Future of Scoliosis Treatment
George H. Thompson, MD Past President, Scoliosis Research Society

The treatment of idiopathic scoliosis, particularly conservative treatment, has been controversial. It has been difficult to determine which patients were going to progress, and who would benefit from conservative treatment (physical therapy, bracing, etc.) or require surgery.

Genetic testing will soon be available, that will help answer some of the questions. An analysis of 51 DNA markers associated with scoliosis has allowed determination of three specific groups of patients: no risk for progression, moderate risk, and those that will progress to 45 degrees or more and probably require surgery. When this testing is available, it may change the entire paradigm of management of scoliosis. Those that will not require treatment will need to be followed only periodically for confirmation. Those that are in-between will still require periodic evaluation and may benefit by conservative methods of treatment, such as physical therapy and bracing. Those in the high risk category for curve progression, may have earlier surgical intervention involving fusionless techniques.

This will make the application of growth modulation techniques, such as, vertebral body stapling, more applicable. This may be effective in controlling curve progression until skeletal maturity, at which time the staples could be removed or perhaps even left in place. As a consequence, spinal mobility will not have been affected but curve progression will have been prevented. Further refinement of genetic testing may ultimately identify those patients who will benefit by physical therapy or bracing, so that these treatments can be begun at the earliest possible stage to maximize their effectiveness.

This is an exciting time as the future of idiopathic scoliosis is changing. Genetic testing will be one of the major advancements in the past 50 years. This type of testing should be commercially available within the next several years. It will result in further opportunities for cooperative relationships between the Scoliosis Research Society (SRS) and SOSORT. New criteria for management will be developed and will also be given an opportunity for more scientific assessment of the results of the various forms of treatment.

The technology is here and the dots are finally being connected......Scoliosis is a condition with both genetic and environmental components (Nature vs. Nurture). Any basic algebra student can tell you that an equation with 2 unknown variables can't be solved and this is why trying to figure out which patients needed which treatments was almost impossible to do with any amount of accuracy. Until now, the Scoliscore test can provide us with the necessary genetic part of the equation and we can now focus on elimination of the environmental aspects of the condition (since altering the genetic component is currently impossible).....this means we can actually start working towards a cure through early stage intervention and elimination of environmental factors.

Genetic testing also provides us with the ability to create a personalized/customized environmental factor reduction treatment plan based on the patient's genetic risk.

I have attached a flow chart outlining the traditional cobb angle directed treatment plan (left) and the new Scoliscore/genetic testing directed treatment plan on the right. It should be noted that "VBS" stands for "vertebral body stapling".

So what are the environmental factors that help drive the condition? Why do at least 4% of scoliosis cases go to surgery when only 1% are considered genetically "high risk"?

We don't have a complete list of environmental factors yet, but I think we can consider some strong "possible/maybe's" to get us started.........

1. Flattening of the thoracic curve through activities (dance, swimming, back bends, stomach sleeping, ect)
2. Foward head posture/lost of cervical lordosis (normal curve in the neck)
3. Hip rotation/translation
4. Alar ligament damage
5. ???????

Feel free to add to this list or comment on any portions of the existing list........