Healthcare

Connections: Grading the curve of pediatric scoliosis | Summer 2018

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From the OHSU Doernbecher Children’s Hospital

Scott Yang, M.D., pediatric orthopedic surgeon

Scott Yang, M.D.

A pediatric orthopedic surgeon, Dr. Yang treats children and adolescents with all orthopaedic conditions but has a special interest in scoliosis and hip dysplasia.

Scoliosis can be idiopathic or stem from other causes such as neuromuscular disorders, tumors or a congenital defect. Early diagnosis is key for monitoring and corrective action. Of the adolescents who develop scoliosis, only a few need bracing or surgery. For that subset, the intervention is helpful for controlling the curve.

Different approaches: a matter of degree in adolescent idiopathic scoliosis Factors for intervention at this age are the degree of curvature and the amount of growth the adolescent has remaining. In the adolescent population, a curvature of 50 degrees or more will indicate surgery as an option. Curves of less than 25 degrees may require only observation if the adolescent is in the late stage of pubertal growth as small curves may have subtle or mild symptoms but won’t lead to major problems.

A curve in the range of 25–45 degrees will likely mean bracing, depending on the amount of growth remaining. If more than a year of growth remains for patients in this group, we use bracing to control the curve, because scoliosis intensifies when growing. The bracing controls the curve during this period of rapid growth. If the patient is nearly finished growing, we can consider observation because the curve is less likely to worsen rapidly.

Each physician may have a different protocol for bracing, but our typical recommendation is to wear the brace for up to 18 hours a day. The brace company develops braces with a built-in compliance monitor that produces a report. Patients can remove the brace for activities, such as playing sports, if they are getting the critical hours in at other times.

Balancing growth and curvature in infantile idiopathic scoliosis

For children above the age of three with a clearly progressive curve over 50 degrees, a newer option of inserting a magnetic growing rod is now available. In the young child with scoliosis, we try to balance two competing interests: stopping the curve and allowing normal growth. Fusing the spine stops the curve, but prevents the thorax from growing appropriately. Traditionally, the response to this challenge was to put in implants that required surgery every six months to lengthen the implant until the results were achieved. With magnetic rods, the need for multiple surgeries for periodic spine lengthening is avoided. Once implanted the rod can be extended by the surgeon without opening the skin using a magnetic rod.

Children younger than five years old with severe scoliosis have a higher mortality risk as this is the time when it can impede lung development. For children younger than three years old presenting with progressive scoliosis, our approach is to perform casting of the spine. Though the child will be under anesthesia for the procedure, it avoids issues that can be related to surgery. We re-cast every couple of months to gradually correct the curve.

Pediatric Spine, Scoliosis and Deformity Clinic for convenient access

Pediatric spine care is very complex. For this reason, OHSU Doernbecher Children’s Hospital offers a multidisciplinary Pediatric Spine, Scoliosis and Deformity Clinic to comprehensively evaluate and treat young patients. Pediatric orthopaedic surgeons and neurosurgeons collaborate in cases where patients require expertise in both areas.

Also, because many spine conditions require monitoring or multiple visits, we are making the multidisciplinary clinic more accessible by offering it twice a month in Portland and once a month in Salem. We also have a quarterly pediatric orthopaedic-only clinic in Medford.

When to refer

For a growing child, any curvature over 20 degrees needs evaluation and monitoring. For a fully-grown child, any curvature over 40 degrees needs evaluation and monitoring. Any child with stiff kyphosis (hunching) of the back that remains despite upright posture. Any child with significant, persistent back pain despite conservative measures, such as therapy and core strengthening.

The Schroth Method

The Schroth Method, named for Katharina Schroth who developed exercises to address her own scoliosis in the 1920, is a physical-therapy-based approach to scoliosis treatment. The method uses postural and breathing techniques to improve spine alignment.

OHSU has one of the few Schroth-certified physical therapists in the state, Kim Marie Osterberger P.T., D.P.T. She leads the Schroth Scoliosis Clinic at OHSU. While not a substitute for bracing, the Schroth Method can be a positive adjunct. For skeletally mature patients with a small degree of scoliosis, Schroth exercises may be beneficial for core strength and posture, though they will not remove the spinal curvature.

Contact us

Our experts are available for consultation and as a resource in the diagnosis and management of scoliosis as well as other conditions of the spine.

If you have questions or would like to refer a patient for evaluation, please call the OHSU Physician Advice and Referral Service at 503-494-4567.