Once scoliosis has been diagnosed by a physician or trained professional, several treatment options are available. The treatment chosen largely depends on the severity of the curve and age of the patient. The majority of the population with scoliosis requires no treatment, only follow-up. Physicians recommend that anyone with a spinal condition exercise regularly, maintain ideal weight, avoid smoking and sedentary (little exercise) lifestyle. Both losing weight and exercising regularly means both having a stronger back, and less for it carry around. Since the cause of scoliosis is not known, most of the accepted treatments are directed at correcting the spinal curve itself.

Only a few treatment options have demonstrated positive results through studies which follow methods approved by much of the scientific community. These studies often enroll large groups of individuals, and attempt to limit bias and error as much as possible. For this reason, physicians are often more inclined to accept and recommend treatments which have undergone this testing. Electrical muscle stimulation, exercise programs, and spinal manipulation (of the kind practiced by chiropractors) have not, by themselves, been found to be effective treatments for scoliosis. Many individuals, however, have found that exercise, massage, and a variety of other therapies go very well with the physician-recommended scoliosis treatments. Other sections of the packet deal with these "supplementary treatments", and these deserve a closer look. The following list, however, is limited to those treatments accepted by most physicians as effective in preventing and/or correcting scoliotic curves.

Do Nothing/ Monitor Progression

Most spine curves (about 95%) in children and adults will remain small and need only be watched by an orthopedist for any sign of progression. The decision to do nothing, that is, limit treatment to monitoring the progression of the curve, may be a reasonable decision depending on the age of the person and the predicted outcome. If a child’s curve is mild (10-25^o) they should be monitored every 6-9 months, from age 9 until age 16 1/2 (if a girl) or age 18 (if a boy).

Studies of untreated patients have indicated that many patients with mild scoliosis and many who were past puberty show no worsening of their scoliosis with observation alone. Not rarely spontaneous lessening of mild curvature is seen without any form of treatment.

Adult scoliosis patients, the majority of which have carried their scoliosis over from adolescence, should have physical examinations at least twice a year during their entire adult life, and if curve progression is noted, should begin treatment as soon as possible. Adult scoliosis is discussed more thoroughly in another section in this packet, entitled "Adult Scoliosis".

Are there any health risks associated with X-rays?
One study found that people with adolescent idiopathic scoliosis had an increased risk for cancer from the full-spinal radiographs (x-rays). The author of the study concluded that this risk can be reduced from one half to three quarters if the anteroposterior view ( front to back) is replaced with the posteroanterior view (back to front). You might want to ask your doctor about this.

Bracing

Braces have been shown to be an effective method for preventing curves from getting worse. By pushing the spine into a straighter position by uneven pressure on the skin, muscle and ribs, braces cause a passive straightening of the curve. Braces are generally worn 23 hours a day with time out of the brace for team sports or swimming exercises. As a teenager slows her growth and reaches skeletal maturity, time in the brace is diminished and eventually the treatment is ended.

Braces need constant attention to ensure that they are reducing the curves and should be re-adjusted or re-fabricated if any curve reduction is lost while wearing the brace.

What size curves are braces used for?
Curves greater than 40 or 45 degrees Cobb have been found to respond poorly in general to bracing and are usually treated surgically instead. Candidates for bracing programs are individuals with either

• progressive curves between 20-30 degrees
• curves over 30 degrees

Curves under 20 degrees generally do not need treatment. Exceptions to these guidelines are many and depend upon a number of other factors.

How effective is bracing?
In children, a moderate curve between 20 and 40 degrees will be reduced by 1/3 or 1/2 of it’s original size. More importantly, a brace prevents a curve from growing during a teenager’s growth spurt, and may help avoid surgery. Though the majority of curves end up where they started when bracing was first applied, about 20% of people braced will have lasting partial correction of their curve. Some people with progressive adolescent idiopathic scoliosis (AIS) only manage to partially slow the curve growth, and continue to worsen. A small percentage (in one recent study, 10%) of these individuals progress enough to require surgery, either during or at the end of their bracing program.

In adults, though the curve may progress slowly over the years, bracing is not a practical solution to prevent curves from increasing. Mild curves under 30 degrees do not usually progress; severe curves over 60 degrees usually progress and scoliosis between 30 and 60 degrees may or may not progress. Adult scoliosis is discussed more thoroughly in a separate part of this packet.

What kinds of braces are used?
The Milwaukee Brace
The Milwaukee Brace was the first modern brace designed for the treatment of scoliosis. Developed by Drs. Walter Blunt and Albert Stemmed of the Medical College of Wisconsin and Milwaukee's Children's Hospital in 1945, it underwent design changes over the years, reaching its present form around 1975. It is still used today, particularly for high thoracic (chest-high) curves. Metal bars in the front and back of the brace extend the length of the torso and are attached to a firm-fitting plastic pelvic girdle and to a throat mold or ring which encircles the neck. Straps attached to the metal bars hold pressure pads, which are precisely placed depending on the individual's curve pattern. While the bars hold the body erect, the neck ring keeps the head centered over the pelvis and the pads push against the curve. Everything works together to keep the body straight and to prevent progression of the curves while the patient is growing.

Though an older model, the Milwaukee Brace is still considered the best treatment for upper thoracic (chest high) curves.

In the early seventies, the most popular of the TLSO systems, the Boston Brace, was developed by Dr. John Hall and Dr. William Miller of The Boston Children's Hospital. The Boston Brace extends from below the breast to the beginning of the pelvic area in front and just below the shoulder blades to the top of the thighs. It is designed to keep the lower back in a flexed position by pushing the abdomen in and flattening the lower back. Pads are strategically placed to provide pressure to the curve, and areas of "relief" or "voids" are provided opposite the areas of pressure.

Most curves in the lower part of the thoracic and entire lumbar (lower back) spine are treated using TSLO braces.

The Charleston Bending Brace
Developed in 1979 by Dr. Frederick Reed and Mr. Ralph Hooper, CPO, this brace is worn only at night during sleep. It is made to "overcorrect" the curve, twisting the spine in the opposite direction from which it curves. Studies have not shown that individuals who use this brace are more likely to wear their brace regularly, but it may be easier to wear a part-time brace at night than during the day.

A recent study conducted by physicians at the Texas Scottish Rite Hospital for Children found that the Boston brace may be a more effective treatment than the Charleston brace. The Charleston brace is usually considered more in the treatment of smaller single thoracolumbar (mid-lower back) or single lumbar (lower back) curves.

How often should the brace be worn?
The role of wearing time is not clear. It is assumed that a brace that is never worn will do nothing and that a brace that is worn for 24 hours per day is doing as much as a brace is capable of doing. The idea of wearing a brace for 23 hours a day as full-time wear was a decision not based on hard objective data. In recent years, the Scoliosis Research Society (for more information on this organization, see the "Resources" section of the packet) has raised doubt as to whether part-time brace wearing is effective and if so, how many hours per day is enough.

What does successful brace treatment require?
1. Early detection while the patient is still growing.
2. Mild to moderate curvature.
3. Regular examination by the orthopedic surgeon.
4. A well-fitted brace.
5. A cooperative patient and supportive family.
6. Maintenance of normal activities, including exercise, dance training, and athletics, with elective time out of the brace for these activities as supervised by the physician.

What are the side effects of bracing?
Bracing has several side effects. Skin rashes will often develop underneath the constant pressure of the brace. These are common, especially in warmer climates, but can be treated with modification of the brace or change in skin care. Probably the greatest side effect of brace wear is psychological, but this is difficult to measure. Bracing for adolescent idiopathic scoliosis comes at a sensitive time in adolescence when body image and peer relations are critical. Although today’s low profile braces are not as visible as the old Milwaukee brace, they are still bulky and unnatural. Girls who wear braces often worry about how their clothes look with their brace. ("Dressing your Curves" a newsletter published by the National Scoliosis Foundation, is an excellent resource for this issue. More information is available in the "Resource" section of the packet.) Hugging and touching also become more complicated issues, as well as changing clothes in front of other kids. Because the brace is worn all the time, it becomes part of who the patient is. If someone gives them a hug, they hug the brace too.

Other emotional issues of bracing include anxiety about whether or not the bracing is working, when she can stop wearing it, and if she will need surgery.

Each visit to the physician becomes a serious event during which an important decision may be made. Each time a new treatment plan evolves, the child has to assimilate a slightly different concept of herself... If most of these occasions are handled with a high degree of empathy, the child may develop a strong, resilient sense of self. (p. 57, Forstenzer and Roye, 1989)

One study showed that girls being treated with bracing felt more control over their condition than those being treated with surgery. This might be because the treatment requires their daily participation; girls are in control each day of whether they will put on their brace. More discussion of a parent’s role in brace wearing is in "Parents and their Children with Scoliosis" and the issues of self image and self esteem in girls who wear braces is found in "Scoliosis and Self Image".

A Study on Adapting to Bracing
(Gratz and Papalia-Finlay, 1984)
Researchers interviewed 16 high school girls between the ages of 14 and 17 who were wearing Milwaukee braces, the type of brace with a chin strap, used for curves high up in the back.

Although some literature suggests that scoliosis or bracing treatment can limit activity, that is not usually the case. These girls participated in many extracurricular activities, including basketball, swimming, track, tennis, skiing, softball. volleyball, band, language clubs, youth, council, and drama club. Most of the girls did not wear their brace during sports.

Some benefits they talked about were better posture, a better figure, and two of the girls said that they were more comfortable when they slept as a result of the brace.

The biggest problem these girls reported was that the chin strap on the brace makes it impossible to look down. Also for some of the girls, the brace was a little uncomfortable and limiting, and made it so they had to relearn how to sit down because it is more difficult to balance with the brace on. Another inconvenience is the inability to drive while wearing the brace. A few of the girls said that it made shopping for clothes more difficult, and that the brace occasionally gave them skin sores. One girl talked about how she and her mother argued with each other about how much she would wear her brace and do her exercises. Some of the girls felt that questions and rudeness from others were the worst aspect of the brace.

Most of the patients said that they went through an "Oh no, why did this happen to me" period, feeling shocked, upset, and depressed, and crying when they learned they would have to wear a brace. All of the girls said that they felt much better about the brace after an adjustment period of three to six weeks. So if you just found out that you need a brace and you are really upset about it, you’re not alone. And you’ll probably feel better soon.

The girls that knew others who wore a brace had an easier time adjusting. So if you can, talk to someone else who wears a brace, they might be helpful. They will be able to talk about how they felt, how they adjusted to it, and tips about making your adjustment to it easier.

Six of the girls said that bracing had been a positive experience in that they felt it helped to emotionally straighten them out and made them more independent and responsible.

The first appearance at school with a new brace caused some anxiety for all the girls, although they said that their friends were very accepting and supportive, which quickly made them feel better.

Surgery

When is surgery recommended individuals with scoliosis?
If the scoliotic curve continues to progress rapidly despite bracing, surgery is the next treatment option considered by physicians. Surgery is usually reserved for teen and pre-teens who already have a curve around 40 degrees or more.

For adults, the reasons for doing surgery are less well defined but include an increasing discomfort or pain in a curve that appears to have increased. For many women the deformity in the hip line and the increasing discomfort combine to make surgery a reasonable option. Many persons note the increase of their curve coupled with an increase in the rib hump. For those persons surgery can ( not always and certainly not guaranteed) reduce the deformity and the discomfort or pain.

When is surgery chosen over bracing?
Sometimes the chance of success of a bracing program is so small that the physical and psychological difficulties may not be worth it. This is a decision made between the physician and individual with scoliosis (and sometimes their parents), and the "conservative" treatment recommends surgery to individuals with severe curves who may still require surgery after a prolonged bracing program.

What are the goals of surgery?
Most scoliosis operations have two goals. The first is a fusion or solid stabilization of the spine. The second goal is a partial straightening or correction of the curve.

How is surgery done?
The surgery that corrects and stabilizes the spine is called a spinal fusion, which depending on where the surgeons work, can be called either anterior or posterior spinal fusion. Most thoracic curves found in individuals with scoliosis require a posterior spinal fusion. A fusion is a procedure where the individual bones are made solid each to the one above and below. Typically 10 or more vertebrae (spine bones) are included.

The surgery begins by moving aside the muscles overlying the back, removing the surfaces of the small joints in the back, and implanting one of several metallic implant systems. The most common of these is the Harrington instrumentation, and others include Cotrel-Dubousset instrumentation, the Zielke procedure, and Luque sublaminar wiring. The Harrington instrumentation consists of a rod and wires. These wires are attached to the back of the individual vertebra and then these are connected to one or two metal rods

Small pieces of bone, usually taken from the hip, are then laid along the spine. These bone chips eventually heal into a solid fusion, the equivalent of a single solid bone over the extent of the spine which has been operated upon. A fusion solidifies the part of the spine that is curved, and prevents the curve from progressing and getting worse.

Most patients are discharged from the hospital in fewer than seven days following the surgery, and the fusion becomes solid after about six months.

Is the surgery safe?
Although all forms of non-operative treatment have as their goal the avoidance of surgery, the operative treatment of scoliosis is widely considered to be safe. The advent of safer anesthesia, better blood transfusions and general surgical techniques over the last two decades have made large surgeries much safer. Before the invention of implantable instrumentation for the spine, patients with scoliosis spent long periods (up to several years) in bedrest casts waiting for their spinal operation to heal. Currently most scoliosis operations enable the patient to walk soon after the operation and require at most a light body cast or brace for external support.

Surgical treatment of scoliosis has improved significantly over the last several decades and has reached a stage where a scoliosis operation is a predictably safe operation with anticipated good outcome. However, more research is needed into the long term effects of currently performed scoliosis operations.

What are potential complications of the surgery?
The complication rate of the spinal fusion surgeries is between 0.1% and 1.0%. Most complications are temporary. Complete spinal cord injury is the most worrisome, but surgeons use the wake up test and spinal cord monitoring during the operation so that adverse effects on the spinal cord can be detected and reversed immediately.

Other common postoperative complications include infection, dislodgement of instrumentation, failure of the bone to fuse, and urinary tract infections. These are infrequent in healthy teenagers but more common in adults and children with scoliosis caused by nerve and muscle disorders.

What are other potential drawbacks of having a spinal fusion?
Drawbacks of surgery include financial costs, inconvenience and lost productivity associated with hospitalization and convalescence. Potential long term complications generally occur in adults and the can cause increasing pain. These complications often require further surgery during adulthood.

Fusion in the lower lumbar spine may be associated with an increased incidence of back pain in later life. Every effort is made by surgeons to have the lowest level of fusion be above the third (L3) or fourth (L4) lumbar vertebra. Unfortunately, some curves require instrumentation below this level.

What others who have undergone the surgery offer as advice:
The following excerpts come in response to a survey mailed to the Scoliosis Mailing list (for more information check the Resource section).

I had Harrington and Luque rods put in at age 17. I would advise them to be very in-shape, to be aggressive with physical therapy after, to deal with emotional issues between caregivers beforehand (perhaps in psychological therapy if possible) I would tell them they will be very empowered by their ability to survive and recover.

Consider it carefully and don’t get just one opinion. Stay with a doctor that you feel comfortable with and ask a lot of questions. Do a lot of reading prior to surgery, no matter what your age group.

My greatest concern about being in the 1/10 of 1% of Americans considered to be "failed" spinal fusion patients with chronic & severe complications is that NO research is being done to better the situation. Since the time I had my first spinal fusion at age 16 in 1966, all research has been in the hands of spinal specialists, who poured it into perfecting their spinal fusion techniques, i.e. better rods, stronger screws, etc. As a result, there has been virtually NO research into the CAUSES of scoliosis (esp. "idiopathic," which are most of the cases), and thus, there are no preventative measures possible. So in the last 30 years, there has been virtually NO progress in

fighting this dreadful disabling condition--and adolescents are undergoing virtually the same surgery I had in 1966, which has the potential to bring on severe complications when they reach the ages of 30, 40 or 50!! My doctor was a typical egoistic spinal surgeon, with a dashing style that obviously was geared to attract women. Even at 16, I just assumed he was off seducing all of the nurses everywhere. However, he was completely business-like with me & completely authoritarian about the need for my surgery. In other words, he left no shred of doubt, so my widowed mother just meekly gave her consent.

Advice: See several doctors before you make your decision. Research the different methods and interview surgery patients of the doctor you select. Familiarize yourself with the various methods of correction. Put together a support group of family and friends who can be with you in the hospital and when you return to your home. Ask your doc to prescribe a hospital bed when you come home. It is a great help and most insurances pay the larger portion for this. Get an adult potty seat for the john. It makes a great difference. It's very hard to sit all the way down at first. Go on a soft and liquid diet the week before surgery to help avoid intestinal problems. Make a list of ALL questions and ask your doc. If he/she doesn't seem interested in answering, check out another doc. It is important that you feel all of your questions are addressed. This is a very big deal. Know your emotional needs and make arrangements to see that they are met. Ex: If you feel you want someone with you all the time in the hospital, get a private room that will allow someone to stay with you. You are completely helpless and having someone you trust to be with you can make a difference. My surgery experience: I took awhile to select a doc. I found someone that I trusted completely. He took time to address all my and my husband's fears and concerns. I knew that I did not want to be alone and we made arrangements for a private room. My husband stayed with me and it made a big difference to me. There were times when I needed to get to the bathroom and I didn't have to wait for a nurse or aid. He was always there. I needed him for moral and physical support and I knew I would. While this is a painful operation, there are meds to help you and you will get through it. The pain is a relatively short time compared to a life of pain and disability, which is what some of us experience. In fact most of us experience those things, otherwise why would we go through something like this? My results were better than expected. I gained two inches in height. My curve, which was mostly lumbar, with a small thoracic curve, was 80 degrees and it was reduced to 20 degrees. My shoulders are even. My hips are even for the first time in my life. The pain I was going through before surgery is gone. The pain after surgery (I am six months post-op) is mostly gone. At this point I experience what I would call discomfort rather than pain. My muscles are still adjusting and I am swimming and walking to strengthen myself.