Scoliosis Surgery – When Is It Time to Consider Surgical Treatment?

Scoliosis, a condition characterized by an abnormal curvature of the spine, affects approximately 3.1% of children and adolescents, with a higher prevalence in females. This spinal disorder can significantly impact posture and body symmetry, leading to visible changes such as uneven shoulders and hips. As scoliosis progresses, it can cause more severe postural deviations and potential complications, affecting balance, coordination, and gait.

The severity of scoliosis is classified based on the degree of spinal curvature, ranging from mild (less than 25 degrees) to severe (greater than 40 degrees). Surgical intervention is typically considered when the curvature exceeds 50 degrees or when non-surgical treatments fail to provide adequate relief. However, the decision to pursue surgery depends on various factors, including the patient’s age, skeletal maturity, and the potential for curve progression.

Early evaluation and monitoring of scoliosis are important for preventing progression, improving treatment outcomes, potentially avoiding surgery, and ensuring better response to treatment. Regular screenings, especially during adolescence when growth spurts occur, are essential for detecting scoliosis early. The American Academy of Pediatrics and other child health associations recommend routine scoliosis screening for adolescents, emphasizing the importance of early detection and intervention for better management of this condition.

Understanding Scoliosis & Its Progression

Scoliosis is a complex spinal condition characterized by an abnormal lateral curvature of the spine. It develops through various mechanisms and can affect individuals at different stages of life.

Scoliosis is classified into four main types based on its etiology:

• Idiopathic Scoliosis: This is the most common form, accounting for about 80% of all cases. It has no known cause and is further subdivided based on the age of onset:
  • Infantile (0-3 years)
  • Juvenile (4-10 years)
  • Adolescent (11-18 years) 
• Congenital Scoliosis: This type results from embryological malformation of one or more vertebrae. While congenital scoliosis is present at birth, it may not be detected until later in childhood.
• Neuromuscular Scoliosis: This form is secondary to neurological or muscular diseases such as cerebral palsy, spinal cord trauma, muscular dystrophy, or spina bifida.
• Degenerative Scoliosis: This type typically emerges in adults over 40-50 years of age due to arthritic changes and spinal degeneration.

Scoliosis progression varies depending on the type and age of onset. During childhood growth spurts, curves can rapidly progress at rates of 10 to 20 degrees per year. After skeletal maturity, progression slows significantly to about 0.5 to 1 degree per year.

Factors influencing scoliosis progression include genetics, skeletal maturity, and degenerative changes in the spine. Early detection and intervention are important for effectively managing the condition and potentially avoiding more invasive treatments later in life.

Signs That Scoliosis May Require Surgery

1. Severe Spinal Curvature
   Surgery may be recommended when the Cobb angle reaches 40-50 degrees or more in adolescents, as curves of this magnitude are likely to progress even after skeletal maturity. In adults, curves greater than 50-60 degrees may continue to worsen over time and potentially cause respiratory issues.
2. Chronic Pain & Functional Limitations
   Persistent back pain that does not improve with conservative treatments, along with difficulty standing, walking, or performing daily activities, may indicate the need for surgical intervention. These symptoms can significantly impact quality of life and may be alleviated through surgical correction of the spinal deformity.
3. Breathing Difficulties & Organ Compression
   Severe scoliosis can affect lung function and heart health, potentially leading to shortness of breath or chest discomfort. When the spinal curvature causes significant respiratory issues or compromises organ function, surgery may be necessary to prevent further complications.
4. Failed Non-Surgical Treatments
   Surgery may be considered when physical therapy, bracing, or pain management are no longer effective in managing scoliosis symptoms or preventing curve progression. If conservative measures fail to halt the progression of the spinal curvature, surgical intervention may be the next step in treatment.

Types of Scoliosis Surgery

Spinal Fusion Surgery

Spinal fusion surgery is the most common procedure to correct spinal curvature in scoliosis patients. This technique stabilizes the spine using rods, screws, and bone grafts to fuse vertebrae together, eliminating motion between the fused segments.

The surgery involves placing bone graft material between the vertebrae to stimulate new bone growth and fusion. Several types of bone grafts can be used, including autografts (patient’s own bone), allografts (donor bone), and synthetic bone substitutes. Autografts, typically harvested from the patient’s iliac crest, are considered the gold standard due to their osteogenic properties. Allografts from bone banks provide an alternative without donor site morbidity. Synthetic options like ceramic-based grafts and bone morphogenetic proteins (BMPs) are also available.

During the procedure, the surgeon places rods and screws to stabilize the spine while fusion occurs. The bone graft is then packed around the instrumentation to promote bone growth between the vertebrae. Over time, this leads to solid fusion and permanent correction of the spinal curvature.

A systematic review and meta-analysis published in 2020 found moderate evidence that spinal fusion improves quality of life for adolescents with idiopathic scoliosis in medium and long-term follow-up. The study reported statistically significant improvements in pain, function, self-image, and overall quality of life at 2- and 5-years post-surgery.

Vertebral Body Tethering (VBT) – A Motion-Preserving Alternative

Vertebral Body Tethering (VBT) is a minimally invasive, motion-preserving alternative to spinal fusion for treating scoliosis in growing adolescents. The FDA approved VBT in August 2019 for skeletally immature patients with idiopathic scoliosis, specifically those with a major Cobb angle of 30 to 65 degrees who have failed bracing or are intolerant to brace wear.

VBT uses a flexible cord (tether) to gradually correct spinal curvature while allowing for continued growth. During the procedure, surgeons place screws on the convex side of the spinal curve and secure a rope-like tether along the vertebrae. As the patient grows, the spine straightens in response to the tension applied by the tether.

This technique offers several advantages over traditional spinal fusion:

• Preservation of spinal mobility
• Potential for continued spinal growth
• Smaller incisions, potentially leading to reduced blood loss and faster recovery
• Less surgical hardware implanted

Recent studies have shown promising results for VBT. A systematic review and meta-analysis published in 2023 found that VBT resulted in a significant reduction of adolescent idiopathic scoliosis at 2 years of follow-up. The mean Cobb angle decreased from 47.8° pre-operatively to 22.2° at final follow-up. Another study with a minimum 3-year follow-up reported a clinical success rate of 73%, with only 7.2% of patients requiring posterior spinal fusion.

Osteotomy & Spinal Reconstruction

Osteotomy and spinal reconstruction are advanced surgical techniques used to correct severe or complex spinal deformities that cannot be adequately addressed through more conservative methods. These procedures involve reshaping the spine to improve alignment, balance, and overall function.

Spinal osteotomy is a surgical procedure in which sections of spinal bone are cut and removed to allow for correction of spinal malalignment. There are three main types of osteotomies:

1. Smith-Petersen Osteotomy (SPO): Provides 10-20° of correction per level by removing bone from the back of the spine.
2. Pedicle Subtraction Osteotomy (PSO): Offers about 30° of correction, mainly at the lumbar level, by removing bone from all three columns of the spine.
3. Vertebral Column Resection (VCR): Allows for maximum correction by completely removing one or more vertebral bodies.

Spinal reconstruction surgery may involve multiple levels of the spine and aims to correct significant deformities, stabilize the newly shaped spine with rods and pins, and fuse the vertebrae together. In some cases, entire vertebrae may be removed and replaced with artificial devices.

These procedures can significantly improve symptoms of severe spinal deformities, including pain reduction, restored balance, improved posture, and enhanced quality of life. However, they are complex surgeries reserved for cases where non-surgical treatments have failed or when significant structural correction is needed.

Benefits of Scoliosis Surgery

Scoliosis surgery offers several significant benefits for patients with severe spinal curvature. These benefits can greatly improve quality of life and overall well-being.

• Improved Spinal Alignment: Surgery can significantly reduce spinal curvature, leading to better posture and alignment. A study published in 2023 found that the mean Cobb angle (a measure of spinal curvature) decreased from 104.5° preoperatively to 21.9° at final follow-up after surgical intervention.
• Pain Relief: Surgical correction of scoliosis can alleviate chronic pain associated with the condition. A systematic review reported that patients experienced significant improvements in pain scores after scoliosis surgery.
• Enhanced Mobility & Function: Correcting spinal deformity can lead to improved mobility and daily function. A study with a 32-year mean follow-up found that most patients (87.3%) maintained regular work activity after scoliosis surgery.
• Prevention of Further Progression: Surgery can halt the progression of scoliosis, preventing potential complications associated with severe curvature. This is particularly important for adolescents with progressive curves.
• Improved Quality of Life: Multiple studies have shown significant improvements in health-related quality of life (HRQL) after scoliosis surgery. A systematic review found that surgery improved HRQL in adult scoliosis patients at a minimum 2-year follow-up.
• Long-term Benefits: Research indicates that the benefits of scoliosis surgery can be maintained long-term. A study with a minimum 5-year follow-up demonstrated sustained improvements in spinal alignment and pulmonary function.

These benefits highlight the potential positive impact of scoliosis surgery for appropriate candidates. However, it is important to note that the decision to undergo surgery should be made in consultation with a spine specialist, considering individual factors and potential risks.

What to Expect Before & After Surgery

Pre-Surgery Preparation

Medical imaging is crucial for assessing spinal curvature and planning scoliosis surgery. The primary imaging modalities used include:

• Radiography (X-rays): This is the primary tool for diagnosing and monitoring scoliosis. It allows measurement of the Cobb angle, which defines the severity of the curve.
• Computed Tomography (CT): Used when more detailed imaging of bony structures is needed.
• Magnetic Resonance Imaging (MRI): Employed when there is suspicion of underlying neurological abnormalities.

Preoperative consultations may involve:

• Orthopedic spine surgeon: Diagnoses the condition, plans the surgery, discusses risks and benefits, and guides treatment.
• Pulmonologist: Assesses respiratory function, which can be affected by severe scoliosis.
• Cardiologist: Evaluates heart function, if indicated.
• Anesthesiologist: Discusses anesthesia plans and risks.

Surgical Procedure & Hospital Stay

The surgery typically lasts several hours, depending on the complexity of the case. The patient stays in the hospital for several days after scoliosis surgery. Pain management often involves a multimodal approach, including epidural analgesia followed by oral pain medications. Patients are encouraged to start moving as soon as possible, often with assistance from physical therapists.

Recovery & Rehabilitation

Recovery and rehabilitation timelines vary, but generally:

• Initial recovery: 2 to 4 weeks of limited activities like walking, dressing, and bathing.
• Physical therapy: Begins almost immediately post-surgery and continues for several months.
• Return to school/work: Often possible around 4 to 6 weeks post-surgery, usually part-time initially.
• Full recovery: Takes 6 months to a year, depending on individual factors.
• Return to sports: Non-contact sports may be resumed around 3-6 months post-surgery, while contact sports may require waiting up to a year or more.

It is important to follow the surgeon’s specific instructions, as recovery timelines can vary based on individual cases and the extent of the surgery.

Risks & Considerations of Scoliosis Surgery

Scoliosis surgery carries potential risks and complications that patients should be aware of before undergoing the procedure. While advancements in surgical techniques have improved outcomes over time, it is important to consider these factors carefully.

Potential complications of scoliosis surgery include:

• Surgical site infection: This is one of the most common complications, occurring in about 0.52% of cases.
• New neurological deficits: Approximately 0.35% of patients experience new neurological issues post-surgery.
• Implant-related complications: These occur in about 0.20% of cases.
• Pseudarthrosis (failure of fusion): This complication has been reported in about 5% of idiopathic scoliosis cases.
• Deep wound infection: Reported in approximately 4.7% of idiopathic scoliosis surgeries.
• Tether breakage: In VBT, tether breakage is the most common complication (21.9%).

While risks are involved in every surgery, the overall complication rate for adolescent idiopathic scoliosis surgery has decreased significantly over time, from 4.95% between 2004 and 2007 to 0.98% from 2013 to 2016.

Non-Surgical Alternatives to Consider First

Non-surgical alternatives to scoliosis surgery offer effective management strategies for individuals dealing with spinal curvature. These methods can help alleviate symptoms, prevent progression, and improve overall quality of life without the need for invasive procedures.

Physical therapy and targeted exercise programs play a crucial role in managing scoliosis. Tailored exercise regimens, such as the Schroth Method, focus on strengthening the muscles surrounding the spine, improving posture, and enhancing flexibility. Research indicates that these exercises can reduce pain and slow the progression of scoliosis by promoting better spinal alignment. A systematic review highlighted that scoliosis-specific exercises not only improve functional outcomes but also enhance self-image and overall well-being in patients with scoliosis.

Pain management techniques are also essential for those experiencing discomfort due to scoliosis. Common approaches include injections, such as corticosteroid injections, which can reduce inflammation and alleviate pain for several months. Image-guided injections allow for precise delivery of medication to affected areas, providing significant relief. Additionally, oral medications like nonsteroidal anti-inflammatory drugs (NSAIDs) can help manage pain and improve daily functioning.

Bracing options are particularly important for growing adolescents with scoliosis. Bracing is recommended for curves typically between 25 and 40 degrees, especially during periods of rapid growth. The goal of bracing is to halt the progression of the curve while allowing for normal growth and development. Research from the Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST) demonstrated that bracing significantly reduces the likelihood of surgical intervention, with 72% of brace wearers avoiding surgery altogether. Modern braces are designed to be more comfortable and effective, providing three-dimensional correction to support proper spinal alignment.

Overall, these non-surgical alternatives provide valuable options for managing scoliosis effectively while minimizing the need for surgical intervention. By combining physical therapy, pain management techniques, and appropriate bracing, patients can achieve improved outcomes and maintain a better quality of life.

Is Scoliosis Surgery Right for You?

Deciding whether scoliosis surgery is right for you involves careful consideration of several factors:

• Curve severity: Surgery is typically recommended for curves exceeding 45 to 50 degrees by the Cobb method. This threshold is based on research showing that curves larger than 50 degrees tend to progress even after skeletal maturity.
• Age and skeletal maturity: For optimal results with certain procedures like Anterior Scoliosis Correction (ASC), patients are ideally between 8 and 15 years old. However, surgical options exist for both adolescents and adults.
• Curve progression: The rate of curve progression is a crucial factor. Curves that continue to worsen despite conservative treatments may indicate the need for surgical intervention.
• Pulmonary function: Curves larger than 60 degrees can impact lung function, with vital capacity below 45% of normal value being a risk factor for respiratory failure.
• Patient motivation: In some cases, a patient’s desire to correct their spine, even with a curve in the 40 to 45 degree range, may be considered.

The importance of a personalized treatment plan cannot be overstated. Patient-centered scoliosis care involves tailoring treatment strategies to meet the specific needs, preferences, and values of each individual. This approach includes:

• Comprehensive management: Utilizing various treatment options, including custom bracing, scoliosis-specific rehabilitation therapy, or surgery when necessary.
• Advanced technologies: Employing modern diagnostics and technology to develop and monitor individualized treatment plans.
• Personalized care plans: Creating strategies that align with the patient’s individual case and health goals.

By focusing on these factors and adopting a patient-centered approach, healthcare providers can deliver more effective and compassionate treatment, potentially leading to improved clinical outcomes and enhanced quality of life for scoliosis patients.

Expert Scoliosis Care with Dr. John Peloza

Scoliosis surgery is typically recommended when the spinal curvature exceeds 45 to 50 degrees, particularly in growing adolescents, or when conservative treatments have failed to halt curve progression. Dr. John Peloza is a trusted specialist in spinal deformity correction, offering expert care for scoliosis patients in Chesterfield, Missouri.

Dr. Peloza brings over three decades of experience in delivering life-changing outcomes for spine patients. He specializes in minimally invasive spine surgery techniques, cervical and lumbar disc arthroplasty, and complex spine surgery. Dr. Peloza’s approach combines innovative treatments with a patient-first philosophy. He offers advanced diagnostics and tailored treatment plans, ensuring each patient receives personalized care. His practice uses cutting-edge technologies to provide optimal outcomes for spine disorders.

Don’t let scoliosis limit your life any longer. Take the first step towards improved spinal health by calling 314.356.2567 or visiting pelozaspine.com.