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Clinical Neuroscience News, September 2013

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Adolescent and Adult Scoliosis

Scoliosis is a complex three-dimensional deformity of the spine. The condition causes lateral curves of the spine to the right or left, decreased forward and/or lateral flexion, and asymmetric shoulder and pelvic positioning. In more pronounced cases of vertebral rotation, a rib hump develops on the convex side of the curve and a lesser protrusion on the chest. In more recent years an increased number of patients have been seeing neurosurgeons to correct their deformities.

With fully half of a neurosurgeon’s seven-year-long residency training devoted to spinal disorders, and another year or more of fellowship training specifically in treating deformities, our team of neurosurgical specialists at the Cushing Neuroscience Institute are particularly well-suited to diagnosing and treating the complexities of both adult and adolescent scoliosis.

Not all consultations at the Cushing Neuroscience Institute lead to surgical intervention; our solutions are highly individualized, depending on each patient’s age, discomfort, coexisting conditions, functional limitations, progress of the disease and cosmetic appearance. We begin our evaluation with a series of visual and radiographic tests. A key indicator is the patient’s Cobb angle, a measurement of the angle of curvature of the spine at its apex. An adolescent with a Cobb angle below 40 degrees is usually treated medically with physical therapy and temporary orthotic bracing, on the premise that the developing bone and musculature are still malleable enough to respond to noninvasive correction. Watchful waiting that includes yearly serial radiographic evaluations is the prescribed follow-up, with the understanding that surgery may be needed later.

By contrast, we regard any teenager presenting with a Cobb angle between 40-50 degrees to be in a “gray zone” concerning surgical intervention. Not only is the curve — in being more pronounced — less amenable to easy correction with bracing, but the youngster’s own self-image and level of activity are probably suffering too. We also look at prior history to get any clues as to how fast the curve has progressed and whether there is a family history of scoliosis. Lastly, when we see an adolescent patient with a Cobb angle of 50 degrees or more we start thinking about an operation, the sooner the better, as this degree of deformity is usually a sign that it will continue to grow if unopposed.

A different set of considerations guides our treatment of adult scoliosis. The condition most commonly develops de novo at an older age, though a small percentage of cases actually trace to mild childhood scoliosis that has gone previously undetected. As the spine goes through wear and tear, compensatory ligamentous and muscular stabilizers can no longer maintain alignment, as the natural regional curves of the spine weaken, significant sagittal plane imbalance (upper body pitched forward) may develop. In yet another version — degenerative scoliosis — the condition may arise in later life, particularly as the result of arthritic changes. The disc spaces and facet joints collapse asymmetrically causing coronal plane (sideto- side) imbalances, with frequent nerve
impingement a result.

The most common clinical complaint of adult scoliosis is chronic back pain and radiculopathy (leg pain). The pain may be caused by the unequal tension placed on back muscles and ligaments, or asymmetrical loading, when individual facet joints compress nerve roots as they are pulled out of alignment. Radicular pain and claudication, neurological symptoms including numbness in the extremities, are other common sources of discomfort.

Neurosurgeons tailor surgical treatment options to the patients in order to get the maximum result with the minimum amount of surgery. If conservative treatments have failed and surgery is an option, minimally invasive surgery is considered foremost. However, if open surgery is elected due to the patient's needs, physicians will customize the surgery to the individual patient. Thanks to our unique practice of using intraoperative imaging (C-arm fluoroscopy), and when needed, stereotactic guidance to place pedicle screws, we are able to achieve positive results in the treatment of adolescent and adult scoliosis patients.

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