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Adult Scoliosis

Adult Scoliosis

The NORMAL SPINE, when viewed from behind, appears straight and symmetrical. Gentle curves are noted in the neck, upper back and lower back, but deviations from the normal alignment and symmetry may reflect scoliosis.

Scoliosis

Scoliosis is defined as a side-to-side curvature from the normal frontal view of the body. In actuality, the deformity occurs in three planes: front-back, side to side, and bottom-top. Though we often think of scoliosis as a condition affecting children, it is also seen in the adult population. Adult scoliosis commonly develops from arthritic changes that cause failure of normal restraints to deformity, such as the facet joints or discs. In other cases of adult scoliosis, there may be progression of a curvature that began in childhood. Curve progression is often associated with degenerative inter-vertebral disc disease. On occasion the arthritic changes of degenerative joint disease of the spine, in middle-aged or older patients, may be due to significant previously present undiagnosed or untreated scoliosis. The remainder of the cases of scoliosis can arise from a variety of causes, including congenital abnormalities, neurological conditions and genetic disorders. Scoliosis is not related to athletic participation, heavy lifting, posture or minor leg length discrepancies.

Clinical

Intermittent backaches occur commonly in adult scoliosis. Complaints of pain radiating into the legs, and limitations in walking are common symptoms that bring patients to the doctor. These types of complaints may be related to spinal conditions associated with adult scoliosis. A family history of spinal deformity is looked for, since certain types of spinal deformity are more prevalent within families.

Examination of the spine is mult-faceted, but begins with an assessment of trunk symmetry. Examining the degree of asymmetry may give the first clues to the presence of an adult scoliosis. Often, patients feel that they have been losing height or find their trunks shifting. Changes in waistline or the fit of clothing are often subtle first signs that a curvature might be developing. Other findings depend on the deformity location and magnitude. Patients may notice that shoulder heights may be uneven and there may be an increased space between the elbow and trunk because of trunk deviation. The “hip”, pelvis or breast may appear prominent. A neurological exam includes evaluation of the function of the muscles and nerves of the extremities.

Radiographic Data

The first step in radiographic evaluation of a patient suspected of developing adult scoliosis is performed with a radiograph done on a single long film. Modern x-ray protocols minimize radiation exposure. These x-rays are assessed for contour and to rule out other abnormalities such as fractures, tumors or metabolic bone disease. If present, the magnitude of the curvature can be calculated from the x-ray. Based on the history of the symptoms, physical examination an plain radiographs further testing might be ordered. An MRI can provide a different set of information that might quantify the space that is available for the spinal cord or spinal nerves. In addition it can also help determine the etiology behind the symptoms of pain, weakness, numbness or loss of function. Other modalities such as CT scans can add to the picture with more detailed imaging of the bony anatomy or prior surgical procedures.

Treatment Options

Many modalities for treatment exist to deal with the complaints of adult scoliosis. These might include physical therapy, medications, or even a type of cortisone injection known as a epidural steroid injection. Physical therapy can often allow a patient to strengthen the muscles about the spine to improve the symptoms. However, it will not correct the deformity that is present. Medications, such as anti-inflammatories, might be appropriate to help quell the pain and improve function.

Epidural steroid injections seek to more aggressively reduce the inflammation around the spinal nerves. However, it too will not alter the mechanical shape of the spine or the spinal canal. This type of cortisone injection can dramatically reduce pain radiating in to the extremities. It is a simp le outpatient procedure that does not require anesthesia and can be performed in minutes with the use of a fluoroscope.

Pulmonary and cardiac function impediments from scoliosis are rare, and are not typically seen until curves approach 70°. On ce a curve reaches magnitudes in excess of 50°, there is a te ndency for the curvature to continue a gradual but persistent increase over time. This magnitude of curvatur e and resultant cardiac and pulmonary compromise are seen later in life, often from previously undiagnosed or untreated scoliosis of childhood.

The choice of treatment in adult scoliosis is determined by a complex equation. Some of the factors include the patient’s physiologic (not chronologic) maturity, curve magnitude and location, and potential for progression.

There is little role for brace (orthotic) management in adult scoliosis, and often the braces are poorly tolerated. When used in a non-operative setting, the primary goal of the brace is to provide symptomatic relief of back pain.

The role of surgery in adult scoliosis is complex and somewhat different than the role in pediatric scoliosis. Often the primary goal in adult scoliosis is to provide relief of the compression of the spinal cord or spinal nerves. Further goals enco mpass correction of the de- formity and improvement in the arthritic pain associated with the deformity. Modern techniques allow for better surgical outcomes an d faster recovery.

Summary

Spinal deformity is due to a myriad of causes. The etiol- ogy of the adult scoliosis often lies with the arthritic changes that develop normally through life or through a progression of scoliosis from childhood. Treatment var- ies according to the deformit y’s cause , location, magni- tude, patient maturity and evidence of progression. Treatment decisions are based on a complex equation taking such factors into account. Modern methods of surgical management allow for patients’ rapid return to daily activity and dramatic relief of pain.

(c) 2008 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author

Arcuplasty

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A Minimally Invasive Option for the Treatment of Spinal Fractures

Vertebral compression fractures will number in excess of 500,000 this year. These fractures stem from underlying weakness of the bone, often from osteoporosis. In fact, one fourth of women reaching menopause can expect to have one or more vertebral compression fractures in their lifetime. Of those women over 70 years of age, 25% have evidence of compression fractures. In those women over 80, 50% have such evidence. The strongest predictive factor of a compression factor is the presence of a prior fracture.

Many of those who suffer from vertebral compression fractures do not realize that they have had such a fracture. In fact, such injuries may arise from atraumatic events. Patients can often recall experiencing severe sharp pain after simply coughing, sneezing, or bending forward. In these situations, the pain is often sharp and severe in nature. Other people cannot re call a specific incident, but simply notice that they have lost height. Loss of height can accompany the development of a so-called “dowager’s hump.” This is a prominence of the upper back that develops as the spin e angles over the fracture. Fortunately, most of these fractures are not accompanied by weakness, numbness or other neurological defects.

There are many risk factors for vertebral compression fractures. The single largest factor is a prior history compression fracture. Other risk fractures include a diagnosis of osteoporosis or menopause. Those patients who are on long term systemic steroids or certain seizure medications are also at higher risk. These risk factors increase the risk for the development of a vertebral compression fracture.

Diagnosis of a compression fr acture can be made with the use of x-rays, MRI, or CT Scans. Plain x-rays are the simplest method of confirming the diagnosis. The normally square or rectangular sh aped vertebrae take on the shape of a wedge or flattened disc. Those who have had compression fractures in the past may need to differentiate an acute frature from a ch ronic one. In these situations, MRI has an excellent role. An MRI can differentiate between an acute injury and a stable healed fracture, by demonstrating signal changes in the marrow of the vertebrae.

Treatment options for these types of injuries include many options such as observation, bracing, pain medications and surgery. Traditional methods entail managing the pain of a fracture with medications and the application of a brace to prevent further collapse and deformity of the broken vertebrae. Th is is analogous to the methods by which a broken limb might be managed with a cast. Unfortunately, the brace is cumbersome and poorly tolerated by many patients.

Arcuplasty is a new minimally invasive method of treating vertebral compression fractures. The procedure shares its roots with other cement augmentation procedures such as, vertebroplasty and kyphoplasty. Arcuplasty represents the latest refinement in the stabilization of compression fractures. Through a single 3 millimeter incision a working channel is established into the vertebral body. Through this tiny access port a variety of instruments can access the fractured bone. An arc shaped osteotome allows the creation of a cavity within the injured bone. This cavity can then be expanded further to restore some of the shape of the fractured bone. After the cavity is prepared, bone cement is gently advanced into the space while under the guidance of live x -rays, or fluoroscopy. This bone cement will cure within minutes, and cure the bone pain associated with the fractured vertebrae. The entire procedure can be done in under twenty minutes. Often times patients awake to immediate relief, and some ar e able to go home the same day.

Vertebral compression fractures are a common painful condition that previously was extremely difficult to treat. Arcuplasty represents a minimally invasive surgical procedure, that has advanced the treatment of this condition. Arcuplasty is one of the cutting edge, minimally invasive spinal surgery procedures that will ease suffering while providing a possible outpatient solution to a difficult problem. Prior to the advent of this minimally invasive procedure, patients often suffered with pain and uncomfortable braces for many months before seeing an improvement in their pain or function.

Those patients that undergo the procedure earlier make more rapid improvements, though many find improvement even after many months of suffering. Now, patients can undergo a minor procedure aimed at rapid alleviation of their painful compression fracture.

© 2008 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author

EpiDural Steroid Injections

An epidural injection delivers steroids into the epidural space around spinal nerve roots to relieve pain - back pain, leg pain, or other pain — caused by irritated spinal ner ves. The steroid used in the epidural steroid injection reduces the inflammation of those nerves, which is often the source of the pain. It is important to note that an epidural steroid injection should not be considered a cure for back pain or leg pain: r ather, the goal is to help patients get enough pain relief in order to be able to progress with their rehabilitation program. An epidural steroid injection significantly reduces pain for approximately 50% of patients. It works by delivering steroids direc tly to the painful area to help decrease the inflammation that may be causing the pain. In addition to relieving pain, the process of natural healing can occur more quickly once the inflammation is reduced.

Prior to your procedure

  • DO NOT take any type of blood thinning medication Non-Steroidal Anti-inflammatory (NSAID), Aspirin, Motrin, or Celebrex 3 days prior to injection
  • If taking Coumadin (Warfarin) or an anti - platelet drug (Plavix, Ticlid) you must be off this medication long enough for your blood to normalize. Please let us know if you are using Coumadin or Plavix or Ticlid.
  • You will need someone to drive you home after the injection, please make plans to have someone with you.
  • Please bring with you a list of your medications and the dosing.
  • Take your medications, EXCEPT NSAIDS, Coumadin and other Anti-platelet drugs, normally.
  • You may have a light meal prior to the procedure.

Epidural steroid injection procedure

The injection procedure for an epidural includes the following steps:

  • The patient lies face down on an x-ray table and the skin is well cleaned with an antiseptic.
  • The area where the epidural needle will be inserted is numbed with a local anesthetic.
  • Fluoroscopy (a guided X-ray procedure where the doctor can watch the placement and movement of the needle) will be used to direct a small needle into the epidural space. The patient will feel some pressure during this part. Fluoroscopy is important in this procedure to help ensure correct placement of the medications.
  • A contrast dye is injected to confirm that the medicine spreads to the affected nerve(s) in the epidural space.
  • A combination of numbing medicine (an anesthetic) and time released anti - inflammatory medicine (a steroid) is injected.

The procedure usually takes approximately 30 minutes, followed by about 30 minutes of recovery time. On the day of the epidural steroid injection the patient should not drive. Rest is needed and strenuous activities must be avoided on the day of the epidural steroid injection.

Epidural injection results and follow-up

Following the epidural injection, some partial numbness from the anesthetic may occur in the patient ’ s arms or legs. Any partial numbness usually subsides after a few hours. Any remaining pain needs to be reported to the physician.

There may be an increase in the patient ’ s pain that may last for up to several days. This may occur after the numbing medicine wears off but before the steroid has had a chance to work. Ice packs may help reduce the inflammation and will typically be more helpful than he at during this time. Improvements in pain will generally occur within 10 days after the epidural injection, and may be noticed as soon as one to five days after the injection.

Regular medicines may be taken after an epidural steroid injection. On the day following the procedure, the patient may return to his or her regular activities. When the pain has improved, regular exercise may be resumed in moderation. Even if improvement is significant, activities should be increased slowly over one to two weeks to a void recurrence of pain.

Epidural results and precautions

As with any medical procedure, there are certain drawbacks and potential risks associated with an epidural steroid injection for back pain, leg pain or arm pain. One of the most important issues to consider is that the procedure only tends to significantly lessen the patient’s pain about half of the time.

Effectiveness of epidural injections

Unfortunately, epidural steroid injections are not always effective — it is estimated that they help relieve t he patient’s pain only about 50% of the time. In some cases the pain relief will be permanent. In others, the pain will be lessened enough to allow the patient to progress with rehabilitation and exercise, which helps the patient heal and find pain relief on a long-term basis.

If excellent pain relief is obtained from the first epidural injection, there will be no need to repeat it. If there is a partial benefit (greater than 30% relief from pain) the epidural injection can be repeated for possible addition al benefit, or it may be necessary to conduct additional tests to more accurately determine what is causing the patient ’ s pain. Up to three epidural steroid injections may be performed, spaced at least two to four weeks apart. If the initial injection prov ides minimal benefit (less than 30% pain relief) the physician may either repeat the injection, or try a different type of injection or treatment.

Potential risks and complications include, but are not limited to:

As with all invasive medical procedures, t here are potential risks associated with epidural steroid injections. However, in general the risk is low, and complications are rare. Potential risks include:

  • Infection. Minor infections occur in 1% to 2% of all injections. Severe infections are rare, occ urring in 0.1% to 0.01% of injections.
  • Bleeding. A rare complication, bleeding is more common for patients with underlying bleeding disorders.
  • Nerve damage. While extremely rare, nerve damage can occur from direct trauma from the needle, or secondarily f rom infection or bleeding.
  • Dural puncture ("wet tap"). A dural puncture occurs in 0.5% of injections. It may cause a post - dural puncture headache (also called a spinal headache) that usually gets better within a few days. Although rare, a blood patch may be necessary to alleviate the headache from a dural puncture.

In addition to risks from the injection, approximately 2% of patients will experience side effects from the steroid medication, such as:

  • Transient flushing with a feeling of warmth ('hot flashes') for several days
  • Fluid retention, weight gain, or increased appetite
  • Elevated blood pressure
  • Mood swings, irritability, anxiety, insomnia
  • High blood sugar — diabetic patients should inform their primary care physicians about the injection prior to their appointment
  • Transient decrease in immunity
  • Cataracts — a rare result of excessive and/or prolonged steroid usage
  • Severe arthritis of the hips or shoulders (avascular necrosis) — a rare result of excessive and/or prolonged steroid usage

Lumbar epidural steroid injections should not be performed on patients who have a local or systemic bacterial infection, are pregnant (if fluoroscopy is used) or have bleeding problems. Epidural injections should also not be performed for patients whose pain is from a tumor or infection, and if suspected, an MRI scan should be done prior to the injection to rule out these conditions.

Copyright © 2011, TOG All rights reserved.
Revised 3/10/11

Herniated Discs

Shirvinda Wijesekera, M.D.

Herniated-Discs.jpgWe have all heard of cases of terrible back pain or sciatica. Some of these ailments can be related to a common injury to the intervertebral disc. The human intervertebral disc is a structure that lies between the vertebral bodies. It functions as a shock absorber to cushion the forces we all experience throughout the course of the day. When this disc becomes injured it can lead to a common scenario described by many names: herniated disc, slipped disc, ruptured disc, or sciatica.

The human disc has an outer layer of tough fibrous bands, much like those of a steel belted tire. These rings of tissue reinforce a soft center, the nucleus pulposis, which works as the force absorbing center. When the disc is injured the tough rings can tear, allowing the soft nucleus to extrude through the tear.

There are many grades or severities to these types of tears. On occasion this can lead to a mild bulge in the disc. At other times a complete tear can create a channel, through which the soft nucleus can travel into the spinal canal. These two components, the torn outer layer of the disc and the encroachment into the spinal canal leads to the common symptoms of back pain and sciatica. In those patients in whom the soft nucleus travels into the spinal canal and impacts upon one of the spinal nerves, sciatica predominates. Those patients with less impact on the spinal nerves often experience more back pain.

The diagnosis of a herniated disc can often be suspected from a simple description of a patients symptoms and a physical examination. An MRI scan can often provide radiographic evidence to support your doctors’ suspicion of a herniated disc. Once your doctor has made the diagnosis a variety of treatment options are available to you.

Many conservative options exist, including observation, medications, and physical therapy. The vast majority, more than 80% of those with a herniated disc will have their symptoms abate with these conservative measures. Most of those patients will have their symptoms considerably improve within 3 months or less.

In the smaller subset of patients that do not improve with conservative care or have worsening neurological examination, surgical treatment is often possible. These microsurgical techniques can result in patients going home with a minimal scar, and a rapid recovery. The techniques that past generations have had to endure have changed. New techniques, have led to better outcomes with much less morbidity. Ultimately, your doctor can provide you with a treatment regimen to return you to a normal life.

© 2008 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author

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