Scoliosis

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Scoliosis is a condition that causes the spine to curve. While commonly thought of as the spine curving “to the side,” it is a complex, three-dimensional deformity. While the cause of scoliosis is unknown, it usually runs in families and typically affects girls and young women more often and severely than boys and young men. Mild cases that do not cause pain or discomfort require no treatment. However, cases that are moderate to severe may require treatment, especially in cases where the curvature cases pain or discomfort. If you or your child has scoliosis, it is important to see a scoliosis expert, such as Dr. Feldman, as the appropriate treatment is best indicated on a case-by-case basis.

Dr. Feldman on Scoliosis

Surgical or non-surgical options may be sought for the treatment of scoliosis. There are three main types of scoliosis:

  • Idiopathic
  • Congenital
  • Neuromuscular

Idiopathic Scoliosis

Idiopathic scoliosis is the most common type of scoliosis and is, in fact, the most common type of spinal deformity. The exact cause is unknown, as indicated by the name “idiopathic,” which in Greek means approximately “a disease of its own kind.” Common explanations, such as poor posture or carrying a heavy backpack, have not been proven to cause idiopathic scoliosis. Genetics may play a role, however, as research has shown that approximately 30% of patients with idiopathic scoliosis have a family history.

Idiopathic scoliosis most commonly presents in small children, between the ages of 10 and 18, though it most often begins during puberty. For reasons not well understood, girls are more likely to develop the condition than boys. It is rarely painful. The curvature progresses slowly (but stubbornly), and the effect is often subtle and goes unnoticed by the patient and parent. Idiopathic scoliosis is usually first diagnosed by a pediatrician or during routine school screenings. Some of the common signs include:

• Uneven, tilted shoulders
• One shoulder blade sticking out further than the other
• An uneven waistline
• One hip rises higher than the other when standing straight

The curves seen in idiopathic scoliosis can vary in size, and the more mild curves are far more common. In many cases, treatment is not necessary; and in cases where it is indicated, treatment usually involves bracing in combination with physical therapy. At the Paley Orthopedic & Spine Institute, we offer the Rigo Cheneau brace as well as Schroth Physical Therapy to correct mild cases of idiopathic scoliosis.

During the examination, Dr. Feldman will perform the “Adam’s forward bend test,” in which the patient bends forward with their feet together, knees straight and arms hanging free. Dr. Feldman will observe the patient from the back, to see if any spinal deformity may be present.

X-rays will also be ordered to provide clear images of the spine. Dr. Feldman will be able to see and measure the exact extent of the curve and recommend the best treatment method.

Congenital Scoliosis

Congenital scoliosis is a form of scoliosis that is present at birth, unlike idiopathic scoliosis, in which the curvature develops during adolescence. Congenital scoliosis is quite rare, occurring in 1 in 10,000 births. It may be associated with other health issues, particularly in the kidneys or bladder.

There are three different types of congenital scoliosis:

Incomplete formation of the vertebra

During the formation of the spine prior to birth, part of the vertebra may not form completely, resulting in an angle in the spine (a hemivertebra). This angle tends to get worse as the child grows.

Failure of separation of the vertebra

During development, the spine initially forms as a single structure and later separates into different segments or vertebra. In some cases, this separation is not complete and some of the bone remains connected between two vertebrae. This prevents the spine from growing on one side, resulting in curvature as the child grows.

Combination of incomplete formation and failure of separation

A combination of an incomplete formation and failure of separation is the most serious case of congenital scoliosis. These patients usually require surgery at a young age to prevent serious misalignment of the spine.

Neuromuscular Scoliosis

Neuromuscular scoliosis (NMS) is a type of scoliosis associated with conditions that impair a child’s ability to control and support their spine. Some of the conditions associated with NMS include:

• Muscular dystrophy
• Cerebral palsy
Spina bifida

Since neuromuscular scoliosis includes a range of medical conditions, it’s imperative that treatment is undertaken at a center that includes a team of doctors who are familiar with these unique needs and concerns of patients with NMS. In addition, seeing a surgeon like Dr. Feldman, who is not only an expert on scoliosis but who also has significant experience in treating neuromuscular conditions, significantly improves treatment outcomes.

Not all children with a neuromuscular condition will develop scoliosis, but it is fairly common. Children who use a wheelchair are at the greatest risk of developing scoliosis. For children who are ambulatory, the signs of neuromuscular scoliosis are similar to those for idiopathic scoliosis. Because NMS is associated with underlying neuromuscular disorders, the rate of complication after surgery is usually higher than with other types of scoliosis. It is crucial that the care received comes from a surgeon who has extensive experience treating these unique cases.

Treatment Methods

Treatment for scoliosis may be either surgical or non-surgical. Dr. Feldman will consider a number of factors when planning for treatment. Some of those include:

• The location of the curve
• The extent of the curve
• The patient’s age
• The number of remaining growing years
• Whether there is an associated neuromuscular condition (the patient has NMS)
• The specific type of vertebral abnormality (the patient has congenital scoliosis)

Non-surgical Treatments

Observation

Dr. Feldman may simply recommend monitoring the curve to make sure it doesn’t worsen if the child has a small curve (less than 25 degrees) or if the child is almost fully-grown. Dr. Feldman will order x-rays taken every 6 months during the patient’s growing years, in order to monitor the progression of the curve. Children may still participate in most sports and hobbies. Contrary to popular belief, the curve does not worsen with certain activities.

An example of the Wood Cheneau Rigo (WCR)® Brace from Align Clinic
An example of the Wood Cheneau Rigo (WCR)® Brace from Align Clinic

External Bracing

Bracing has been used for generations to prevent mild to moderate cases of scoliosis from progressing. A brace is only effective in young patients with significant growth remaining. X-rays of the hands or the top of the pelvis can determine the amount of growth remaining. Once bracing begins, the brace often needs to be worn until growth is completed which is usually around age 14 in females and 16 in males.

At the Paley Orthopedic & Spine Institute, we recommend the Rigo Cheneau Brace. This is a highly advanced device that provides individual scoliosis treatment. The unique bracing system was developed by Dr. Cheneau and later improved by Dr. Rigo. Since each brace is custom-tailored to the patient, it is designed to account for all aspects of the scoliosis curve.

The Paley Orthopedic & Spine Institute partners with Align Clinic to offer the Wood Cheneau Rigo (WCR)® brace. Align Clinic holds monthly brace clinics at the Paley Orthopedic & Spine Institute. Click here to see the upcoming clinics for this year.

Schroth Physical Therapy

Dr. Feldman may also prescribe Physical Therapy using the Schroth Method. This is a highly specific method of physical therapy that is used to treat scoliosis. Schroth therapy is usually combined with the Rigo Cheneau brace.

The Paley Orthopedic & Spine Institute Rehabilitation Department is experienced in treating a variety of complex orthopedic conditions. The Rehabilitation Department works closely with Dr. Feldman in order to provide his patients with the highest level of care. The Paley Institute Rehabilitation Department is proud to offer the only dedicated Schroth Center in the Southeast United States. Our therapists have been specially trained to perform this advanced type of physical therapy.

Dr. Feldman's out-of-state patients are referred to other locations that have been trained in the Schroth Method.

It is also vitally important for individuals who have scoliosis and/or wear a brace to keep their core strong. While no one method of exercise or manipulation has been proven to help prevent the progression of scoliosis, Dr. Feldman still recommends back exercises for his patients. Physical therapy regimens such as the Schroth method have been found to be effective in maintaining core strength and increasing comfort.

Surgical Treatments

Spinal Fusion

An example of a before & after spinal fusion with Dr. Feldman
An example of a before & after spinal fusion with Dr. Feldman

This is the most common type of surgery for scoliosis. Rods and screws are attached to the vertebrae to fuse the bones together, helping to straighten the spine. This procedure is only utilized for severe curves where all other treatment methods have failed. There is often no need for bracing after this surgery and patients may return to their activities in as little as one to two months.

For all of this spinal fusion patients, Dr. Feldman utilizes a specialized multilayered closure technique by a plastic surgeon in order to dramatically lower the rate of postoperative wound complications.

For more information, please see Dr. Feldman’s research paper on:
Wound Closure in Nonidiopathic Scoliosis: Does Closure Matter?

Fusionless Surgery

Devices such as the Vertical Expandable Prosthetic Titanium Rib (VEPTR) and growing rods are used to straighten the spine without fusing vertebrae. This surgery is less commonly performed and is usually utilized for very young patients with progressive scoliosis who have a great deal of growth remaining. There is currently a great deal of interest and research into these techniques, as they would allow for the avoidance of fusion.

Spinal Tethering

Spinal tethering is a new method of fusionless surgery that aims to correct scoliosis while maintaining motion. There are two techniques of spinal tethering:

• Vertebral Body Stapling
• Screw and Cable

Vertebral body stapling involves the insertion of staples across the growth plates of the vertebrae. The staples are inserted on the side with the longer curve, which is growing faster than the opposite side. The staples inhibit growth on that one side but allow it on the opposite side, resulting in gradual straightening of the spine as the patient ages. This technique is a form of guided growth. The procedure is only effective in younger patients since it relies on patient growth.

The screw and cable technique was developed to treat patients older than 10 years of age, in which stapling is less effective. The screw and cable technique is also used for curves of large magnitude (over 40 degrees). The technique involves the insertion of special titanium screws into the side with the longer curve, along with a flexible cable that connects the screws. The cable resists growth in the deformed direction, but allows growth in all other directions, resulting in spontaneous and complete correction as the patient grows.

Thoracoplasty

A cosmetic procedure that involves the removal of a protruding rib and is at times combined with other procedures.

 

The treatment options for scoliosis are continuously evolving and constantly improving. The non-surgical and surgical methods used today are very different from what they used to be. Choosing the right intervention at the optimal time remains a crucial step in achieving the best possible outcome.

Dr. Feldman is proud to offer a comprehensive spinal deformity treatment center at the Paley Orthopedic & Spine Institute in West Palm Beach, Florida. He offers top-of-the-line nonsurgical and surgical treatments for scoliosis and other spinal deformities. Dr. Feldman brings his extensive experience as head of Pediatric Orthopedics at NYU Langone Medical Center here to South Florida.

If your child has scoliosis, remember: the best care is Paley Care. Contact Dr. Feldman today and set up a consultation to see which treatment method would be best for your child. Call us at 561-844-5255 to schedule your consultation.