Patient Education Materials

Condition and Treatment Information

Most adults with scoliosis either had scoliosis as a child or they have unequal degeneration of the bones and discs of the spine, referred to as degenerative scoliosis.

Degenerative scoliosis can be due to disc degeneration and/or compression fractures. Osteoporosis of the vertebral body can result in collapse of the vertebrae.

Adult Scoliosis is usually diagnosed secondary to pain or change in posture. A scoliosis X-ray will reveal curvature of the spine.

Stenosis (narrowing of the spinal canal) is often associated with degenerative scoliosis. If the patient has radiating leg pain or numbness, a CT or MRI may also be ordered for further evaluation.

Treatment: Treatment is based on the severity of the curve and the severity of the patient's symptoms.

Options include: observation, physical therapy, injection therapy, medication for pain, or surgery. Reasons to pursue surgical intervention include: a curve that is progressing in size, pain that is not responsive to non-operative treatments, or physical deformity that is bothersome to the patient.

Scoliosis occurs when the spine develops an abnormal curvature that looks like a 'C' or an 'S'. On an x-ray, you can see this curvature. These curves can make the person's shoulders or waist appear uneven. Some of these bones may also be rotated slightly, making one shoulder blade more prominent than the other.

Scoliosis in patients between 10 and 18 years of age is called adolescent scoliosis. By far the most common type of scoliosis is one with an unknown cause. It is called adolescent idiopathic scoliosis (AIS).

Causes

There are significant efforts being made toward identifying the cause of AIS, but to date there are no well-accepted causes for this particular type of scoliosis. The vast majority of patients are otherwise healthy and have no previous medical history. There are many theories about the cause of AIS. Approximately 30% of AIS patients have some family history of scoliosis, and therefore there seems to be a genetic connection. Despite not knowing the exact cause, we currently have accurate methods to determine the risk for curve progression of scoliosis and good methods of treatment.

Symptoms

Often, children do not even notice that they have a spinal problem. In some cases the child or parent may notice that one shoulder blade sticks out or that one shoulder is higher than the other. Adolescent idiopathic scoliosis generally does not result in pain or neurologic symptoms. In some patients, however, they do experience pain or discomfort. Many teens in general experience back pain due to participating in a large number of activities without having good core abdominal and back strength, as well as flexibility of the hamstrings. Often this can be relieved with physical therapy.

Evaluation of Scoliosis

The typical radiographic images that are obtained to define scoliosis include a standing X-ray of the entire spine looking both from the back as well as from the side. Your physician will be able to measure the radiographs to determine your curves magnitude, which is measured in degrees.

Growth is a very important determinant in the treatment of scoliosis and therefore the child's growth stage must be evaluated. One way in which we do this is by taking an X-ray of the child's hand to assess the growth plates. We also take into account the child's age and the presence or absence of menstruation in female patients. We use all of this information to determine what phase of growth the child is in and to predict how much growing the child has left.

Treatments

Non-operative treatments

  • Observation
    Observation is generally for patients whose curves are less than 25-30° who are still growing, or for curves less than 45° in patients who have completed their growth. Physicians often wish to observe the scoliosis every few years after patients complete their growth to make sure it does not progress into adulthood.
  • Bracing
    Bracing is recommended for patients with curves that measure between 25° and 40° during their growth phase. The goal is to prevent the curve from getting bigger. This is accomplished by correcting the curve while the patient is in the brace so that the curve does not progress with time. Growth plates on the vertebrae are more likely to grow symmetrically if they have equal pressure over their surface as the child grows. Straighter spines equalize pressure better than curved spines. Once the brace is discontinued, the goal is to maintain the curve at the magnitude present when the brace was started. Even if slight curve progression occurs despite wearing the brace, surgical treatment may not be necessary as long as the curve remains below 45° at the end of growth. Braces are worn under the clothes and cannot be seen by others. Bracing is most effective when it is worn more than 18-22 hours per day. Your physician will often recommend removing the brace for bathing and sports. When bracing treatment is started, radiographs are usually performed with the brace on to ensure that the brace is effective in achieving some correction of the curve(s).
  • Alternative Treatment
    Alternative treatments to prevent curve progression or prevent further curve progression such as chiropractic medicine, physical therapy, yoga, etc. have not demonstrated any scientific value in the treatment of scoliosis. However, these and other methods can be utilized if they provide some physical benefit to the patient such as core strengthening, symptom relief, etc. These should not, however, be utilized as a primary treatment of scoliosis.

Operative Treatments

  • Surgery
    Surgical treatment is recommended for patients whose curves are greater than 45° while still growing, or are continuing to progress greater than 45° when growth stopped. The goal of surgical treatment is two-fold: first, to prevent curve progression and secondly to obtain some curve correction. Surgical treatment today utilizes metal implants that are attached to the spine, and then connected to a single rod or two rods. Implants are used to correct the spine and hold the spine in the corrected position until the instrumented segments fuse together as one bone. The surgery is usually performed from the back of the spine (posterior approach) through a straight incision along the midline of the back. Following surgical treatment, no external bracing or casts are used. The hospital stay is generally between 5 and 7 days. The patient can perform regular daily activities and generally returns to school in 3-4 weeks.

A) Front and side X-rays of a patient with adolescent idiopathic scoliosis in her thoracic spine.

B) Post-surgical correction through a posterior approach using two rods and pedicle screws.

Information and figures adapted from Scoliosis Research Society

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What is Cervical Stenosis?

Cervical stenosis occurs when the spinal canal in the neck narrows and compresses the spinal cord or nerve roots.

Causes

Cervical stenosis is most frequently caused by aging and degeneration. The discs in the spine that separate and cushion vertebrae may dry out. As a result, the space between the vertebrae shrinks, and the discs lose their ability to act as shock absorbers. At the same time, the bones and ligaments that make up the spine become less pliable and thicken. These changes result in a narrowing of the spinal canal. In addition, the degenerative changes associated with cervical stenosis can affect the vertebrae by contributing to the growth of bone spurs that compress the nerve roots.

Symptoms

The symptoms of cervical stenosis can range from mild to severe symptoms. Symptoms may include:

  • Neck pain and stiffness
  • Pain shooting down arm(s)
  • Tingling, numbness or weakness in arms or hands
  • Decreased muscle tone in arms/hands
  • Headaches in back of head
  • Decreased grip strength
  • Difficulty with balance
  • Loss of coordination in arms or legs

Diagnosis

Diagnosis is made based on history, symptoms, physical examination, and results of diagnostic studies. These tests may include:

  • X-rays
  • Magnetic Resonance Imaging (MRI)
  • Computed Tomography Scan (CT or CAT scan)
  • Electromyography (EMG)
  • Nerve Conduction Studies (NCS)

Treatments

Mild stenosis can be treated conservatively. Conservative treatments include observation of symptoms, medications, physical therapy, chiropractic care, and cervical injections.

If stenosis is severe, progressive, or does not respond to conservative treatments, then surgical intervention should be discussed. Surgeries vary depending on many factors including the severity of the stenosis, the location of the stenosis, and the patient’s symptoms.

The disc is a cushion that sits between each vertebrae of the spine. The disc is made of a soft, gel-like inner core (the nucleus pulposus) with a layered tougher outer covering (the annulus). In a young person the disc is flexible but with age it becomes more rigid and vulnerable to injury.

As the disc becomes less elastic, the outer portion (annulus) can start to tear. When this happens, a portion of the softer inner core (annulus) pushes through the outer covering--this is called a herniated disc. When a herniated disc bulges out from between the vertebrae, the spinal nerves can become pinched. Because there is so little space around the nerves, the disc that herniates pinches the nerves causing symptoms along the nerve.

A herniated disc may occur suddenly in an event such as a fall or an accident, or may occur gradually with repetitive straining of the spine.

Common Symptoms

  • Electric Shock Pain along the nerve. If the herniation is in the neck then the pain is typically down the arm; if the herniation is in the lower back the sensation is down the leg
  • Tingling and Numbness along the nerve that is being pinched
  • Muscle Weakness of the muscles that the nerve innervates
  • Bowel or Bladder Problems: this is a MEDICAL EMERGENCY

Diagnosis

Diagnosis is based on a thorough history, physical examination, as well as diagnostic imaging. Imaging includes X-ray to evaluate alignment and degenerative changes and MRI to evaluate for disc herniation and nerve impingement.

Treatments

Non-surgical

Symptoms are frequently self-limited and respond to restriction of activity, non-steroidal anti-inflammatory medications, and short periods of rest. Other options include physical therapy and steroid injections

Surgical

If there is no improvement with non-operative treatment measures or if leg pain or weakness worsens, surgical treatment may be suggested. The most common procedure for this condition is a discectomy in which a small incision is made in the back and the herniated portion of the disc is removed.

Early onset scoliosis (EOS) is defined as scoliosis in children aged 5 years and less. There are many causes of EOS including congenital scoliosis and infantile idiopathic scoliosis.

Congenital scoliosis

Congenital scoliosis and congenital kyphosis refers to a spinal deformity caused by vertebrae that are malformed. The malformation occurs in the first six weeks of pregnancy. The abnormalities include vertebra that are not completely formed, vertebra that are fused (attached) together, and mis-shaped vertebra.

Because the vertebrae are abnormally shaped, there is an imbalance in the growth of bones of the spine. This growth imbalance results in a deformity such as scoliosis (curve to the right or left) or kyphosis (rounding of the back).

In the thoracic (chest) part of the spine, there are often anomalies of the ribs as well.

Treatment options include: observation with serial x-rays to monitor for curve progression; body casting; brace therapy; or surgery. Surgeries include growing rods, Vertical Expandable Prosthetic Titanium Rib (VEPTR), or spinal fusion. The age of the child as well as the severity of the spinal curve will help to determine the best treatment option.

Infantile scoliosis

Infantile scoliosis is scoliosis that is first diagnosed in a child between birth and 3 years old. Many infantile curves will resolve without treatment, however some do progress.

Infantile scoliosis can be associated with Thoracic Insufficiency Syndrome. This is defined as the inability of the thorax to support normal breathing or lung growth. This can occur with severe spinal or rib deformities.

Treatment options include: observation with serial x-rays to monitor for curve progression; body casting; brace therapy; or surgery. Surgeries include growing rods, Vertical Expandable Prosthetic Titanium Rib (VEPTR), or spinal fusion. The age of the child as well as the severity of the spinal curve will help to determine the best treatment option.

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There are natural curves of the spine because of the mobility that the vertebral bodies allow. From the side the neck (cervical spine) has a lordosis (swaying in); the upper back (thoracic spine) has a kyphosis (sway out); the lumbar spine (lower back) has a lordosis. These curves provide a balance when a person is standing and allow the head to be upright.

If there is an excessive curve in one region of the spine the other regions compensate so the person’s head remains upright. A loss of lumbar lordosis is call flatback.

Someone with Flatback Syndrome often experiences thigh and back pain. The person may get tired easily and in extreme situations have difficulty standing upright – standing with their hips and knees bent in order to get their head upright. There may be symptoms of sciatica (pain in the buttocks and leg) that are associated.

Causes of Flatback Syndrome

Flatback syndrome can be caused by previous spinal instrumentation.The rods flatten the normal lordosis of the lumbar spine. Patients may do well for years after their surgery, but eventually the discs below the fusion wear out and the person is unable to stand upright.
Other causes of flatback syndrome:

  • Degeneration of the intervertebral discs occurs with age. As the discs degenerate in the lower back, the lumbar spine stiffens and there is loss of normal lordosis.
  • Compression fractures of the lumbar vertebral body, often due to osteoporosis, can lead to loss of lumbar lordosis.
  • Ankylosing spondylitis is a chronic inflammatory arthritic disease that causes stiffness of the entire spine and can lead to loss of lumbar lordosis.

Treatment

Conservative treatment may be the first choice in flatback syndrome. This is typically physical therapy. This may provide a relief of symptoms of flatback syndrome. If, however, the structural problem is severe enough then surgery is likely indicated.

The goal of surgery is to correct spinal alignment. To achieve this, multiple wedge shaped cuts (osteotomies) are made in the vertebrae of the affected area. The placement of the osteomies is essential in correcting the flatback. Spinal instrumentation is used to hold the corrected alignment while the bones fuse and heal.

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Determining the source of spine pain is very difficult because of the number of structures in the spine that can contribute to the pain. Spinal injections can be used to diagnose the source of pain or they can be used as a treatment to relieve pain.

To diagnose the source of pain the medication is placed in or near the suspected area that is causing pain. If the patient reports their specific pain is relieved the injection can help the doctor understand the source of the pain.

Epidural Steroid Injections

Arm or leg pain often occurs when a nerve is irritated due to compression ("pinched nerve") near the spine. Epidural injections are used to treat pain that starts in the spine and radiates to an arm or leg.

A diagnostic injection involves injecting medicine at a very specific, isolated nerve to determine if that particular nerve is the source of pain. The response to the injection is closely monitored and if the pain is completely or nearly completely relieved, then that specific nerve is the primary cause of the pain symptoms. If there is little pain relief, then the cause of pain is from another area.

Spinal stenosis is a condition that is caused by a narrowing of the space surrounding the spinal cord or the spinal nerves. The cause is typically because of arthritis of the bones that make up the spine. Arthritis includes formation of bone spurs, thickening and/or calcification of ligaments, and degeneration of the spinal disc. Spinal stenosis is most often seen in people over the age of 50. If it does occur in younger people it is often related to a prior traumatic injury or to acquired conditions such as rheumatoid arthritis, spinal tumors, scoliosis, and congenital stenosis.

Spinal stenosis causes the spinal nerves to become compressed. Compression of these nerves leads to the symptoms experienced by patients who have spinal stenosis.

The most common symptoms are:

  • Pain
  • Numbness
  • Tingling
  • Weakness
  • Difficulty walking

If the area of narrowing of the spine is in the cervical (neck) region, the symptoms are felt in the arms, and if the area of narrowing is in the lumbar (low back) the symptoms are felt in the legs.

Diagnosis

A thorough medical history is important for a physician to be able to diagnose any spine problem. In addition, X-ray, CT, or MRI may be done to help determine the area of stenosis and cause.

Treatment

  • Injections
  • Physical Therapy
  • Decompression
  • Spinal Fusion

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Spine tumors are rare but can occur in any area of the spine or spinal column. They can be benign or malignant and can be a primary tumor (meaning it originates from the spine structures, such as with osteosarcoma) or can be a metastatic lesion from another type of cancer (breast, or lung for example). Spine tumors can arise from nerve or bony structures that make up the spine.

The first symptom for most patients with a spinal tumor is pain. The pain may occur at rest, be worse at night, and might not be related to any type of activity. Other symptoms can include pain in the arm or leg, numbness, weight loss or fever. Pain is a common symptom for most spine problems, so you doctor will help in identifying the true cause of the pain.

Benign spine tumors include:

  • Aneurysmal Bone Cysts (ABCs)
  • Giant Cell Tumors (GCTs)
  • Osteoid Osteoma
  • Osteochondroma
  • Hemangioma
  • Eosinophilic Granuloma

Malignant spine tumors include:

  • Chondrosarcoma
  • Chordoma
  • Ewings Sarcoma
  • Lymphoma
  • Osteosarcoma
  • Plasmacytoma

Diagnosis of spinal tumors requires radiologic exams to determine the exact location and extent of the tumor. Biopsy is necessary to determine type of tumor. The type of tumor is very important in determining the best treatment.

CT reconstruction of spine tumor. Arrow points to the tumor wrapped around cervical vertebra.

CT scan of spine tumor, the arrows point out the tumor that is wrapped around the vertebra" so the bone doesn't show on the scan.

Rocky Mountain Scolios and Spine is closely associated with The Denver Clinic for Extremities at Risk; Dr. Bess is a member physician of The Denver Clinic. Through work with CSU Animal Cancer Center, The Denver Clinic has developed a treatment protocol for osteosarcoma in kids and adults that has the best reported long-term survival for those affected with bone cancer.

The pars interarticularis is a portion of the lumbar spine that joins the upper and lower joints together. The pars is normal in the vast majority of people, however some people are more susceptible to injuring this specific area.

There are three stages of injury to the pars interarticularis:

  1. stress reaction
  2. fracture (spondylolysis)
  3. slippage (spondylolisthesis)

Stress reaction:

After approximately 8 years of age, certain patients begin to experience abnormal growth and development of this particular region in the bone. Stress reaction or injury may occur when the bone experiences excessive wear and tear from activities of daily living, sports, or a fall. The symptoms may include lumbar pain, stiffness, and hamstring muscle tightness. X-rays may not reveal any abnormality. A bone scan will demonstrate the inflammation in the pars. Treatment consists of relieving the pain and restoring spinal flexibility. After several months, the majority of patients resume most activities.

Fracture (Spondylolysis):

If the pars "cracks" or fractures, the condition is called Spondylolysis. An X-ray or CT scan confirm the bony abnormality. Treatment is customized based on the severity of symptoms. Anti-inflammatory drugs, physical therapy, and activity modifications will be considered. Prior to a release to activities after the pain resolves, a course of truncal core muscle strengthening (pilates or yoga) may be prescribed to condition the muscles and minimize reinjury.

Spondylolisthesis:

If the fracture gap at the pars widens, then the condition is called Spondylolisthesis. Widening of the gap leads to the fifth lumbar vertebra shifting forward on the part of the pelvic bone called the sacrum. Normally, the pars interarticularis stabilizes a bony hook that keeps the L5 vertebra from sliding downhill on S1. If the fracture removes this stability, the bone may move forward to varying degrees. Standing lateral spine X-rays are measured to determine the amount of forward slippage. Symptoms may include low back pain or pain in the buttocks or legs related to irritation of the nerve roots. Spondylolisthesis is called “Isthmic” when the chronic fracture leads to the slippage. Another common type of spondylolisthesis in adults is called “degenerative spondylolisthesis”.

Treatment

Nonoperative Treatment

Treatment is customized based on the severity of symptoms. Treatment is prescribed to decrease any acute spasm and restore spinal flexibility. Anti-inflammatory drugs, physical therapy, pars injections, and activity modifications will be considered. One of the mainstays of physical therapy treatment is to perform truncal core strengthening exercises. The therapist will caution the patient on avoiding hyperextension maneuvers and excessive abdominal "crunches". Prognosis is affected by the amount of slippage. In general, most patients with less than 50% slippage fend to fare well through adolescence. With slippage of 50% or greater, the potential for additional slippage with growth and aging is greater. The small numbers of patients who do not respond to conservative medical management are evaluated for a spinal fusion.

Operative Treatment

If the pain, spasm, or slippage increases despite conservative management, then the surgeon will discuss potential spinal fusion.

For a majority of children and adults, fusing the 5th lumbar vertebra to the sacrum is the first choice. The fusion involves removing the loose bony fragments and placing bone graft that will lead to the successful "gluing together" of the two vertebra. Often a cage full of bone is placed in the disc space to increase the likelihood of fusion.

Depending on the degree of the slippage, the bones may be realigned to various degrees. The most important steps are restoring stability and making sure the nerves have no pressure on them.

Spondylolysis and Spondylolisthesis Spondylolysis and Spondylolisthesis Spondylolysis and Spondylolisthesis

Information and figures adapted from Scoliosis Research Society

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Radiographs provide a look at the overall balance of the spine, from neck to pelvis.

CT Scans (Cat Scans) are useful to evaluate the bones in the spine. They provide a 3-dimensional view to determine if vertebrae are abnormally rotated or tilted.

MRI is valuable to determine if there is any associated involvement of the nerves or spinal cord.