The Scoliosis Treatments, Conservative vs the Life Altering (for better or worse)

Scoliosis is an unnatural lateral curvature of the spine. Scoliosis can be a dangerous medical condition due to the progression over time of the Cobb angle. The Cobb angle is used by specialists to measure the magnitude of scoliosis and other spinal conditions, first used in 1948 (“Cobb Angle,” 2016) it is still the orthodox method for scoliosis. There are two main types of scoliosis degenerative and idiopathic. Idiopathic scoliosis is the most common form of scoliosis and occurs mainly in adolescents, while degenerative scoliosis occurs mainly in adults due to the degeneration of the facet joints and intervertebral disks. Scoliosis, Idiopathic (IS) or Degenerative (DS) can be treated mainly in two ways, Spinal Fusion (SF) or by bracing (orthotics) (“Support for People with Scoliosis.” N.d.). A SF uses rods, hook, screws and wires to straighten and fuse the spine, therefore reducing the cobb angle. While treatment through bracing involves fitting a custom mould that prevents the cobb angle from progressing, as it is worn many hours throughout the day. This article will evaluate studies in their effectiveness to examine the optimal treatment of Scoliosis, each paragraph will examine a particular theme (bracing, SF and quality of life after treatment), with the final paragraphs comparing and contrasting these studies and themes.

Under arm bracing is a particularly invasive method of treating scoliosis (idiopathic or degenerative), as one of the oldest treatments of scoliosis, and has in particular very little evidence that bracing is an effective treatment. However, This study (Palazzo et al., 2016) looked into the effectiveness of Bracing on reducing or reversing the Cobb angle in patients with scoliosis, used only female patients and a relatively small sample size. They concluded that in their particular study, under arm bracing works very well to reduce the Cobb angle in female patients with adult scoliosis, therefore, reducing the progression makes surgical treatment much less likely. However, this study is limited by its purely female sample population. However, a large majority (Mcintosh et al., 2012) of the scoliosis patient population is female (10:1 ratio). This could lead to the conclusion that Palazzo et al have provided a rough estimate of how effective bracing is for males and females when it comes to scoliosis. Although the authors did have a reasonably small amount of references (11), this could potentially leave room for inadequate research performed by Palazzo et al. However, this is not an issue because a large majority of the references are from peer reviewed journals and contain specific and detailed information about scoliosis treatment. While fairly invasive, these sources demonstrate how under arm bracing can be an extremely effective conservative treatment of Scoliosis with up to 83.5% (Palazzo et al,. 2016) decrease in the rate of progression of the Cobb angle.

 

When the Cobb Angle in a patient has progressed to more than 45-50˚ a SF operation can be performed. (“Surgical Treatment for Scoliosis.” N.d.) This is a much less conservative treatment but usually more effective in particularly reducing the Cobb Angle. Since the treatment is undertaken when there is generally no other option as in the future the curve may progress to dangerous proportions. Potential flaws of SF have been examined (Nohara et al,. 2015) in a study by Japanese researchers that found lumbar Disk Degeneration (DD) was found in 48% of patients (average follow up time 15.2 years, and 25 years of age), from this we can conclude that SF may not be the best method in the long term when it comes to treating scoliosis. However, this study does have a slight lack of references furthermore the references includes are particularly old, however, the study did not receive any funding. Conversely, there is a particular lack of research that is primary and peer reviewed when it comes to SF studies and the Positives and negatives in Scoliosis. Therefore, more research should be conducted before a consensus can be made.

 

Each method of treatment may leave the patient with different levels of athleticism. While a SF stops a large portion of movement in the back, there is still the opportunity for adequate movement due to the Lumbar spine producing the majority of the spinal mobility (“Understanding Spinal Anatomy: Regions of the spine.” N.d ). Two Studies (Jeans et al., 2016;  Sperandio et al., 2014) have shown that surgical (growth rods that are taken out, similar to fusion) and non operative patients both have impaired cardiovascular function. However, the non surgical treatment did show a more “significant” level of contrast between the control, where as the postoperative group were not too far off the control. Although, this cannot be representative of the general population of postoperative patients because, the sample size is not very large, therefore, limiting the reliability of the evidence to predict the entire population. Furthermore, the study was performed on children of the ages 3.7-10.4, with an average of 7.1 (follow up age). This does not represent postoperative patients overall as the median age of Adult idiopathic scoliosis was (Verla et al., 2016) 53.3 years and in Adolescent Idiopathic Scoliosis it was 16.9 years (http://www.medscape.com/viewarticle/523414_4). This is a huge contrast to the study of Growth rods. Therefore, it can be concluded that scoliosis treatments all leave the individual with less function than a normal human in some respects but may vary between methods on the functionality left after treatment.

 

The studies used in this essay are for the most part peer reviewed, primary studies that display evidence in a comprehensible and eloquent fashion. However, limited specific research is available relating to themes of SF, bracing and exercise after treatment. This may be due to the relatively small sample sizes in studies (Jeans et al., 2016;  Sperandio et al., 2014), in particular a lack of evidence for the male scoliosis population (Mcintosh et al., 2012). However, two out of  three of the studies involving surgical treatments received funding (Jeans et al., 2016; Verla et al., 2016) while the studies with no treatment or bracing treatments (Palazzo et al., 2016 ; Sperandio et al., 2014) both did not receive any funding (no disclosures), while also the study that found negative effects of a SF on DD. This follows a similar trend that could point to pro SF research being funded for an external reason. Another reason could be, this may be happening due to difficulty in conducting SF research and financial gain needed to conduct these expensive studies. There may be a plethora of reasons why there is a funding difference between the two types of studies but consistent with all studies is a lack of evidence for the male gender.

 

Scoliosis treatment methods and the studies that evaluate them present many positives negatives and interesting questions as seen through the research in this article. SF does tend to be a very effective treatment to reverse the Cobb Angle and stop it from progressing. However SF does have a potential long term down side of DD especially in adults, this is backed up by a reliable study. Furthermore, the other studies I have found regarding SF or other surgical methods, for the most part, have funding, therefore, there is room for potential bias. While back bracing doesn’t seem to be as effective as a treatment the studies I have found show that it does significantly improve the progression of the Cobb angle but is rather invasive, and does not present any real opportunity for reduction of the Cobb angle. As a result, there is more definitive research that needs to be done on all methods of treatment of scoliosis and many more studies should be examined and compared.

 

References:

Palazzo, C., Montigny, J. P., Barbot, F., Bussel, B., Vaugier, I., Fort, D., Courtois, I., Marty-Poumarat, C. (2016). Effects of Bracing in Adult with Scoliosis: A Retrospective Study.  Archives of Physical Medicine and Rehabilitation, 98(1), 187–190. doi: http://dx.doi.org/10.1016/j.apmr.2016.05.019

 

 

Verla, T., Adogwa, O., Toche, U., Farber, S. H., Petraglia, III. F., Murphy, K. R., Thomas, S., Fatemi, P., Gottfried, O., Bagley, C. A., Lad, S. P. (2016). Original article: Impact of Increasing Age on Outcomes of Spinal Fusion in Adult Idiopathic Scoliosis. World Neurosurgery, 87, 591–597. doi: http://dx.doi.org.ezproxy.aut.ac.nz/10.1016/j.wneu.2015.10.061

 

Sperandio, E. F., Alexandre, A. S., Yi, L. C., Poletto, P. R., Gotfryd, A. O., Vidotto, M. C., Doruado, V. Z. (2014). Clinical Study: Functional aerobic exercise capacity limitation in Adolescent Idiopathic Scoliosis. The Spine Journal, 14(10), 2366–2372. doi: http://dx.doi.org.ezproxy.aut.ac.nz/10.1016/j.spinee.2014.01.041

 

Nohara, A., Kawakami, N., Seki, K., Tsuji, T., Ohara, T., Saito, T., Kawakami, K. (2015). Long-Term Follow-Up Case Series: The effects of Spinal Fusion on Lumbar Disk Degeneration in Patients with Adolescent Idiopathic Scoliosis: A minimum 10-Year Follow-up. Spine Deformity, 3(5), 462–468. doi: 10.1016/j.jspd.2015.04.001

 

Jeans, K. A., Johnston, C. E., Stevens, Jr., W. R., Tran, D. (2016) Case Series: Exercise Tolerance in children With Early Onset Scoliosis: Growing Rod Treatment “Graduates”. Spine Deformity, 4(6), 413–419. doi: 10.1016/j.jspd.2016.06.002

 

Wilk, B., Karol, L. A., Johnston, C. E., Colby, S., Haideri, N. (2006). The Effect of Scoliosis Fusion on Spinal Motion: A comparison of Fused and Nonfused Patients With Idopathic Scoliosis. Spine, 31(3), 309–314. doi: http://www.medscape.com/viewarticle/523414_4

 

Thuaimer, A., Niknejad, M., Rezaee, Y., Weerakkody, Y., Goel, A., Samir, B., Gaillard, F. (2016) Cobb Angle. Retrieved from https://radiopaedia.org/articles/cobb-angle

 

“Support for People with Scoliosis.” Types of Scoliosis – Scoliosis Association. N.p., n.d. Retrieved from http://www.sauk.org.uk/types-of-scoliosis/types-of-scoliosis

 

“Surgical Treatment for Scoliosis.” AAOS – Orthoinfo. N.p., n.d. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=A00638

 

“Understanding Spinal Anatomy: Regions of the spine  – Cervical, Thoracic , Lumbar, Sacral.” Understanding Spinal Anatomy: Regions of the spine  – Cervical, Thoracic , Lumbar, Sacral/. N.p., n.d. Retrieved from http://www.coloradospineinstitute.com/subject.php?pn=anatomy-spinalregions14

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