Scoliosis Research Institute : Ronald Blackman M.D. (English version)

กระดูกสันหลังคด ( Scoliosis )เป็นอย่างไร
เป็นภาวะของกระดูกสันหลังที่ผิดไปจากแนวตรงกลาง อาจจะมีการเอียงซ้าย เอียงขวาแล้วแต่ระดับของ
กระดูกสันหลัง

กระดูกสันหลังคดทำให้เกิดอะไรขึ้นได้บ้าง
เกิดภาวะไม่สมมาตรของร่างกายทำให้ข้อที่อยู่ใกล้เคียงกับกระดูกสันหลังในระดับนั้นมีการปรับตัวให้เกิด
สมดุลของร่างกายขึ้น ภายหลังจากที่ข้อต่อมีการปรับสมดุล กล้ามเนื้อที่อยู่รอบๆข้อต่อเหล่านั้นก็จะมีการ
ปรับตัวตาม คราวนี้ถ้ากล้ามเนื้อเหล่านี้ถูกใช้งานในลักษณะที่ผิดตำแหน่งนานๆ ก็จะเกิดภาวะปัญหาเกี่ยวกับ
กล้ามเนื้อตามมา นั้นคือ กล้ามเนื้อด้านใดด้านหนึ่งจะถูกหดสั้นเข้า อีกด้านหนึ่งจะถูกยืดยาวออก 
กระดูกสันหลังคดสามารถเกิดขึ้นได้ตั้งแต่กำเนิด หรือภายหลังการเกิดแล้วก็ได้ ไม่มีระยะเวลาในการกำหนด 
ส่วนมากประเภทที่เกิดภายหลัง มักจะเนื่องมาจากลักษณะท่าทางที่ไม่ถูกต้องในชีวิตประจำวัน อย่างเช่น 
ท่านั่งไม่ว่าจะระหว่างการทำงาน , เรียนหนังสือ เป็นต้น คนส่วนมากจะนั่งตามสบายจึงมักจะเอียงไปเอียงมา
ไม่ตรงจึงเกิดลักษณะการนั่งที่ผิดและเกิดความเคยชินนานๆเข้ากล้ามเนื้อเริ่มทำงานไม่เท่ากันทั้งสองด้าน
ก็จะดึงให้กระดูกสันหลังเอียงตามแล้วก็จะทำให้กระดูกสันหลังคดตามมา

วิธีการ - สังเกตตัวเองในกระจก (ไม่ควรมีสิ่งปกคลุมร่างกาย )จากตำแหน่งต่อไปนี้

1. ระดับไหล่ทั้ง 2 ข้าง
2. ระดับเชิงกรานทั้ง 2 ข้าง
3. ระดับซี่โครงทั้ง ซ้าย และขวา เปรียบเทียบกัน ( ดูว่ามีความเว้าหรือนูนเกิดขึ้นไม่เท่ากันทั้ง 2 ด้านหรือไม่ )

เมื่อมีการสังเกตตัวเองเบื้องต้นแล้ว ถ้าพบความผิดปกติเกิดขึ้น ควรรีบปรึกษาผู้เชี่ยวชาญ (นักกายภาพบำบัด) 
เพื่อตรวจและรักษา รวมทั้งการป้องกันไม่ให้เกิดกระดูกสันหลังคดมากขึ้น

ความผิดปกติของโรคเกี่ยวกับกระดูกและข้อ ที่พบได้บ่อยในวัยรุ่น ได้แก่ กระดูกสันหลังคด 
พบได้ในวัยรุ่นผู้หญิงมากกว่าผู้ชาย ส่วนใหญ่เป็นชนิดที่ไม่ทราบสาเหตุ และมักพบใน
ครอบครัวที่มีญาติพี่น้องเคยมีกระดูกสันหลังคด ส่วนกรณีที่เป็นมาตั้งแต่แรกเกิด 
มักจะเกิดจากความผิดปกติของการเจริญเติบโตของกระดูกสันหลัง

กระดูกสันหลังคดมากๆจะเห็นได้ชัดเจน แม้ใส่เสื้อมิดชิดก็ตาม โดยเห็นจากด้านหลังว่า
กระดูกสะบักสูงต่ำหรือใหญ่เล็กไม่เท่ากัน ตัวเอียง เนื่องจากกระดูกสันหลังที่คดจะไป
ดันกระดูกซี่โครงให้บิดตัวผิดรูปไป กระดูกสะบักที่วางอยู่บนกระดูกซี่โครงเลยบิดหรือ
เอียงตามไปด้วย สำหรับปัญหาจะเกิดขึ้นกับคนที่เป็นไม่มาก 
การเปลี่ยนแปลงจะไม่เห็นจากภายนอก ยกเว้นแต่ในบางโรงเรียนโดยเฉพาะต่างประเทศ 
จะมีการตรวจดูเรื่องกระดูกสันหลังคดเป็นประจำ เพื่อให้การรักษาตั้งแต่เริ่มแรก

สำหรับการรักษาถ้าเป็นไม่มาก แพทย์จะแนะนำให้มาพบเป็นระยะๆ เพื่อติดตามดูว่า
การเอียงหรือการคดมีมากขึ้นแค่ไหน แพทย์จะแนะนำเรื่องการบริหารกล้ามเนื้อเพื่อป้องกันไม่ให้คดมากขึ้น ในกรณีคดมากขึ้น 
ในระยะแรกแพทย์อาจให้ใส่เสื้อหรือเครื่องช่วยในพยุงประคองกระดูกสันหลังไม่ให้คด
มากขึ้น ถ้ากระดูกสันหลังคดอย่างรวดเร็ว หรือศัลยแพทย์ออร์โธปิดิกส์ที่ดูแล้ววัดมุม
จากภาพถ่ายเอ๊กซเรย์กระดูกสันหลังว่าคดมาก 
แพทย์อาจแนะนำให้ผ่าตัดจัดกระดูกสันหลังให้ตรงขึ้นและดามด้วยโลหะ เพื่อป้องกัน
โรคแทรกซ้อนจากกระดูกสันหลังคดมาก ซึ่งได้แก่ ปอดจะถูกเบียดทำให้เหนื่อยง่าย 
กระดูกสันหลังคดมาก ทำให้เสียบุคลิกเมื่อโตเป็นผู้ใหญ่

Scoliosis is the medical term for curvature of the spine. This paper deals primarily with the surgical treatment of scoliosis. Xray pictures of scoliosis before and after treatment are shown. The thumbnail pictures of scoliosis can be enlarged by clicking on them.

Scoliosis occurs in approximately 2% of women and less than 1/2% of men. It usually starts in the early teens or pre-teens and may gradually progress as rapid growth occurs. Once rapid growth (puberty) is over then mild curves often do not change while severe curves nearly always progress.

There is a fine line between the term scoliosis and a very mild curve in a normal spine. Curves are measured in degrees. Persons with a curve of ten degrees or less are often thought to have just an asymmetry of the spine - but in children who end up with significant curves we have to consider that they started with a straight spine so even a ten degree curve can progress to a fifty degree curve and a significant deformity, if there is enough growing time remaining. Persons with curves measuring under thirty degrees entering adulthood are considered having a mild curve while those over 60 degrees are considered severe.

Symptoms
There are several different "warning signs" to look for to help determine if you or someone you love has scoliosis. Should you notice any one or more of these signs, you should schedule an exam with a doctor.

A standard exam that is often used by pediatricians and in initial school screenings is called the Adam's Forward Bend Test. Most schools test children in the fifth or sixth grade, and the Adam's Forward Bend Test can be administered easily by school nurses or parent volunteers. For this test, the patient is asked to lean forward with his or her feet together and bend 90 degrees at the waist. The examiner can then easily view from this angle any asymmetry of the trunk or any abnormal spinal curvatures. It should be noted that this is a simple screening test that can detect potential problems, but cannot determine accurately the exact severity of the deformity.

Once suspected, scoliosis is usually confirmed with an x-ray, spinal radiograph, CT scan, MRI or bone scan of the spine. The curve is then measured by the Cobb Method and is discussed in terms of degrees. Generally speaking, a curve is considered significant if it is greater than 25 to 30 degrees. Curves exceeding 45 to 50 degrees are considered severe and often require more aggressive treatment.

The following is a list of questions your physician/orthopaedic specialist may ask:

• At what age was the spinal deformity first noted? This information is important in determining the prognosis and severity of the scoliosis.
• Who first noted the problem? Parent? Teacher? Physician?
• What is the patient's prenatal history? Did the child experience any problems while still in his or her mother's womb? Was there anything unusual about the pregnancy?
• Did the patient meet normal developmental milestones? Walking? Talking?
• Is there a family history of scoliosis or other spinal problems? You are 20 percent more likely to develop scoliosis if someone in your family also has scoliosis.
• Is the patient experiencing any back pain? Generally speaking, scoliosis in children and adolescents is not painful. If pain exists, further tests should be conducted for tumors, herniated discs or other abnormalities.

It is important to realize that the Cobb measurement is never exactly the same each time the spine is x-rayed since the measurement is affected by the position of the patient, the way the x-ray is taken, and the way the lines are drawn. As a result, there is a standard measurement error of 3 to 5 degrees. Therefore, major treatment decisions should not be made upon single measurements and small changes.

This is an example of a right thoracic curve in a 14-year-old female measuring 47 degrees by the Cobb Method.

The treatment options 
Depend on the severity and the age of the person. We can, of course, make up a long list of treatments; only a few have actually been shown to affect the outcome of scoliosis. Numerous studies have failed to show any benefit from exercise, manipulation, meditation or drugs. While exercise is beneficial to maintaining good muscle tone and a healthier heart and lungs, there is no evidence that it affects, one way or the other, the curve progression. It may help in reducing discomfort.

Option 1. Do nothing. The decision to do nothing may be a reasonable decision depending on the age of the person and the predicted outcome. If the person is a teen or pre-teen and the prediction is that this curve will worsen then doing nothing may not be appropriate. Increasing curves usually give an increase in the deformity. That is the chest twists throwing the shoulder blade off in back causing a rib hump and the chest in front rotates as well causing unevenness to the breasts. At the same time the hips at the waist become more uneven. So doing nothing in the teen years may be disastrous.

On the other hand, if the person has reached maturity ( physical at least!) then if the curve is mild, below forty degrees, it may not increase any more. So not doing anything may be okay.

Observation is appropriate for small curves, curves that are at low risk of progression, and those with a natural history that is favorable at the completion of growth. These decisions are based on the expected natural history of a given curve. For example, if your child is diagnosed with a curve of 25 to 40 degrees and has completed growth (i.e., boys older than 17, girls older than 15), then observation is appropriate. Statistically, these curves are at low risk of progression and are not likely to cause problems in adulthood. Follow-up x-ray once per year for several years would then confirm that the curve is not progressing after completion of growth. As an adult, an x-ray every five years, or if there are symptoms, is sufficient. This 14-year-old female presented from school screening with a 14-degree right thoracic scoliosis. She had begun menstrual periods over a year ago and was risser 3 in terms of skeletal maturity. The doctor's recommendation was observation, since the likelihood that her curve would progress was low.   This is a three-year-old male with a complex pattern of congenital anomalies of the spine, including multiple hemi-vertebra and a failure of segmentation on the convex side of the curve. This curve has a significant risk of further progression. However, no intervention was recommended at this point.

Option 2. Wear a brace. Bracing has been shown to be an effective method to prevent curves from getting worse. From a practical aspect though this treatment is reserved for children and adolescents in whom the prediction of a rapid increase in the curve needs to be thwarted. A brace worn 16 or more hours per day has been shown to be effective in preventing 90% or more of the curves from getting worse. Unfortunately, a brace worn 23 hours per day and worn properly does not guarantee that the curve will not continue to increase. Still, in curves that are mild i.e. between 20 and 35 degrees a brace may be quite effective.

In adults, 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.

It must be remembered that a brace for a teenager is not an easy treatment. The brace is hot, hard, uncomfortable, ugly and while it normally can't be seen under the clothes definitely makes a teenager more selfconscious.

We tend to use a brace for 23 hours per day. Using it part time seems to create problems of when to put it on, when to take it off, and for how long; whereas if it becomes part of the routine it becomes a standard function. Additionally, logic supported by data shows that the more the brace is on the better the chance of maintaining correction.

NOTE HOWEVER THAT A BRACE USUALLY DOES NOT CORRECT A CURVE. AT BEST IT WILL STOP IT FROM WORSENING.

There are numerous anecdotes from many kinds of practitioners, including ourselves, who have seen curves straighten both spontaneously and while using a brace. In medicine there are always exceptions.
The inset shows such an exception
of a teenager in a brace for 18 months.
On the left is an X-ray of the person
before starting brace treatment.
On the right is the same person
18 months after wearing a brace
23 hours per day.

Orthopaedic braces are used to prevent further spinal deformity in children with curve magnitudes within the range of 25 to 40 degrees. If these children already have curvatures of these magnitudes and still have a substantial amount of skeletal growth left, then bracing is a viable option. It is important to note, however, that the intent of bracing is to prevent further deformity – it is not to correct the existing curvature or to make the curve disappear.

There are several different types of braces used by adolescents with scoliosis. The Milwaukee Brace is quite common and is used particularly for high thoracic curves. The brace extends from the neck to the pelvis and consists of a plastic pelvic girdle and a neck ring connected by metal bars in the front and the back of the brace. Pressure pads push against the patient's curve to prevent further deformity. The metal bars help extend the length of the torso, and the neck ring keeps the head centered over the pelvis.

Other types of braces include the TLSO (thoracic-lumbar-sacral orthosis) braces. These braces are also called "low-profile" or "underarm" braces. They are not as large or bulky as the Milwaukee Brace, as the TLSO braces use plastic materials shaped to fit the patient's body.

The Boston Brace covers from below the breast to the beginning of the pelvic area in the front and from below the scapulae to the tailbone in the back. The brace's design forces the lumbar area to flex, which pushes in the abdomen and flattens the posterior lumbar curve. Pressure pads are also placed strategically along the curve.

Another bracing option is the Charleston Bending Brace. This brace is molded to conform to the patient's body while he or she is bent against the curve (towards the rounded-out portion of the curve). This brace is worn only at night while the patient is sleeping, thus "overcorrecting" the curve for eight hours per day.

Although studies support the use of bracing in adolescents with curves at risk of progression, specialists disagree about what the appropriate indications for bracing are, what the best type of brace is and how long the brace should be worn. Nonetheless, according to several large bracing studies, using a brace is successful in stopping curve progression in about 80 percent of children with scoliosis.

Whereas a short period of adjustment is normal for teenagers wearing braces for scoliosis, many studies show that these young people live very normal lives. They can participate in athletic functions and are able to easily interact socially, regardless of which type of brace they wear.

Bracing Case Study

This is a 13-year-old female who presented with a 30 degree lumbar scoliosis. She is skeletally immature, (Risser 0), and therefore at significant risk of progression with growth. She was placed in a scoliosis brace and demonstrates an in-brace correction of ~70 percent. Initial brace correction should be 50 percent or greater.

Option 3. SURGERY: For those persons who already have a significant curve with a significant deformity surgery can reduce the curve and significantly reduce the deformity. Usually surgery is reserved for teen and pre-teens who already have a curve around 40 degrees or more. In our practice we tend to be more aggressive than many in doing surgery around 40 degrees while there are many excellent surgeons who defer to 45 or 50 degrees. In the adult age range 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 increasing deformity in the chest 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.

Surgery however is a big deal and not to be undertaken lightly. We invariably use metal rods or screws to help straighten and hold the spine in the corrected position.

There are three major types of curves each with their own method of correction. However, what we do may not be what someone else would do. Surgeons base their procedures on many different factors including their experience with techniques and their outcomes.

The usual scoliosis curve is a thoracic curve ( i.e. at the level of the chest.) In these curves the procedure is 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 segments are included. In order to first get as much correction of the curve, multiple hooks or wires are attached to the back of the individual vertebra and then these are connected to one or two metal rods which have been pre-bent to the desired contour. The correction is done and then little bits of bone are flaked off the back of the vertebra so that when healing occurs the flakes of bone cross and become solid. The metal rod hopefully holds the correction until it is solid approximately in one year.

Showing the curve before surgery
and after surgery with rods in place.
Click on picture to see an
enlarged view.

Scoliosis is a three dimensional problem. It is easy to think of the curves from looking at the back or the front; but the side view also must be considered. Flattening of the normal roundness to the side view of the back affects the general look of the back and the person. One of the aims of surgery is to try to restore the normal contour of the back from both the front view and the side view.

Note the increase
in the roundness.

We have developed a technique to assist us in getting a maximum of correction with a minimum of scar and morbidity. We have developed the use of the endoscope to go into the chest (similar to the way surgeons take out gallbladders now) in front where the actual vertebra are and take out the discs in front thus loosening up the spine so we can get better correction when we do the fusion in back. This is called ENDOSCOPIC DISCECTOMY SURGERY. Placing the arrow on this at the bottom of the page will give you a report on this technique as presented to the North American Spine Society in 1995.

This method goes in through the chest using three or four small incisions to reach the front of the spine. Once inside the chest the spine is clearly visible and "soft" tissues can be cleaned off exposing the spine. The discs are easily seen and can be removed.

These are four views of the spine
as seen through the endoscope.
The views are taken through the chest
Click on this to enlarge the picture.

ANTERIOR APPROACH: For those curves which present more as a distortion of the waistline or hips going in through the front of the abdomen can reach the vertebra and using screws the spine can be exceedingly well corrected ( again not always though). Going in through the front can often allow us to fuse fewer vertebra and get better correction. So we "save a level" and get better motion remaining and usually better correction than posteriorly.

The spine is actually in the middle of the body and the larger weight bearing part of the vertebra is in the front. To correct the curve by going in front,the incision is across the chest in line with a rib and down the front of the abdomen for a short distance. It sounds like a big approach ( and it is ) but the actual incision is no longer than the one in back. The chest is entered and the area of the curve is identified. The discs are removed so that the curve becomes much more mobile and screws are then placed in the vertebra and connected together with a metal rod. Bone graft is placed in the space where the discs were so that later fusion between each adjacent vertebra will occur.The screws are then compressed together, shortening the distance on the outside of the curve and so straightening the curve. Usually fusion occurs in a shorter time than the posterior method and the number of vertebra fused are usually less.

This was a teenager
with an increasing curve
out of balance. Note the
return of the center of gravity.

This is a side view or lateral view. It shows the bodies of the vertebra with the screws and rod in place. Note the slight sway back which is built into the correction.

And for those who have a double curve then often a combination of any of the above may be needed. That is, we may just go in from the back and fuse a long segment of the curves or we may go in from the front and fuse the lower curve and correct it and then fuse from the back or we may do all three procedures, to try to get the maximum correction possible.

This 15-year-old female was diagnosed with scoliosis at age 12. Despite bracing, her curve progressed to 55 degrees. Surgery was chosen because her curve was still at risk of further progression with growth and her long-term natural history was unfavorable. Posterior spinal instrumentation and fusion produced an excellent correction of her curve.

There are different techniques and methods used today for scoliosis surgery. The most frequently performed surgery for adolescent idiopathic scoliosis involves posterior spinal fusion with instrumentation and bone grafting. This kind of surgery is performed through the patient's back while the patient lies on his or her stomach. Two common instrumentation techniques are called Cotrel-Dubousset (CD) instrumentation (rod rotation technique) and COLORADO instrumentation (translation technique). During these types of surgery, the surgeon attaches a metal rod to each side of the patient's spine by using hooks attached to the vertebral bodies. Then, the surgeon fuses the spine with a piece of bone from the patient's hip (a bone graft). The bone grows in between the vertebrae and holds them together and straight. This process is called spinal fusion. The metal rods attached to the spine ensure that the backbone remains straight while the spinal fusion takes place.

The operation usually takes several hours. With recent advances in technology, most people with idiopathic scoliosis are released within a week of surgery and do not require post-operative bracing. Most patients are able to return to school or work in two to four weeks after the surgery and are able to resume all pre-operative activities within four to six months.

Another surgery option for scoliosis is an anterior approach, which means that the surgery is conducted through the chest walls instead of entering through the patient's back. The patient lies on his or her side during the surgery. During this procedure, the surgeon makes incisions in the patient's side, deflates the lung and removes a rib in order to reach the spine. This approach allows the surgeon to operate higher up in the spine than through posterior approaches, and studies have shown favorable results with this type of surgery. Video-assisted thoracoscopic surgery allows surgeons to enhance their vision of the spine and to conduct a less invasive surgery than with an open procedure. The anterior spinal approach has several advantages: better cosmetic results, quicker patient rehabilitation, improved spine mobilization, and fusion of fewer segments. Most patients require bracing for several months after this surgery.