Patient Education
The Spine Center is committed to helping our patients understand what ails them. As a tool, we offer videos and brochures to help you understand the conditions you may have.
Understand the condition you have or learn what may be the root cause of your pain. Search through our spine specific animations to learn more about the causes, symptoms, and treatment options. Each condition page contains a brief description, list of symptoms you may experience, and treatments.
Treatment of IS depends on a number of factors. The two most important factors are age at presentation and the size of the curvature (measured in degrees by the Cobb Method). Scoliosis can progress rapidly in the growing child. The younger the child, the more growth potential that exists, and therefore the larger the spinal deformity can get. The size of the curve at presentation is very important as well. Larger curves create more visible deformity, and can potentially get big enough to cause problems with the heart and lungs, and lead to painful spinal arthritis. Therefore, large curvatures in young patients are the most worrisome.
From long term studies on scoliosis patients, we know that curves less than 30 degrees tend not to cause many problems in adulthood. However, curves in excess of 50 degrees tend to get larger with time- by about 1-2 degrees per year. For this reason, most spinal deformity surgeons will recommend stabilizing scoliosis greater than 50 degrees in skeletally mature patients, and at 40 degrees in the growing child. Those curvatures between 30-50 degrees in the adult are in a grey zone and are generally observed and treated conservatively.
So…. our goal in the child diagnosed with scoliosis is to keep that curvature below 40 degrees. So how do we do that? Traditionally we have had two treatment options- observation and bracing. Obviously, observation does nothing to prevent progression, but does allow us to intervene with bracing or surgery before the scoliosis gets to be too big. Traditional spinal bracing can work to keep the curve where it is, but it is not easy for patients or families. The braces, also known as thoracolumbosacral orthoses (TLSO), are rigid, and can be uncomfortable. Bracing studies show that best results occur when the brace is worn 18-23 hours per day. Soft braces, unfortunately, have not been shown to work in clinical trials. Brace wear often becomes a point of contention between kids and their parents. And even with a compliant brace patient, the scoliosis can get worse and need an operation anyway.
A third option for treatment exists. It is known as the Schroth Method. Schroth is a non-tradional physical therapy regimen aimed specifically at controlling scoliosis. It incorporates some traditional exercises, but focuses on strengthening weak muscles, and loosening tight areas. It includes breathing exercises, because the rib cage attaches to the spine, and is affected by the scoliosis. Core strengthening and general conditioning are also emphasized. Often, night-time bracing is instituted as well. Most importantly, the exercises are done every day. My personal experience with Schroth Therapy over the last few years is very encouraging. Unfortunately, there really is not any clinical studies to back this up, but hopefully there will be in the next few years.
In my practice, for children with idiopathic curves more than 20 degrees, but less than 30 degrees (maybe up to 40 degrees), I at least recommend a night brace and Schroth Therapy. I certainly see no significant downside to an intensive therapy program. The most difficult part of all is finding a properly trained and certified Schroth Therapist in the area. Only a few exist in our large metropolitan program.
Now what about adults with scoliosis? Again, those curves larger that 50 degrees may best be treated with surgical intervention. But often, patients will only consider that option if all else fails. Or perhaps a patient may not be able to tolerate a surgery for any number of reasons. In these cases, once again, I have been impressed with the Schroth Method, often combined with pain management programs that can include medications and injections.
In conclusion, surgery is generally recommended for idiopathic scoliosis greater than 40 degrees in the growing child and 50 degrees in an adult. In terms of non-operative treatment for AIS, observation and rigid bracing can be combined with the Schroth Method. Schroth Therapy is appropriate for both adults and children.
© Christopher J. Bergin, MD and The Spine Center, SC
Instability of the slipped vertebrae can cause pain. The pain may be in the low back, which is called axial back pain. Narrowing of the passageway for the nerves can lead to nerve pinching and can lead to radiating pain down the legs, also known as sciatica. Severe narrowing can lead to weakness, heaviness, or numbness in the legs when walking or standing. The medical term for these types of nerve symptoms is neurogenic claudication. So the patient with a degenerative spondylolisthesis may present with complaints of low back pain, sciatica, leg weakness or heaviness or numbness, or a combination of the above symptoms. Often times, the symptoms are brought on by walking and standing, and relieved by rest or bending over, such as walking on a shopping cart.
Treatment options for degenerative spondylolisthesis include observation, anti-inflammatory medications, mild analgesics, physical therapy and exercise programs, injections into the spine, and surgery. We usually start with non-operative treatments to try to control symptoms. Often times the instability and stenosis are too severe and non-operative treatments provide only temporary relief. In this situation, the only long-term solution is to take pressure off of the nerves and stabilize the spine through a surgical procedure.
In general, the appropriate procedure for the treatment of degenerative spondylolisthesis is a laminectomy and fusion at the affected level. A laminectomy is a removal of the back covering of the spine, or lamina. This portion of the procedure can be referred to as a decompression. The fusion involves placing screws and rods into the spine and laying bone graft along the side of the spine. The bone graft will eventually be incorporated into the spine and turn into one solid piece of bone. Often the disc will be removed and shims, also known as cages, will be placed between the vertebrae to reestablish disc height and enhance the fusion.
Bone graft can be obtained from multiple sources. The removed lamina is a good source of bone and is commonly utilized. Bone can be taken from the back side of the pelvis, called the iliac crest, through the same or separate incision. Bone marrow can be harvested and concentrated through a needle placed into the iliac crest. This technique harnesses the patients own stem cells to promote bone healing. Donor bone, or allograft, is often used to extend available graft material. Synthetic grafts are available, but lack clinical data. Genetically engineered bone protein is available and can be highly effective. This product is BMP-2 and goes by the trade name of Infuse. Use of Infuse from a posterior approach is off-label per the FDA, but may be the best solution depending on the circumstances.
There are multiple ways to perform laminectomy and fusion procedures. They can be done through standard open techniques or through less invasive or minimally invasive approaches. No matter the technique, the operation needs to be done safely, effectively, and efficiently. When choosing a procedure, or a surgeon, remember that the most important factor in determining success for a spinal operation is the indication for the operation, and not the technique. In other words, it is not how we do it, but why we do it. Standard open techniques for the treatment of degenerative spondylolisthesis have extremely high success rates. All procedures need to be compared to this standard, in terms of effectiveness, complications, and safety.
© Christopher J. Bergin, MD and The Spine Center, SC
Understand the condition you have or learn what may be the root cause of your pain. Search through our spine specific animations to learn more about the causes, symptoms, and treatment options. Each condition page contains a brief description, list of symptoms you may experience, and treatments.
Non-Operative Treatment of Idiopathic Scoliosis
There are traditional and non-traditional conservative methods for treatment of idiopathic scoliosis (IS). It is important to understand that there are important differences between idiopathic scoliosis and other forms of spinal curvature. Idiopathic is basically Greek for “We don’t know where it comes from.” Other forms of scoliosis include congenital, neuromuscular, and syndromic. For this discussion, I will focus on the idiopathic form.Treatment of IS depends on a number of factors. The two most important factors are age at presentation and the size of the curvature (measured in degrees by the Cobb Method). Scoliosis can progress rapidly in the growing child. The younger the child, the more growth potential that exists, and therefore the larger the spinal deformity can get. The size of the curve at presentation is very important as well. Larger curves create more visible deformity, and can potentially get big enough to cause problems with the heart and lungs, and lead to painful spinal arthritis. Therefore, large curvatures in young patients are the most worrisome.
From long term studies on scoliosis patients, we know that curves less than 30 degrees tend not to cause many problems in adulthood. However, curves in excess of 50 degrees tend to get larger with time- by about 1-2 degrees per year. For this reason, most spinal deformity surgeons will recommend stabilizing scoliosis greater than 50 degrees in skeletally mature patients, and at 40 degrees in the growing child. Those curvatures between 30-50 degrees in the adult are in a grey zone and are generally observed and treated conservatively.
So…. our goal in the child diagnosed with scoliosis is to keep that curvature below 40 degrees. So how do we do that? Traditionally we have had two treatment options- observation and bracing. Obviously, observation does nothing to prevent progression, but does allow us to intervene with bracing or surgery before the scoliosis gets to be too big. Traditional spinal bracing can work to keep the curve where it is, but it is not easy for patients or families. The braces, also known as thoracolumbosacral orthoses (TLSO), are rigid, and can be uncomfortable. Bracing studies show that best results occur when the brace is worn 18-23 hours per day. Soft braces, unfortunately, have not been shown to work in clinical trials. Brace wear often becomes a point of contention between kids and their parents. And even with a compliant brace patient, the scoliosis can get worse and need an operation anyway.
A third option for treatment exists. It is known as the Schroth Method. Schroth is a non-tradional physical therapy regimen aimed specifically at controlling scoliosis. It incorporates some traditional exercises, but focuses on strengthening weak muscles, and loosening tight areas. It includes breathing exercises, because the rib cage attaches to the spine, and is affected by the scoliosis. Core strengthening and general conditioning are also emphasized. Often, night-time bracing is instituted as well. Most importantly, the exercises are done every day. My personal experience with Schroth Therapy over the last few years is very encouraging. Unfortunately, there really is not any clinical studies to back this up, but hopefully there will be in the next few years.
In my practice, for children with idiopathic curves more than 20 degrees, but less than 30 degrees (maybe up to 40 degrees), I at least recommend a night brace and Schroth Therapy. I certainly see no significant downside to an intensive therapy program. The most difficult part of all is finding a properly trained and certified Schroth Therapist in the area. Only a few exist in our large metropolitan program.
Now what about adults with scoliosis? Again, those curves larger that 50 degrees may best be treated with surgical intervention. But often, patients will only consider that option if all else fails. Or perhaps a patient may not be able to tolerate a surgery for any number of reasons. In these cases, once again, I have been impressed with the Schroth Method, often combined with pain management programs that can include medications and injections.
In conclusion, surgery is generally recommended for idiopathic scoliosis greater than 40 degrees in the growing child and 50 degrees in an adult. In terms of non-operative treatment for AIS, observation and rigid bracing can be combined with the Schroth Method. Schroth Therapy is appropriate for both adults and children.
© Christopher J. Bergin, MD and The Spine Center, SC
Treatment of Degenerative Spondylolisthesis
One of the most common conditions we encounter as spinal surgeons is degenerative spondylolisthesis. Spondylo means spine, and listhesis means slip. In other words, it is a slip of one vertebra on another. The most common level involved is L4-5, but any lumbar level may be involved. A spondylolisthesis implies that there is underlying instability, and often times there is associated narrowing of the passage for the nerves. This narrowing of the spinal canal is called spinal stenosis. The cause of this type of spondylolisthesis is wearing out of the intervertebral disc in the front and the facet joints in the back of the spine. Simply put, it is due to spinal arthritis.Instability of the slipped vertebrae can cause pain. The pain may be in the low back, which is called axial back pain. Narrowing of the passageway for the nerves can lead to nerve pinching and can lead to radiating pain down the legs, also known as sciatica. Severe narrowing can lead to weakness, heaviness, or numbness in the legs when walking or standing. The medical term for these types of nerve symptoms is neurogenic claudication. So the patient with a degenerative spondylolisthesis may present with complaints of low back pain, sciatica, leg weakness or heaviness or numbness, or a combination of the above symptoms. Often times, the symptoms are brought on by walking and standing, and relieved by rest or bending over, such as walking on a shopping cart.
Treatment options for degenerative spondylolisthesis include observation, anti-inflammatory medications, mild analgesics, physical therapy and exercise programs, injections into the spine, and surgery. We usually start with non-operative treatments to try to control symptoms. Often times the instability and stenosis are too severe and non-operative treatments provide only temporary relief. In this situation, the only long-term solution is to take pressure off of the nerves and stabilize the spine through a surgical procedure.
In general, the appropriate procedure for the treatment of degenerative spondylolisthesis is a laminectomy and fusion at the affected level. A laminectomy is a removal of the back covering of the spine, or lamina. This portion of the procedure can be referred to as a decompression. The fusion involves placing screws and rods into the spine and laying bone graft along the side of the spine. The bone graft will eventually be incorporated into the spine and turn into one solid piece of bone. Often the disc will be removed and shims, also known as cages, will be placed between the vertebrae to reestablish disc height and enhance the fusion.
Bone graft can be obtained from multiple sources. The removed lamina is a good source of bone and is commonly utilized. Bone can be taken from the back side of the pelvis, called the iliac crest, through the same or separate incision. Bone marrow can be harvested and concentrated through a needle placed into the iliac crest. This technique harnesses the patients own stem cells to promote bone healing. Donor bone, or allograft, is often used to extend available graft material. Synthetic grafts are available, but lack clinical data. Genetically engineered bone protein is available and can be highly effective. This product is BMP-2 and goes by the trade name of Infuse. Use of Infuse from a posterior approach is off-label per the FDA, but may be the best solution depending on the circumstances.
There are multiple ways to perform laminectomy and fusion procedures. They can be done through standard open techniques or through less invasive or minimally invasive approaches. No matter the technique, the operation needs to be done safely, effectively, and efficiently. When choosing a procedure, or a surgeon, remember that the most important factor in determining success for a spinal operation is the indication for the operation, and not the technique. In other words, it is not how we do it, but why we do it. Standard open techniques for the treatment of degenerative spondylolisthesis have extremely high success rates. All procedures need to be compared to this standard, in terms of effectiveness, complications, and safety.
© Christopher J. Bergin, MD and The Spine Center, SC