Adolescent Idiopathic : Associated Factors, Progression, and a Risk-Benefit Analysis of Treatment Options Davis, Bonnie E.

ABSTRACT

Objective: The purpose of this paper is to discuss the associated factors of adolescent idiopathic scoliosis (AIS), the progression of AIS, and to compare conservative vs. surgical management of AIS with respect to the benefits, risks, and costs of each. After reviewing the literature, a conclusion will be made as to which type of management has the most reasonable and beneficial approach.

Methods: Research literature covering AIS was obtained through colleagues, databases such as PubMed, and relevant websites.

Discussion: Associated factors of AIS include female gender and genetic predispositions, respiratory deficiency, melatonin-signaling pathway deficiencies, pes cavus, and high platelet calmodulin levels.

Treatment options for AIS patients include conservative care (electric stimulation, manual therapy, bracing, acupuncture), and surgical care, which may also include post-surgical bracing.

Conservative care has shown some promising results for both immediate and long-lasting effects on scoliotic curvatures. Side effects are limited due to the non-invasive procedures.

Surgical management of AIS can be very effective at immediate curve reduction, however long- term results may not be as promising. It also has many more serious side effects such as implant failure, infections, and decreased spinal range of motion.

Conclusion: Due to numerous factors involved in the development of AIS, a holistic approach must be taken when dealing with these patients. Surgical management, due to its cost, its risks, and its limited applications for AIS patients should be considered a last option for most patients with AIS.

Key Words: Adolescent Idiopathic Scoliosis, Melatonin, Pes Cavus, Platelet Calmodulin, , , Manual Therapy, Chiropractic, Acupuncture, Thoracoplasty, Harrington rod

2 INTRODUCTION The History, Prevalence, and Treatment of Scoliosis

Scoliosis has been a recognized deformity of the human body for thousands of years. The deformity was first described by Hippocrates (430-370 B.C.)38, and the term "scoliosis" was first coined by Galen (131-201 A.D.). Just recently, however, did the Scoliosis Research Society

(founded in 1965) solidify the term. The agreed upon definition of scoliosis is a deviation of the spine in which there is a curvature of 10 degrees or more, as measured by the Cobb method, and the spinous processes of the vertebrae involved are directed towards the concavity of the curvature.

The prevalence of scoliosis is estimated to be between two and four percent, and it effects all countries and all races. Scoliosis is not just a skeletal problem, however. Its consequences reach much further, affecting the gross physiology and psychology of the patient. Therefore, having the tools to effectively treat scoliosis is an asset to any doctor.

Scoliosis is rapidly progressive during the periods of growth in adolescence20. However, a less known fact is that most scoliotic curvatures continue to progress after the end of a person’s growth, the average having been found to be 0.4 degrees per year2. Because of this, it is imperative that doctors approach all scoliosis cases, regardless of the age of the patient, with a degree of seriousness.

Today, doctors choose to manage scoliosis in a number of different ways. The most common type of scoliosis treated is adolescent idiopathic scoliosis (AIS), which describes one or multiple curvatures found in young adults that has/have developed from unknown reasons. AIS makes up roughly 90% of all cases of scoliosis in North America49. Treatment options for these patients include surgical intervention and conservative treatments (chiropractic adjustments,

3 strengthening and rehabilitative , bracing, and acupuncture, among others). The effectiveness of each of these types of treatment has been evaluated.

Topics that will be discussed in this paper include factors known to be associated with

AIS such as gender & genetics, respiratory deficiency, melatonin levels, pes cavus, and platelet calmodulin levels. After which, the natural progression of untreated AIS will be discussed.

Finally, the treatment options for AIS, the effectiveness, and the estimated costs of these treatment options (surgical vs. conservative) will be compared.

METHODS

Most of the articles used for this review were graciously donated by a chiropractic colleague of the author.

Other sources of information for this review included various internet sites dedicated to scoliosis and research databases such as PubMed.

DISCUSSION

Associated Factors

Gender and Genetics

The incidence of mild scoliotic curvatures that are noted during school screenings is relatively equal between girls and boys, with a ratio of 1.2:147. However, the ratio jumps up to

8:1 in favor of girls when moderate to severe forms of scoliosis are compared between genders8.

Girls are also more at risk for severe progression of AIS than boys are, with a ratio of 3.6 to 149.

The prevalence of scoliosis has been observed to be higher among relatives than it is within the general population18. With mothers who had a scoliotic curvature of more than 15

4 degrees, one researcher found that their daughters showed a 27 percent prevalence of the disorder26. In addition, monozygous twins have shown a 73 percent concordance rate, while dizygous twins have shown a concordance rate of 36 percent22. Ogilvie et al concluded that

“Nearly all (97%) AIS patients have familial origins”46.

With these observations, the role of genetic factors for scoliosis has received much support. Several studies have been done to look at the type of inheritance pattern of scoliosis

(dominant, recessive, or multifactorial)59, and whether or not scoliosis is an X-linked trait15,43. In the end, studies have supported both dominant, recessive, and multifactorial patterns of inheritance59, and have also found that X-linkage has been supported in some, but not all populations43. With this information, it can be concluded that hereditary and genetic factors for scoliosis are definitely present, however the complexity of transmission from one family member to another may be much more complex than simple Mendelian genetics.

Respiratory Deficiency

The relationship between scoliosis and respiratory deficiency has long been established, and was attributed by Hippocrates to the restriction of chest movement due to the size and shape of the deformed thorax50. However, respiratory deficiency has only been correlated with a severe thoracic curvature, and has been found in both humans and animals. In a study done by

Smith et al., the researchers induced spinal deformity in a group of rabbits to study the effect of scoliosis on respiratory function. They found that there was, in fact, a relationship between thoracic scoliosis and respiratory deficiency, but only in rabbits with severe, rapidly progressing curvatures50.

5 Melatonin

The idea of decreased melatonin levels playing a pivotal role in the development of AIS has been present since 1983, when Dobousset et al. discovered that chickens who had had their pineal glands removed often developed scoliosis21. Following this study, several researchers measured the levels of melatonin in humans with AIS, only to find that there was no consistent correlations between AIS and decreased melatonin levels44.

In response to this, Moreau et al performed a study in 2004, looking instead at the melatonin-signaling pathway in AIS patients. After obtaining osteoblastic cultures from several

AIS patients during surgery and comparing their melatonin pathway efficiencies, they found that there was a significant relationship between AIS and a dysfunction with the melatonin-signaling pathway in all 41 patients studied. These findings suggest that there may be distinct mutations in

AIS patients that interfere with melatonin signal transduction44, and that this dysfunction could play a significant role in the development of AIS.

Pes Cavus

Pes cavus, high plantar arches, has been found to be correlated with AIS. In a study done in 1994 by Carpintero et al, researchers compared the incidence of pes cavus and scoliosis between 3 groups: a group with established idiopathic scoliosis (Group A), a group with established idiopathic pes cavus (Group C), and a control group with neither (Group B).

Carpintero et al found that 65% of the subjects in Group A had abnormally high plantar arches, compared to only 9.5% of the subjects in the control group. From these results, the researchers concluded that “both deformities may share a common origin in muscle imbalance, either

6 through primary involvement of the muscle or as a result of changes in the central nervous system or the organs of balance”10.

Platelet Calmodulin

Platelet calmodulin is a receptor protein that helps to regulate the contractile protein systems in and platelets. In a study done in 1994, Kindsfater et al measured the levels of platelet calmodulin in AIS patients with both progressive (over 10 degrees of progression in 12 months) and stable (less than 5 degrees of progression in 12 months) curves.

They found that AIS patients with progressive curves had significantly higher platelet calmodulin levels than those with stable curves, or with no curve at all. They made no hypothesis as to why the levels were higher in AIS patients, but concluded that platelet calmodulin levels may now serve as a useful predictor of the progression of AIS33. This could lead to a more accurate prediction as to whether or not extreme measures such as surgery are needed for a particular patient.

The Natural History of Untreated AIS

To Progress or Not to Progress

The natural history of untreated AIS has long been a controversial topic, and there still appears to be no agreed-upon conclusions between researchers regarding the incidence of progression.

Some of the controversy could be resolved if all researchers used the same definitions of

“scoliosis” and “progression”. Many researchers, when defining scoliosis, have used participants

7 with less than a 10 degree curvature of the spine, who don’t meet the current criteria for scoliosis.

Progression is also a difficult subject due to the documented lack of precision with measurement of the Cobb angle, which can vary from 5-7 degrees between examiners8. To add more complications, simple positioning and posture of the patient in the X-ray beam can also lead to a significant difference in measured Cobb angles. Due to these problems, “progression” is not normally concluded until the scoliosis has increased by atleast 10 degrees.

One largely cited piece of work was done by S.L. Weinstein in 1985, who after his research, produced a table with values for the risk of progression depending on the size of the curvature and the age of the patient. According to Weinstein, these two factors in combination could lead to a risk of progression of 0% (in the case of the 16 year old child with a curve less than 20 degrees) up to a risk of 100% (in the case of the 12 year old child with a curve of over 60 degrees)53.

In another study performed the same year, looking at the progression of scoliosis after skeletal maturity, E. Ascani et al reviewed 187 cases of untreated AIS at a 15 year minimum post-skeletal maturity follow-up. They concluded that all 187 patients had progression of their scoliosis2. However, in review of their results, they included any average difference greater than

0 degrees into their definition of “progression”. When a minimum average of 10 degrees of change is used to define progression, only the patients with a curvature of atleast 30 degrees at the end of skeletal maturity would have been considered to have progressed at follow-up.

8 Risk Factors for Progression

One set of facts that researchers do seem to agree upon is the major risk factors for the progression of a scoliosis. Age at diagnosis is one of the most reliable predictors. It has been well recognized that the fastest progression of scoliotic curvatures occurs during an adolescent’s growth spurt20. Therefore, if a child is diagnosed with scoliosis at the age of 8, his/her chance of progression is much higher than the child who is diagnosed at age 16.

Likewise, the Risser sign, which tracks the amount of iliac apophyseal ossification, has also been found to be a predictor of curve progression 8,9,37. The Risser sign is numbered from 1 to 4, with “1” signifying up to 25% ossification of the iliac apophysis and “4” signifying complete ossification, and therefore the cessation of skeletal growth. The larger the Risser sign in a child diagnosed with AIS, the less likely that scoliosis is to progress.

Another reliable predictor of progression is the severity of the curve. The larger the scoliotic curvature is at diagnosis, the more likely it is to progress8, 9, 37.

Finally, curve pattern has also been found to be a predictor of progression. Thoracic curvatures have the highest risk of progression, with thoracolumbar curvatures following closely behind, while a lumbar scoliosis has a much lower risk 8,9,37.

Treatment Options

Conservative Care

Conservative care includes a very large amount of practitioners and techniques. And while it is likely that nearly every one of these techniques has been used to treat scoliosis, only the techniques with sufficient evidence for effectiveness will be evaluated in this review. These techniques include bracing, electrical stimulation, manual therapy, and acupuncture. Very often,

9 two or more of these techniques are used in conjunction to treat scoliosis. As a result, in some cases, it will not be possible to separate the effectiveness of each technique alone.

There are several types of braces used for scoliosis patients. The Boston brace and

Milwaukee brace are often prescribed by medical doctors, which may or may not be post- surgical. For the purposes of conservative care, the author will only include braces prescribed without accompanying surgery. The SpineCor brace is another type of scoliosis brace. It was constructed by a chiropractor, and consequently, most prescribing physicians for this brace are chiropractors as well.

Electrical stimulation employs the use of pads placed along the paraspinal musculature.

Electrical impulses are run through these pads, producing either strengthening or fatigue of involved muscles.

Manual therapy includes chiropractic adjustments and rehabilitative exercises.

Chiropractic adjustments for scoliosis vary from doctor to doctor since the chiropractic profession has numerous accepted adjusting techniques. The adjustments may include a high velocity low amplitude thrust or a slower, sustained, directional force.

Acupuncture is relatively new to the treatment of scoliosis. There is a small amount of research that supports further investigation into the use of acupuncture to reduce scoliotic curvatures.

Surgical Care

Surgical care for scoliotic patients is generally not recommended until the scoliosis has progressed to 40 degrees or more. Before that point, medical doctors often use a “watch-and- wait” approach, or they may recommend bracing if the curvature is between 20 and 40 degrees5.

10 The most common surgery for scoliotic patients between the early 1960’s and the late

1990’s included the implementation of Harrington Rods. These rods are made of stainless steel, and they were inserted into the concavity of the patient’s spinal curvature. The rods contain a ratcheting mechanism, which incorparate hooks anchored to the the top and bottom of the curve.

Employing the racheting mechanism, the doctor would then “stretch” the spine to decrease the curvature30. This method was used in addition to the fusion of the entire length of the that was incorparated into the patient’s curvature. This fusion was added to the procedure because without it, the patient’s spine would often regress so much after surgery that the rods would fatigue and eventually break, requiring yet another surgery30. The fusion is often performed by harvesting bone from the patient’s iliac crest and laying those bone chips along the length of the spine5. After the rod placement and surgery, the patient was then required to wear a hard brace for 6-12 months to allow for full spinal fusion5.

Today, many other surgical techniques may be used for scoliotic patients, however the mechanics of the procedures remain roughly the same. The Luque-To procedure implements

L-shaped rods, placed on both sides of the spine. A wire is then strung through the spinal canal, connecting both rods together and encouraging straightening of the spine. A brace is generally not needed after this surgical method because of its reported stability, however since wires must pass through the spinal canal in this procedure, neurological damage is a serious risk30.

Another surgical technique implements multiple hooks and coutourable rods. This technique was introduced to the U.S. in 1984 by Drs. Yves Cotrel and Jean Dubousset of France.

Other American developers have introduced very similar procedures. These newer systems claim to also address the other dimensions of scoliotic curvatures, which include the loss of the natural

11 anterior to posterior curves of the spine (kyphosis and lordosis), and the “ hump” produced by the rotation of the into the concavity of the scoliotic curvature30.

With these procedures, rods are placed on either side of the spine, usually connected to the spine by multiple hooks or screws, and connected to each other through transverse rods. The patient doesn’t usually need to be braced after this surgery, since it is reported to be more stable than the traditional Herrington rod procedure.

Regardless of the method, a large amount of destruction is done to the posterior elements of the spine during surgery for scoliosis. Spinous processes, facet joints, and the connecting muscles and ligaments are all completely removed or detached during surgery since they will no longer be of use to the patient due to spinal fusion.

No surgical rods are placed above the level of T4, or below the level of L4. As a result, the surgical method is slightly limited in the type of curvatures it can reduce5.

Effectiveness of Treatment Options

Conservative Care

Spinal Orthoses (Bracing)

Due to the fact that they were very cumbersome and difficult to wear, spinal orthoses were not commonly used for scoliosis until the Milwaukee brace was developed by Drs. Blount and Schmidt during the 1950’s19. Currently, the two most common types of braces include the

Milwaukee brace and the Boston brace. A third brace, the SpineCor brace, is beginning to be used for AIS patients and will be discussed as well.

The Milwukee brace is commonly called the CTLSO brace, which represents the levels of the spine it encompasses: cervical, thoracic, lumbar, and sacral. However, it is not able to treat

12 scoliotic curvatures with an apex above T7 due to the limited amount of lateral pressure it can produce above this level. It consists of a pelvic girdle, a single anterior upright, 2 posterior uprights, and a neck ring. The neck ring is used to establish distractive forces on the spine19.

The Boston brace is commonly called the TLSO brace. It does not encompass the cervical spine, but rather stops superiorly at the axilla. It can be used to treat lower thoracic, thoracolumbar, or lumbar curvatures. It is made of 2 plastic half shells that open in the back19.

Both the Milwaukee brace and the Boston brace require intricate fitting and molding procedures by the physician so that they are custom made to fit the vertical and horizontal dimensions of the patient. Because of this specific fitting, however, they do not offer a significant amount of room for growth of the patient, and must be checked frequently when the patient in still growing19. They both are recommended to be worn 23 out of the 24 hours every day until roughly 1 ½ years after menarche, at which point the patient will be weaned off the brace at a rate of 4 hrs every 3 months until they only wear the brace at night. Night-wearing is continued for 6 more months, and then the patient can discontinue use upon completion. Patients in these braces are generally advised not to participate in sporting activities, but some physicians may allow for this7.

Numerous short and long-term studies have been conducted to determine the efficacy of bracing on AIS patients. While a few researchers proclaim that Boston and Milwaukee bracing procedures produce no significant difference on scoliotic curvatures23, most agree that these braces are effective at decreasing the lateral curvatures somewhat34,19,7.

According to one group of researchers who performed a retroactive study, the degree of correction through traditional bracing depended largely on whether the patients had experienced menarche. With those patients who were between 18 months and 6 months pre-menarche, a 37%

13 improvement of curvatures was found at a 5 year follow-up. This improvement decreased to

20% with girls who were between 6 months pre-menarche and 6 months post-menarche, and it decreased altogether with individuals who were 6-18 months post-menarche at 5 year follow- ups7.

In another study, researchers analyzed the long-term effects of Boston bracing in AIS patients and found that in 86 patients with a minimum of a 12 years follow-up of clinical and radiological exams, the mean scoliotic curvature was only 0.8 degrees higher than before they had started orthotic treatment34.

The Boston and Milwaukee braces have some complications that should be discussed.

With the Milwaukee brace, mandibular growth deformities have been reported due to the pressure on the mandible by the neck ring. Other complications with both types of spinal orthoses include skin irritation or ulceration, frontal thigh numbness, and psychological effects.

Another significant problem with the Boston Brace is that it has been found to decrease both the vital capacity and maximum breathing capacity of patients due to its restrictive properties.

Makley et. al found that patients wearing the Risser localizer cast (a type of Boston brace) had a mean decrease in vital capacity of 500 cubic centimeters and maximum breathing capacity of 10-

20 liters40. Since many scoliotic patients are found to have some degree of pulmonary deficiency already, this finding is very significant and must be taken seriously when prescribing the Boston brace to an AIS patient.

Contraindications of the Boston and Milwaukee braces should also be discussed. Both braces are relatively contraindicated when the patient presents with a thoracic hypokyposis, or flattening of the normal sagittal curves of the midback19. This is an important point, because it has often been found that AIS patients have a general decrease in their sagittal curves17.

14 The SpineCor brace is the last brace that will be discussed. It was developed at Sainte-

Justine Hospital between 1992 and 1993 and was created using the unique spinal curvature- specific “corrective movement principle”. This principle takes into account the 3D deformation of the spine in AIS patients and uses corrective movement to act indirectly on the spinal comlum to allow some degree of controlled mobility and movement. Theoretically, this approach

“provides the opportunity to re-educate and maintain the neuromuscular control of spinal corrective movement throuh active bio-feedback”. The brace consists of two main parts: the pelvic base, made of thermodeformable plastic stabilized by 2 thigh bands and 2 crotch bands, and the bolero, which is made of cotton and has 4 corrective bands12.

In their initial pilot study using the SpineCor brace, researchers studied 29 patients with an initial Cobb angle of 15-50 degrees and an Risser sign of 0,1,2, or 3. The brace was worn for

20 out of 24 hours every day and was stopped after roughly 2 years of regular menstruation in females or skeletal maturity in males. They found that at a 2 year follow-up, 55% of patients had an overal correction of more than 5 degrees, 38% of patients had stabilized, and only 7% had worsened more than 5 degrees12.

Since the SpineCor brace is largely a soft brace, it allows much more freedom of movement for the patients. Patients wearing this brace are encouraged to continue in their usual activities, including sports. Also, since it seeks to address the 3D deformations of the spine, thoracic hypokyphosis is not a relative cotraindication in this brace12, as it is with the Boston and

Milwaukee braces. Due to its recent introduction, longer term studies and pulmonary function studies have not been done on the SpineCor brace.

15 Electric Stimulation

Due to the lateral deformity of the spine in AIS patient, the musculature on the convex side of the curvature becomes atrophied60, while the opposite musculature on the concave side becomes hypertonic. Electrical stimulation is one modality that seeks to reduce this disparity.

The electrodes producing contraction can be placed externally on the skin or implanted inside the body.

To obtain maximal correction, it is suggested that the electrodes be placed over the lateral trunk musculature in the mid axillary line on the convex side of the curve19 with a

“strenghtening” setting to help reverse the muscle atrophy. A second set of pads may also be used along the concave side of the curve and set to “fatigue” mode. This second set is believed to fatigue and relax the paraspinal musculature on the concave side, further enhancing the correction.

Researchers have found that nighttime use of electrical stimulation may be beneficial to scoliotic patients. In preliminary animal studies, stimulation of paraspinal muscles with implanted electrodes led to a correction of surgically induced scolioses19.

In another study, researchers reported 83% success with treatment of single curvatures and 84% success with treatment of double curvatures. When only compliant patients were taken into account, these values jumped to 97% and 93% respectively6.

External and internal stimulation have had more than an 80% success rate in arresting or partially correcting idiopathic scoliosis. Long-term studies have not yet been performed to see if these changes are lasting.

16 Manual Therapy

Manual therapy includes chiropractic adjustments and rehabilitative exercises. The aim of this type of treatment is to restore proper motion and alignment to the spinal verterbrae and enhance the proprioceptive input from the spine.

In a retrospective study published in 2004, researchers randomly selected 19 patients age

15-65 from 3 separate chipopractic facilities. The patients were treated 3 times per week for 4-6 weeks. Treatment included chiropractic adjustments (upper cervical adjustments, thoracic adjustments, side posture lumbopelvic adjustments, and supine pelvic blocking), traction with high-density foam blocks, weighting devices on the head, , and , and home care exercises, (weighting devices and foam blocks placed under the lordoses of the spine). Before and after x-rays were taken and one researcher performed the Cobb measurements on all patients. Of the 19 patients included, none showed any increase in curvature, every patient’s curvature improved by atleast 25%, and the average reduction in curvature was 17 degrees, or

60% (from 28 degrees to 17 degrees)45. This study gives very strong evidence towards the use of manual therapy in the treatment of idiopathic scoliosis, and also proves that patients who are beyond skeletal maturity can still show marked reduction in curvature. This study was not a long-term study, however, so the lasting results of these patients is unknown.

Logan Basic Technique (LBT) is a chiropractic adjusting technique that focuses on using applied forces on and around the pelvis to affect the entire spinal alignment. In 2004, a retrospective study was performed by several chiropractic graduate students to evaluate the effectiveness of LBT on the reduction of idiopathic skeletal curvatures. They reviewed 72 cases submitted by 30 field chiropractors of idiopathic scoliosis patients treated for rougly one year with LBT. The patients ranged in age from 10 to 70 years old. Before and after x-rays were

17 submitted by the D.C.’s and measured with the Cobb system. Upon compilation of these 72 cases, the researchers found an average correction of 4 degrees with the use of LBT16. However, only 33 of these cases had curvatures of more than 10 degrees and would have been formally defined as scoliosis. In taking only these 33 patients into account, an average correction of 5.3 degrees was found.

Acupuncture

Acupuncture has only recently been used to study the effectiveness of treatment on scoliosis patients. In 2008, a group of researchers published the results of a single blind controlled pilot study using acupuncture to influence change in scoliotic curvatures. They used

24 female patients from 14-16 years of age that had an average Cobb angle of 33 degrees (range:

16-49 degrees). The patients were split into two groups, one who received a sham acupuncture treatment the first day, and a second who received a real acupuncture treatment the first day. On the second day, these groups were reversed so every participant was able to receive one real treatment. The Formetric surface topography meausurement system was employed to produce a computer reconstruction of the surface angles of back. These measurements were taken after patients had lain on their side for 25 minutes, and then after a 25 minute real or sham treatment while laying on their side55.

The points chosen for treatment were influenced by the spine’s close anatomical relationship with the bladder meridian, the related syndromes, and general energetic points. The points included BL 23, BL 67, KI 3, ST 36, DU 20, DU 3, SI 3, and two additional points on the bladder meridian at the concavity of the main curvature55.

18 When the study was restricted to only patients with curvatures of 16-35 degrees, a significant change was found in pre and post treatment measurements of surface rotation, as well as a strong difference found in lateral deviation. This treatment did not significantly change any measurements with curvatures over 35 degrees however55.

The results of this study demand further research on acupuncture treatments for scoliosis.

Since the patients were only treated one time, longer treatment plans as well as long-term results should both be evaulated in the future.

Surgical Care

Surgical management of scoliosis has changed dramatically in recent years, however the underriding similarity between all methods, both old and new is spinal fusion. Spinal fusion has been used to treat scoliosis for nearly 100 years27, however it did not have a great deal of success until Harrington rods were developed in the 1950’s. For the first few decades of successful surgical treatment, Harrington rods were the most commonly used method by far. Now in recent years, several more methods of instrumentation have been developed to address some of the short-comings of Harrington instrumentation. With the new modern types of posterior segmental spinal instrumentation, the patient often doesn’t need to wear a brace after surgery, better control of the sagittal plane is obtained, there is a lower implant failure, and there is a lower psuedoarthrosis rate5, all in comparison to Harrison instrumentation.

Due to the vast amount of implants and combination of these implants the modern-day surgeon has at his disposal for the treatment of scoliosis, it is impossible to determine a consistent success rate and/or side effect rate of surgical management. Only generalizations can be made.

19 Modern surgical management of AIS has been consistently found to reduce the scoliotic

Cobb angle by an average of roughly 50% immediately after surgery28,4. In one review of 78 patients treated surgically with Harrington rods, it was found that the average curve was 53 degrees +/- 10 degrees before surgery, 38 degrees +/- 11 degrees at the 2-year follow-up, and 45 degrees +/- 12 at the 20 year follow-up. In review, this showed an average correction of 15% after 20 years28, which is drastically lower than the 50% which is comonly found immediately after surgery.

In comparison, Danielsson AJ, et al reported in 2001 after reviewing 156 patients treated surgically for AIS that the initial average loss of spinal correction in the first year after spinal surgery was 3.2 degrees, 6.5 degrees after two years, with a continued loss of 1.0 degrees per year throughout life17. In other words, if a patient who had a 50 degree pre-surgery curve had that curve reduced to 25 degrees immediately following surgery, it would take roughly 21 years for the curve to regress back to its initial curvature. If the patient was 15 years old at the time of surgery, she would then be about 36 years old at the time of complete regression.

When discussing the success rates of surgical management, one must also look at the amount of side effects as a result of this treatment. Conservative treatment has a limited number of side effects due to its low-risk methods, but surgery is another story. Possible side effects of surgical treatment include implant failure4, infections4,5, neurological deficit4, corrosion of the implants1, decreased spinal range of motion28,58, increased back pain13,36, segmental osteoporosis41, loss of sagittal curves17, decreased pulmonary function 3,35,52, and the “crankshaft phenomenon25. Some of these side effects are only found with certain procedures. A few side effects will be discussed in further detail below.

20 When evaluating 34 females who underwent spinal fusion, Bryan Wile et al found that the average patient suffered a 25% reduction in their spinal ranges of motion after surgery58.

Helenius, I. et al found that in a review of 78 post-surgical patients, 59% showed a significant decrease in spinal mobility28. It is intuitive that decreased spinal motion would be a direct result of spinal fusion surgery. By destroying several joints of the spine and fusing the vertebrae together with harvested bone, the involved spinal segments are no longer able to function in movement. However, the segments above and/or below the fused area may compensate for this lack of motion, leading to gross spinal movement that looks rather normal. While this gross spinal movement may seem only slightly impaired, one must recognize the dysfunction in the spine as a whole. The spine is designed to have movement at each spinal segment that is complementary to the surrounding segments. Taking away several adjacent levels of motion puts undue stress on the spinal levels above and below this area, which may lead to early joint and disc degeneration.

Decreased pulmonary function is found in patients who undergo thoracoplasty or anterior fusion. Thoracoplasty is used to help in de-rotation and reduction in rib hump5. This is generally done for cosmetic reasons because the rip hump is the main cosmetic complaint that AIS patients have. However, when this procedure is performed, it has a negative impact on pulmonary function3,35,52, reducing function significantly. If rib hump is one of the main reasons patients want surgical correction of their AIS, and surgeons are not able to reduce this hump without compromising the patient’s pulmonary function, this is a serious conversation that surgeons should be required to have with patients so that the patients can make an informed decision.

The “crankshaft phenomenon” refers to the progressive deformity of the spine that can occur in spite of spinal fusion. This can happen when the patient’s triradiate cartilage in the

21 vertebral bodies hasn’t closed yet, and as a result the bodies continue to grow after surgery, causing the progressive spinal deformity. This is a serious risk in children under the age of 12 who undergo surgery. The risk in this population has been estimated to be between 30-40%25.

Cost of Treatment Options

Conservative Care

According to reports from various conservative care specialists who deal with AIS patients, the average treatment program generally lasts several years, and the cost of treatment varies from $8,000-$19,000. The total cost depends on whether the treatment includes just bracing and the relevant evaluations for that treatment (ex: x-rays, surface EMG’s), or if it also includes regular manual therapy such as chiropractic adjustments during the child’s growing years.

Surgical Care

Because of the wide range of surgical instruments and procedures that can presently be used to treat AIS, the price of this care varies widely. Because the more modern procedures may not require post-operative bracing and may have a shorter post-surgical hospital stay, this can reduce overall treatment costs. However, the new instrumentation is also more expensive, which can bring the total cost back up. The average price of surgical treament has been reported to be anywhere between $30,000 and $120,00011,32,39,61.

22 CONCLUSION

Difficulty in Determining the More Successful Procedure

Currently, many reports on the “success rate” of both surgically and conservatively treated AIS patients rely solely on changes in the the Cobb angle measurements. This method may often fall short however, because the researcher is making a one-dimensional, unifactorial analysis of a three-dimensional and multi-factorial deformity. This makes it very difficult to determine whether one method of treatment is superior to another in AIS patients.

One fact that can’t be ignored is that the consequenses and associated factors of AIS make it much more than simply a structural spinal deformity. If a truly holistic approach is going to be taken to address this disease, one must focus on treating all related factors, whether they be structural, visceral, chemical, or mental. Perhaps as health care and knowledge of AIS progresses, practitioners will better be able to see and treat AIS as more than a single factor.

Cost/Benefit Analysis of Conservative vs. Surgical Care

When comparing the cost versus the success and possible complications of conservative versus surgical treament of AIS, the author is of the opinion that surgical management should be saved as a last resort for treament. Surgical treatment disrupts the natural movement and function of the spine and its surrounding tissues, can cause very serious complications, costs much more than conservative management, and most importantly, falls short of addressing the person as a

Whole.

23 Works Cited

1. Akazawa T, et al. Corrosion of spinal implants retrieved from patients with scoliosis. Journal of Orthopedic Science. 10(2):200-5. 2005.

2. Ascani, E., Bartolozzi, P., et al: Natural History or Untreated Idiopathic Scoliosis After Skeletal Maturity. Spine. 11(8):788. 1986.

3. Barrett DS, et al. Costoplasty in adolescent idiopathic scoliosis. Objective results in 55 patients. Journal of Bone and Joint Surgery. 75B:881-5. 1993.

4. Benli IT, et al. Minimum 10 years follow-up surgical results of adolescent idiopathic scoliosis patients treated with TSRH instrumentation. European Spine Journal. 16(3):381-91. Mar 2007.

5. Bridwell, Keith. Surgical Treatment of Idiopathic Adolescent Scoliosis. Spine. 24(24): 2607. 15 December 1999.

6. Brown et al. Multicenter trial of a non-invasive stimulation method for idiopathic scoliosis: a summary of early treatment results. Spine. 9:382. 1984.

7. Bunch, Wilton H., and Avinash G. Patwardhan. Clinical Experience in Orthotic Treatment. Scoliosis: Making Clinical Decisions. St. Louis: Mosby, 1989. Print. 237-254.

8. Bunnell, W.P.: The Natural History of Idiopathic Scoliosis. Clinical Orthopaedics and Related Research. 229, 1988.

9. Bunnell, W.P.: The Natural History of Idiopathic Scoliosis Before Skeletal Maturity. Spine 11(8): 773-776, 1986.

10. Carpintero, P., et al: The Relationship Between Pes Cavus and Idiopathic Scoliosis. Spine 19(11): 1260-1263, 1994.

11. Cleere, E.: Scoliosis and Chiropractic. Dynamic Chiropractic. 22(12), 2004.

12. Coillard, Christine et al: SpineCor: A non-rigid brace for the treatment of idiopathic scoliosis: Initial post-treatment results. European Spine Journal. 12:141-1. 2003.

13. Connolly PJ, et al. Adolexcent idiopathic scoliosis. Long-term effect of instrumentation extending to the lumbar spine. Journal of Bone and Joint Surgery. 77A: 1210-6. 1995.

14. Cordover, A.M., Betz, R.R., et al: Natural History of Adolescent Thoracolumbar and Lumbar Idiopathic Scoliosis into Adulthood. Journal of Spinal Disorders. 10(3) 193-196, 1997.

24 15. Cowell, H.R.; Hall, J.N.; and MacEwen, G.D.: Genetic aspects of idiopathic scoliosis. Clinical Orthopedics. 86:121-131, 1972.

16. Curtin, John et al. The Effectiveness of Logan Basic Technique on Scoliosis.

17. Danielsson AJ, et al. Radiologic findings and curve progression 22 years after treatment for AIS. Spine. 26(5):516-25. Mar 1 2001

18. De George, F.V., and Fisher, R.L.: Idiopathic scoliosis: genetic and environmental aspects. Journal of . 4:251-257, 1967.

19. De Smet, Arthur A. Spinal Orthosis Treatment. Radiology of Spinal Curvature. St. Louis: C.V. Mosby, 1985. Print.111-125.

20. Drummond, D.S., and Rogala, E.J.: Growth and maturation of adolescents with idiopathic scoliosis. Spine. 5(6): 507, 1980.

21. Dubousset, J.; Queneau, P; and Thillard, M.J.: Experimental scoliosis induced by pineal and diencephalic lesions in young chickens. Its relation with clinical findings in idiopathic scoliosis. Orthopedic Transactions. 7:7, 1983.

22. Fisher, R.L., and De George, F.V.: A twin study of idiopathic scoliosis. Clinical Orthopedics. 55:117-126, 1967.

23. Goldberg, C.J., Dowling, F.E., et al: A Statistical Comparison Between Natural History of Idiopathic Scoliosis and Brace Treatment in Skeletally Immature Adolescent Girls. Spine. 18(7): 907, 1993.

24. Griffet, J., Leroux, M.A. et al: Relationship between gibbosity and Cobb angle during treatment of idiopathic scoliosis with the SpineCor brace. Eur Spine J. 9:516-522, 2000.

25. Hamill CL, et al. Posterior arthrodesis in the skeletally immature patient. Assessing the risk for crankshaft. Is an open triradiate cartilage the answer? Spine. 22:1343-51. 1997.

26. Harrington, P.R.: The etiology of idiopathic scoliosis. Clinical Orthopedics. 126:17-25, 1977.

27. Hawes, M. Impact of spine surgery on signs and symptoms of spinal deformity. Pediatric Rehabilitation. 9(4): 318-39. Oct-Dec 2006.

28. Helenius, I., Remes, V., et al: Comparison of long-term functional and radiologic outcomes after Harrington instrumentation and spondylodesis in adolescent idiopathic scoliosis: a review of 78 patiets. Spine. 27(2), 2002.

29. Inoue, M., Minami, S., et al: Idiopathic scoliosis in twins studied by DNA fingerprinting. The Journal of Bone and Joint Surgery. 80-B(2) 212-217, 1998.

25 30. Instrumentation Systems for Scoliosis Surgery. National Scoliosis Foundation. http://www.scoliosis.org/resources/medicalupdates/instrumentationsystems.php. Sept. 12, 2010

31. Justice, C.M., Miller, N.H., et al: Familial Idiopathic Scoliosis. Spine. 28(6) 589-594, 2003.

32. Kamerlink JR, et al. Hospital cost analysis of adolescent idiopathic scoliosis correction surgery in 125 consecutive cases. Journal of Bone and Joint Surgery American. 92(5):1097-104. May 2010.

33. Kindsfater, K et al: Levels of platelet calmodulin for the prediction of progression and severity of adolescent idiopathic scoliosis. The Journal of Bone & Joint Surgery. 76:1186-1192, 1994.

34. Lange, J.E., Steen, H., Brox, J.I.: Long-term results after Boston brace treatment in adolescent idiopathic scoliosis. Scoliosis. 4(17), 2009.

35. Lenke LG, et al. Analysis of pulmonary function and chest cage dimension changes after thoracoplasty in idiopathic scoliosis. Spine. 20:1343-50. 1995.

36. Lenke LG, et al. Radiographic results of arthrodesis with Cotrel-Dubousset instrumentation for the treatment of adolescent idiopathic scoliosis: a 5 to 10 year follow-up study. Journal of Bone and Joint Surgery. 80A:807-14. 1998.

37. Lonstein, John E., and Carlson, J. Martin: The Prediction of Curve Progression in Untreated Idiopathic Scoliosis during Growth. The Journal of Bone and Joint Surgery. 66-A(7). September 1984.

38. Lowe, Thomas G., et al: Etiology of Idiopathic Scoliosis: Current Trends in Research. The Journal of Bone and Joint Surgery. 82-A(8) Aug 2000.

39. Luhmann SJ, et al. Financial analysis of circumferential fusion versus posterior-only with thoracic pedicle screw constructs for main thoracic idiopathic curves between 70 degrees and 100 degrees. Journal of Child Orthopedics. 2(2):105-12. March 2008.

40. Makley, John et al: Pulmonary Function in Paralytic and Non-Paralytic Scoliosis before and after Treatment. The Journal of Bone and Joint Surgery. 50-A(7). October 1968.

41. McAfee PC, et al. The effect of spinal implant rigidity on vertebral bone density. A canine model. Spine. 16(6S): S190-7. 1991.

42. Mead, K.P., Bunch W.H., et al: Progression of Unsupported Curves in Adolescent Idiopathic Scoliosis, Spine. 12(6). 520-526, 1987.

43. Miller, N.H. et al: Genomic Search for X-Linkage in Familial Adolescent Idiopathic Scoliosis. Burlington, Vermont, International Research Society of Spinal Deformities, 1998.

26

44. Moreau, Alain et al: Melatonin Signaling Dysfunction in Adolescent Idiopathic Scoliosis. Spine. 29(16): 1772-1781, 2004.

45. Morningstar, M.W., Woggon,D., Lawrence, G.: Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series. BMC Musculoskeletal Disorders. 5(32), 2004.

46. Ogilvie, James W. et al: The Search for Idiopathic Scoliosis Genes. Spine. 31(6): 679-681, 2006.

47. Rogala, E.J.; Drummond, D.S., and Gurr, J.: Scoliosis: Incidence and natural history. A prospective epidemiological study. Journal of Bone and Joint Surgery. 60A:173, 1978.

48. Shapiro, G. Medical Complications in scoliosis surgery. Current Opinion in Pediatrics. 13(1):36-41. Feb 2001.

49. Simoneau, Martin, et al: Altered sensory-weighting mechanisms is observed in adolescents with idiopathic scoliosis. BMC Neuroscience. 7:68, 2006.

50. Smith, R.M., et al: Respiratory Deficiency in Experimental Idiopathic Scoliosis. Spine. 16(1): 94-99, 1991.

51. Sponseller PD, et al . Results of Surgical Treatment of Adults with Idiopathic Scoliosis. Journal of Bone and Joint Surgery American. 69(5):667-75. June 1987.

52. Vedantam R, et al. A prospective evaluation of pulmonary function in patients with adolescent idiopathic scoliosis relative to surgical approach used for spinal arthrodesis. Spine (in press).

53. Weintstein, S.L.: Adolescent Idiopathic Scoliosis—Prevalence, Natural History, Treatment Indications. Chicago, Scoliosis Research Society, 1985.

54. Weinstein, S.L., Zavala, D.C., et al: Idiopathic Scoliosis. The Journal of Bone and Joint Surgery. 63-A(5), 1981.

55. Weiss, H.R. et al. Acupuncture in the treatment of scoliosis-a single blind controlled pilot study. Scoliosis. 3:4. 2008.

56. Weiss, H.R.: Is there a body of evidence for the treatment of patients with Adolescent Idiopathic Scoliosis (AIS)?. Scoliosis. 2(19), 2007.

57. Weiss, H.R.: The Effect of an Program on Vital Capacity and Rib Motility in Patients with Idiopathic Scoliosis. Spine. 16(1): 92, 1991.

27 58. Wile, Bryan et al. The effect of Scoliosis Fusion on Spinal Motion. Spine. 31(3):309-314. 2006.

59. Wynne-Davies, R.: Familial (idiopathic) scoliosis. A family survey. Journal of Bone and Joint Surgery. 50-B(1):24-30, 1968.

60. Yamada et al: Etiology of Idiopathic Scoliosis. Clinic Orthopedics. 184:50. 1984.

61. Yawn BP. The estimated cost of school scoliosis screening. Spine. 25(18):2387-91. Sept 15 2000.

28