Rapid Diagnosis and Excellent Management Help Control Scoliosis

Technology and genetic research are having an impact in almost every area of health and medicine. In the assessment and treatment of scoliosis, new tools have led to more rapid diagnosis and more effective treatment.

Scoliosis, an abnormal sideways curve of the spine, is typically diagnosed during adolescence, although there are rare types in which onset occurs during infancy or young childhood. If it goes untreated, scoliosis can change posture and impair respiratory function.

The disease doesn't usually cause pain or rapid physical changes, so it often goes undetected until a family member, teacher, or healthcare provider notices that a child has uneven shoulders, hips, or waist, or is leaning to one side.

Severe scoliosis can eventually cause deformities in the rib cage that can lead to compromised pulmonary function and lung growth. In the most severe untreated cases, scoliosis can affect the function of the heart.

"Conservative management can help control progression of the deformity," said John G. Thometz, MD, Medical College of Wisconsin Professor of Orthopaedic Surgery. Dr. Thometz practices at Children's Hospital of Wisconsin Orthopedic Center.

Structural vs. Nonstructural
Scoliosis is defined by whether it is nonstructural or structural.

In nonstructural scoliosis, the spine remains structurally normal and the curve is temporary. It can be caused by underlying conditions such as a difference in leg length, muscle spasms, or inflammatory conditions. This type of scoliosis is treated by correcting the underlying causes.

In structural scoliosis, the deformity of the spine has become inflexible, often due to unequal bone growth. Neuromuscular diseases like cerebral palsy, birth defects, injury, infections and tumors cause structural scoliosis. Other causes of structural scoliosis include metabolic diseases, connective tissue disorders and rheumatic diseases.

Genetics Could Lead to Better Treatment
Research is underway that could genetically identify the sources of "idiopathic" scoliosis, in which the cause is unknown.

It has long been known that there is a correlation between scoliosis and genetics, noted Dr. Thometz, adding that although gene research is still in its infancy, it is very promising. Researchers recently have identified a defect in a gene in humans associated with the development of scoliosis.

The identification of a gene defect that causes scoliosis could lead the way to doctors being able to more quickly counter the effects of the disease. Ultimately, doctors hope to use genetic markers to tell which scoliosis patients will experience progression of the spine curvature, and which patients' curvatures will stay stable.

"If we can determine which curves are most progressive, then we will try to have a very early aggressive treatment to prevent the deformity from worsening," Dr. Thometz said.

"The question is whether genetics is the primary cause in all cases," said Dr. Thometz. He noted that researchers have also found abnormalities in protein formation and subtle neurological dysfunction that might lead to scoliosis.

3-D Analysis
In addition to genetic research, Medical College of Wisconsin physicians are utilizing surface topography rather than X-rays to visualize the spine. Doctors at Children's Hospital use the Quantec System, a type of 3-D surface topography that uses light beams and a scanning device to document the three-dimensional contour of the spine.

"We use Quantec to look at surgical correction of the deformity. Since it is a three-dimensional deformity and an X-ray is only two-dimensional, correcting the rotation component and other components of the deformity can't easily be assessed by use of the X-ray alone," Dr. Thometz said.

The other advantage of using the Quantec System to monitor patients with scoliosis comes by way of decreasing radiation exposure from X-rays that can lead to an increase the potential risk of carcinoma, Dr. Thometz said.

"Some of the patients that we have followed since an early age have had 15 or 16 Quantec studies, significantly decreasing their total X-ray exposure," Dr. Thometz said.

Treatment
Treatment for scoliosis is based on the patient's age, growth patterns, the degree and pattern of the curve, and the type of scoliosis. In many cases, scoliosis does not require treatment, but the curve is watched and measured carefully over the years to make sure it doesn't become any worse.

Treatment is initiated based on certain parameters used to determine the extent of the scoliosis. In addition to the Quantec System, the Cobb method is used to measure the severity of the scoliosis on regular X-rays. This helps create baseline measurements that allow doctors to watch the patient's condition evolve over time.

Generally, Dr. Thometz explained, treatment can be determined by the degree of curve. The more immature the patient, the more likely the curve will progress. If the curves are less than 20 degrees, observation is the course of action. If the patient shows a curve of 20 to 25 degrees, then there is an increased chance for progression.

Curves of 30 degrees and greater call for brace treatment, if the patient is still growing. A scoliosis brace will help keep the curve from becoming more severe. There are a wide variety of braces and bracing techniques; doctors will assess each patient to find the system that will give them optimum results.

Surgery, which is needed in the most progressive cases, has begun to benefit from growth modulation research. Growth modulation, in which staples or tethers are applied to the spine, forces it to grow straight.

"Our traditional method for the bad curves is to fuse the spine, which obviously takes the motion away - certainly not the ideal situation," Dr. Thometz said. At times it is needed to prevent severe deformity, but other methods for controlling the curvature continue to be explored.

Brendan O'Brien
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.