Ask the Expert: Scoliosis, Part II
Hospital for Special Surgery partnered with Curvy Girls Scoliosis to host our first-ever scoliosis Facebook chat, titled “Life with Scoliosis: Diagnosis and Treatment.” Thank you to all who participated! Dr. Matthew Cunningham, Orthopedic Spine Surgeon, answers the remaining questions from the chat.
Q1. Do you have plans for studies 15 to 20 years after surgery? This seems to be the commonality of many degenerative issues after long spinal fusion. Are there any treatments available then? My daughter had epidurals, radio frequency ablation and other temporary ways to block the pain. Short of more fusion and worse disability in limitations…we are out of options to address her degenerative discs due to scoliosis fusion surgery.
Dr. Cunningham: Yes, long term follow-up is critical to determining if what we do is durable. Unfortunately, because technology changes so rapidly and 15-20 year follow up takes so long, these long term follow-up studies are not very common. There are treatments: at first non-operative with PT, activity mods, meds by mouth, and meds being injected to name a few. If all that happens to fail, then surgery to “add on” the degenerated segments to the index fusion will take place. The discs degenerate below and above the fusion zone. It is more a matter of the mechanics of a fused portion of the spine, and less due to the specifics of the surgery or the implants used.
Q2. Why don’t more surgeons prescribe PT before and after surgery? Core strength is so important and after muscles become atrophied from non-use in healing. PT should be offered to every scoliosis patient facing surgery.
Dr. Cunningham: I routinely try PT as a first try to treat just about anything. I’d have to assume that the physicians don’t try conservative measures first don’t think that the non-operative means to treat work as well as the surgical interventions do.
Q3. What about the causes of scoliosis? We read there are environmental factors. What would those be?
Dr. Cunningham: Causes of scoliosis include genetic predispositions (scoliosis is more common in healthy family members of affected individuals, more common in identical twins, and genes have been identified that correlate with increased risk), associated neuromuscular conditions (cerebral palsy, neurofibromatosis, muscular dystrophy to name a few), and environmental (mostly shown in animal research, but there is suggestion that exposure to carbon monoxide can cause devastating abnormalities in fetal rat pups- it would follow that other exposures, such as heavy metals, could possibly have a similar role, albeit data is lacking).
Q4. As a 55 year old person who was told at 13 no brace and no surgery, what kind of health issues can I expect at this age?
Dr. Cunningham: You don’t have to have symptoms at all. You don’t have to have scoliosis that gets any worse than it is right now. However, for adults with scoliosis over 50 degrees, there is an increased risk for progression (at a slow rate of 1 degree per year), and a risk that you might get arthritis changes in the spine that could cause back pain or leg symptoms (sciatica, or stenosis). It would be very unlikely for you to get lung function problems (curves tend to need to be 80-100 degrees for this), or issues related to the heart (right heart failure, an end-stage problem in severe scoliosis). For prevention, I’d recommend PT and keeping the “core” trunk muscles strong and well-conditioned.
Q5. I have a friend whose daughter had surgery last year. Her top rods have broken loose. 3 screws are backing out. Her doctor wants to watch it. She is in extreme pain. Is it dangerous to have rods that have broken loose inside her?
Dr. Cunningham: It might be safer to have the spine re-instrumented, as the bones are less likely to fuse/heal correctly if they are not held still. If the screws and rods are “pulling out,” then they sound like they are not doing their job. I might recommend that she’d have better pain control, and ultimately a better chance at getting the fusion desired if the implants and fusion was revised. I will have to add that the above opinion is rendered only with the information provided and I do not know any other specifics of the case that would allow me to render a more credible professional opinion, such as her possibly having very fragile health status and her treating physician respecting the fact that they would rather have the patient be uncomfortable for a while and perhaps heal eventually, rather than being physiologically stressed in a second surgery to the point where she has a heart attack or stroke, and ends up with a worse situation.
Q6. I know flat back is associated with Harrington Rods. Are girls that are fused into the lower lumbar or sacrum at risk? Even with pedicle screws and newer materials?
Dr. Cunningham: H-rods normally get a bad rap. It isn’t the rod as much as it is the fact that the spine was fused at all, which predisposes to flatback. Patients typically fuse and then go about their lives. Every day brings hundreds or thousands of loading events to the spine, and when a fusion is present, all of those forces are transmitted and dissipated in the disc segments that were not fused. Hence, the discs below the fusion tend to wear out at an accelerated rate- independent of the H-rod, newer Clotrel-Dubosset, or newest all-pedicle screw construct used. Having no discs below the end of the fusion (i.e. being fused to the sacrum/sacropelvis does not allow the lumbar disc degeneration to occur. Hence, there is no flatback for these patients.
Q7. Are there any studies on the number of patients that the surgery doesn’t take, fusions that failed, rods that came loose, or chronic pain that resulted in rod removal? How many years after surgery?
Dr. Cunningham: Yes, there are dozens of studies to document failure of fusion & implant failure. I would direct you to www.pubmed.gov, where you can type in keywords and the search engine can identify specific papers to read. Far fewer reporters focus on patients following implant removal, but there are a few. Implants can be removed once the bones have healed together: as early as 2 years, and as late as 30 years or longer after surgery.
Click here to learn more facts about scoliosis through an infographic on Adolescent Idiopathic Scoliosis, presented by the HSS Lerner Children’s Pavilion.
Matthew E Cunningham MD PhD is an orthopedic surgeon at HSS, specializing in Pediatric and Adult, Spine and Scoliosis surgery. Dr. Cunningham’s interests include minimally invasive and open surgery for spine deformity and degenerative conditions. He currently is the Interim Chief of the Scoliosis Service, Director of the John Cobb Scoliosis Fellowship, Principal Investigator of the Molecular and Cellular Spine Research Laboratory at HSS, and acts as a reviewer for Clinical Orthopedics & Related Research, Hospital for Special Surgery Journal, Journal of Orthopedic Research, Arthritis Research & Therapy Journal, Scoliosis Journal, Biochemistry Journal, American Academy for Laboratory Animal Science Journal, and Journal of Biomechanics.