Case Study: Correcting Adolescent Idiopathic Scoliosis

What is Adolescent Scoliosis?

Scoliosis occurs when a child (or an adult) develops an abnormal sideways bend in his or her spine. If scoliosis emerges between the ages of 10 – 18, then we say that the child has “adolescent scoliosis.” If the cause of the scoliosis is unknown (as is often the case), then we additionally say that the child has adolescent idiopathic scoliosis (or AIS).

AIS typically emerges between the ages of 10 – 12, when growth spurts in the spine are common. In fact, according to the Scoliosis Research Society, 4% of adolescents will develop scoliosis by age 18, when adulthood height is finally achieved.

For reasons not fully understood, girls are 10 times more likely to develop AIS than boys. And, approximately 30% of these girls have a family history of scoliosis. Although researchers have yet to detect a “scoliosis” gene, this strongly suggests that AIS might have a genetic component.

Meet The Patient

The patient was a 16-year-old female with severe AIS. Physical examination, patient history, and x-rays revealed the following symptoms of scoliosis:

• Severe Spinal Deformity: The x-rays revealed that the patient had severe AIS, which is defined as >40 degrees of spinal curvature. In the patient’s case, the thoracic spine arced 59 degrees to the right side (a condition also known as dextroscoliosis or DS). DS creates a C- or S-shaped bend in the spine. As such, the patient had developed a second, compensatory curve to the left in her lumbar spine.
• Body Image Issues: Because the patient’s scoliosis was visible, the patient admitted to experiencing body image issues. In addition to wanting spinal fusion to relieve her pain, the patient also wished to reduce the outward signs of her spinal deformity.
• Rib Hump: Because the patient’s scoliotic curve was more prominent on the right side, the patient had also developed a noticeable right rib hump. This condition can sometimes require thoracoplasty, in which a doctor must remove sections of the patient’s ribs. Although this was not the case for our patient, you might need a thoracoplasty if:
  • Your doctor can’t fix your rib hump with spinal fusion or having you wear a brace
  • Your rib hump endangers or restricts your lung function

Although these were the signs of scoliosis that were most common in our patient, keep in mind that other individuals with scoliosis may have:

• Asymmetrical shoulders, hips, or torso
• Reduced range of motion in the torso
• Difficulty walking or the start of a limip
• Neurological issues, such as tingling, numbness, or urinary incontinence
• Spinal cord compression
• Muscular issues, such as cramps, spasms, or weakness
• Trouble breathing or regulating heart and lung function

When Does AIS Require Surgery?

If your child has a large curve from scoliosis (> 50 degrees), then your child will likely require surgery to improve their quality of life. Sometimes, the progression of the curve can be halted in children if the curve is <50. However, once your child reaches skeletal maturity, bracing is no longer an effective option for scoliosis correction.

To determine if your child has reached skeletal maturity, your doctor may take x-rays of the child’s pelvis. By examining the crest of the hip, your doctor can determine how advanced your child’s growth is. (Often, your doctor will measure this growth on the Risser Scale. 0 to 1 on the scale indicates that your child is in the midst of a rapid growth spurt. In contrast, a 4 or 5 on the scale would signal that growth is nearly complete.)

Once your doctor has determined how “mature” your child’s spine is, he or she will decide if observation, bracing, or surgical treatment will be the most effective. Usually, your doctor will only consider observation to be appropriate when the curve is very small. (Unfortunately, scoliosis can progress very rapidly when we don’t take prompt action.)

To prevent your child’s curve from progressing further, your doctor may recommend scoliosis bracing. These flexible or rigid orthotics are used to halt the progression of the curve during times of rapid spine growth. Although braces can’t reverse scoliosis, they can sometimes prevent a child from needing scoliosis surgery.

However, when all else fails, or if your child’s curve is already too advanced, then your doctor will suggest surgical treatment options. Because your child’s treatment plan will vary according to their unique curvature, consult with an orthopedist to find out which type of procedure your child will need.

Correcting the Patient’s Adolescent Idiopathic Scoliosis With Spinal Fusion

To correct the patient’s AIS, Dr. Daveed Frazier used minimally invasive ALIF & PLIF. During this method of scoliosis correction, the doctor accesses and fuses the patient’s spine from the anterior (front) and posterior (back) sides. (As a result, you may sometimes hear doctors refer to this method as a 360 degree approach.) Although some curves may benefit from using a single approach, combining ALIF and PLIF often affords the spine with greater long-term stability.

First, Dr. Frazier began the combined approach by performing an ALIF. Using retractors and tiny instruments, Dr. Frazier entered the patient’s thoracic spine from the front side. Dr. Frazier then moved any muscles and ligaments gently to the side to provide an unobstructed view of the spine.

Next, Dr. Frazier excised the front portion of any spinal discs that would be fully removed during the procedure. Removing these discs would subsequently allow Dr. Frazier to install the fusion hardware.

Then, using rods and screws, Dr. Frazier manipulated the patient’s spine into a more ideal alignment. A bone graft sourced from the patient’s hip was inserted into the interbody space, between adjacent vertebrae. Over time, this bone graft would mature, fusing the side-by-side vertebrae into one vertebral body. After completing the ALIF on the front side, Dr. Frazier completed this same process on the back side of the spine (a process now known as PLIF).

With the ALIF and PLIF complete, Dr. Frazier sutured the patient’s incisions and prepared the patient for recovery.

Minimally Invasive Spine Surgery (MISS) In Action

Minimally Invasive Spine Surgery (MISS) for scoliosis refers to any operation that enables the patient to heal faster, with less pain and scarring. Although MISS is not suitable for every patient, our patient enjoyed the following advantages of MISS:

• Shorter Operative Time: Dr. Frazier was able to perform the entire procedure in just under 4 hours. Prior to the advent of MISS, a spinal fusion of this magnitude would have taken at least 8 – 12 hours to perform.
• Less Blood Loss: Throughout the entire procedure, the patient lost only 400 cc of blood. This amounts to less than 2 cups of blood loss – an incredibly small volume for a 4-hour procedure.
• Typical Hospitalization Time: Because of the patient’s age, she spent 5 days in the hospital for observation after surgery. (This is standard practice for pediatric scoliosis patients following spine surgery.)
• Faster Recovery Time: The patient elected to have her procedure performed during her summer break from school. When the school year resumed, the patient was able to attend school and participate in sporting activities without any issues.
• Improved Body Image: The patient reported having enhanced self-esteem as a direct result of improvements in her spinal curvature. Her scoliosis was no longer observable, which allowed the patient to feel less self-conscious about her appearance.

If you are interested in reaping the benefits of MISS, then don’t hesitate to contact Dr. Daveed Frazier, Harvard-trained scoliosis surgeon. Dr. Frazier has over 20 years of experience as a pioneer of minimally invasive techniques. If you suffer from AIS or complex spinal deformities, then Dr. Frazier knows how to use MISS to resolve your pain!