Scoliosis Treatment

Advancement of technology has brought about a lot of changes in the treatment of Scoliosis. Scoliosis is not a disease and the affected person can lead a normal life like others. Clinical treatment varies with the character of Scoliosis. Most of the treatment is based on the inhibition of Scoliosis progression and surgical correction of the deformity.

The clinical management of Scoliosis composes of four parts:

a. Observation

b. Physiotherapy

c. Bracing

d. Surgery

Clinical Management

Observation and mild physical therapy are for the clients who have a moderate size curves from 0 to 20. Many times Scoliosis below 20 is self limiting and doesn’t need medical treatment. The physician will measure the curve on a regular schedule and base treatment decisions on the rate of curvature progression. This is mainly for the clients at growing stage. (Infantile scoliosis, Juvenile Scoliosis and Adolescent scoliosis) .
Physiotherapy
The Schroth method is the widely implemented physiotherapy method for treating scoliosis. It has been used successfully in Europe since 1920.

Schroth method is based on the thesis that scoliosis always involves asymmetrical muscle groups in the back and elsewhere, which in normal bodies are more evenly symmetrical, that can be at least partially corrected by targeted exercises.
It is a noninvasive, physiotherapeutic treatment, developed in Germany by scoliosis sufferer Katharina Schroth. Now as the part of health education, this procedure is taught to scoliosis patients in clinics specifically devoted to Schroth therapy in Germany, Spain, England and North America.

The indications for treatment depend on degree of curvature, maturity of the patient, and the individual curve pattern. While evidence supporting such conservative, non-invasive treatments is weak, today conservative management of scoliosis can be regarded as being evidence-based; no substantial evidence has been found to support surgical intervention.
Bracing

Braces are used to restrict the progress of scoliosis. It restricts the increase in spinal curvature and protects the client from developing complications. There are different types of scoliosis braces:

1. Thoraco-Lumbo-Sacral-Orthosis (TLSO)
In a TLSO brace the posterior portion of the brace extends from the sacrococcygeal junction to just inferior of the scapular spine. This excludes elastic or equal shoulder straps or other strapping. The anterior portion extends from the symphysis pubis to the xiphoid. Some TLSO’s may require the anterior portion to extend up to the sternal notch.

The most common form of a TLSO brace is called the “Boston brace”, and it may be referred to as an “underarm” brace. This brace is fitted to the client’s body and custom molded from plastic. It works by applying three-point pressure to the curvature to prevent its progression. It can be worn under clothing and is typically not noticeable. The TLSO brace is usually worn 23 hours a day and it can be taken off to swim, play sports or participate in gym class during the day. This type of brace is usually prescribed for curves in the Lumbar or Thoraco-lumbar part of the spine.

2. Cervico-Thoraco-Lumbo-Sacral-Orthosis (known as a Milwaukee brace)
The CTLSO brace was originally designed by Blount and Schmidt in 1946 for postoperative care when surgery required long periods of immobilization. The Milwaukee brace (CTLSO) is similar to the TLSO, but includes a neck ring held in place by vertical bars attached to the body of the brace. It is usually worn 23 hours a day. This brace is normally used with growing adolescents to hold a 25° to 40° advancing curve. The brace is intended to minimize the progression to an acceptable level, not to correct the curvature. For corrective measures, special exercises or physical activities are used. If the curvature continues despite the brace, surgery may be required. Like TLSO brace, Milwaukee brace can also be taken off while doing activities during the day. This type of brace is often prescribed for curves in the Thoracic spine.

3. Charleston Bending Brace
Charleston bending brace is otherwise known as “night-time” brace because it is only worn while sleeping. A Charleston back brace is molded to the patient while they are bent to the side. When the child bend against the curve, pressure is generated and it helps to improve the corrective action of the brace. Nighttime only wear frees the adolescent of the negative body image so often associated with this type of treatment, allowing full participation in normal, social, athletic, and academic activities. Curves must be in-between 20 – 40 degree range and the apex portion of the curve needs to be below the level of the shoulder blade for the Charleston brace to be effective.

SURGICAL MANAGEMENT

Surgery is the most effective treatment at present through which the progression of scoliosis is effectively blocked and the condition can be reversed in most cases. Surgical management is the only option for the clients having progressive scoliosis over 50 degree curvature of spine in order to protect internal organs. Surgery is also performed if the deformity is cosmetically unacceptable to the client.
Surgery is the preferred option if,

1. The client is having progressive scoliosis over 50 degree curvature of spine.

2. Deformity is cosmetically unacceptable to the client.

3. Clients with Spina bifida and cerebral palsy

4. Curves that affect physiological functions such as breathing and cardiac functions.


Fig 1.Scoliosis treatment: before and after surgery

The main types of surgeries are:
§ Anterior fusion: In this procedure an incision is made at the side of the chest wall for surgical approach.
§ Posterior fusion: It involves the use of a metal instrument. In this procedure an incision is made on the back for the surgical approach.
One or both of these surgical procedures may be needed. The surgery may be done in one or two stages and, on average, will take four to eight hours.

Spinal fusion with instrumentation

Spinal fusion composes of two parts:
· Fusing the vertebrae along the curve
· Supporting these fused bones with instrumentation (steel rods, hooks, and other devices) attached to the spine


Fig 2.Implimentation of instruments

In this surgical procedure, bone obtained from elsewhere in the body (autograft) or from a donor (allograft) is grafted to the vertebrae. Gradually, they will form one solid bone mass and the vertebral column becomes rigid. This can be performed by anterior (front) aspect of the spine by entering the thoracic or abdominal cavity or, more commonly, performed by posterior (back) aspect. A combination of both aspects may be used in more complicated condition.

Cotrel-Dubousset instrumentation
The technique of using a combination of rods, screws, hooks, and wires fixing the spine, to apply stronger, safer forces to the spine is known as the Cotrel-Dubousset instrumentation. This is the most effective technique available currently.
Thoracoplasty

Thoracoplasty is the procedure of shortening selected ribs in the thoracic or chest area. This procedure is done to reduce the size and severity of a rib hump which may accompany scoliosis. This procedure is also called costoplasty rib hump is evidence that there is some rotational deformity to the spine. Thoracoplasty may also be performed to obtain bone grafts from the ribs instead of the pelvis, regardless of whether a rib hump is present. Thoracoplasty can be performed as part of a spinal fusion or as a separate surgery.
Surgery without fusion
Researches and studies conducted on Scoliosis are novel and promising. Advanced proimplants that aim to delay spinal fusion and to allow more spinal growth in young children have been developed. The cases in which thoracic insufficiency compromises physical ability to breathe and applies significant cardiac pressure, ribcage implants that push the ribs apart on the concave side of the curve may be especially useful. These vertical expandable prosthetic titanium ribs (VEPTR) provide the benefit of expanding the thoracic cavity and straightening the spine in all three dimensions while allowing it to grow.
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References:
Scoliosis: Causes, Tests and Treatments by John Hewitt MA and Mohamed Awad MD
Scoliosis and the Human Spine – National Scoliosis Foundation
The National Center for Biotechnology Information – U S A

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