was accomplished by pressing down on her feet and pulling up on her chin. The orthopedic trappings of the story are unmistakable, including excellent immediate posttreatment results and no long-term follow-up…”
(That last sentence is a medical joke. Orthopedists are like mechanics. They fix the patient and then we, the Family docs, end up caring for the person and their problems for the next twenty years).
There is an ongoing controversy about what to do for Scoliosis, at least for what we doctors call Idiopathic Scoliosis. There are other forms due to spine problems, congenital vertebrae problems (born with an extra bone or half bone in your back), tuberculosis or infection, polio, and neurological problems such as cerebral palsy.
About one in seven women develop Idiopathic scoliosis, and many don’t know they have it. The idiopathic type is less common in men.
About twenty years ago, it was decided to screen all girls nearing puberty to find “mild” cases of this problem, and treat it to prevent it from becoming severe. So if you got a letter from the school nurse, try this LINK …another LINK HERE is from Mayo Clinic.
This table gives you the summary on what we do in scoliosis.
None to 20 Degrees: No treatment. Recheck in six months
20 to 30 degrees: Observe or brace…
30 to 40 degrees: Brace
Over 40 degrees. Surgery
Now the “mild” cases are what we usually see in our office. It’s actually easier to see if a person bends over, then the “hump” appears.
But a lot of these women have no symptoms, or just mild back pain, which we treat like ordinary back pain, with NSAIDS (e.g. Motrin, Advil) and exercizes. The muscles act like guidewires holding up a pole, the muscles support the spine. And if your muscles are strong, they are less likely to ache.
So most cases of scoliosis are mild and never get treatment.
And the severe cases, over 50 degrees, get surgery, described HERE
The surgery is complicated. Most adults know someone who has had back fusion. Well, think of a super fusion surgery, and you would be closer to the truth.
There are several techniques, and which one to use depends on the patient and the surgeon. The strangest (or one might say most revolutionary) technique is the Hariington Rod , which essentially is like a car jack. You attach hooks on top and bottom, and ratchet the spine straight. Once it’s straight, you do the fusion, and the person wears a brace until it’ s healed. The article describes several variations of the surgery, but you get the idea.
The brace, alas, doesn’t “fix” the problem: After you stop using it, your spine goes back to where it was. However, a lot of doctors think that it prevents the curve from getting worse.
So when do you treat? Well, under 20 degrees, exercise. Over 50 degrees, surgery. In between, ask a doctor you trust, and follow their recommendations on whether or not you or your daughter should use a brace. The advantage is that it MIGHT keep it from getting worse. The disadvantage is that it’s hot, has to be adjusted frequently, and what teenager wants to wear one.
Some doctors are even questioning if we should screen these girls. Most never get bad enough to treat, but if you pick up a case, the parents want you to X Ray them, and then you are stuck doing X rays every six months. Not only is this expensive, you have the radiation risk to the girl….and of course, some of these sweet young girls get pregnant and don’t mention it to the X ray technician. On top of this you have anxious parents, and sometimes young adolescents are hypochondriacs and over worry about it affecting their life. And, of course, since bad cases do end up with braces or surgery, you can’t tell them not to worry, even if most of them will be okay.
If it were my daughter, I’d use a brace at 30 degrees, but I’ve had two male patients who had 40-50 degree curves and were athletes and didn’t want a brace. Both will probably end up with fusion once they stop growing.
There are Children’s Hospitals in larger Urban areas that specialize in these things, but often the mild cases just go to the local Orthopedic surgeon for a second opinion.
(For those new to an area, the way to find a doctor is to talk to a good nurse and ask her who SHE goes to. The nurses know).
Remember: if you are too shy or intimidated by the doctor who mumbles long complicated medical terms at you, then ask his nurse your questions, or ask if you can phone her later if you have questions. They can check with the doctor and get back to you, and most can translate long complicated medical words into plain English.
Nancy Reyes is a retired physician living with her husband in the Philippines. Her webpage is Finest Kind Clinic and Fishmarket . She often blogs on medical matters at Hey Doc Xanga blog .