Can surgery wait in large scoliosis curves?

[Dr Kalla]

This should be a very hot topic for parents and patients facing the recommendation to go for surgery from their MD.

What is your thoughts?

Here is truly a interesting paper on the subject and I will read it so that I can share my thoughts on it.

"The goal of this study was to determine whether the available studies provide enough evidence that, in a borderline case of adolescent idiopathic scoliosis with a large (35 to 50 degrees) curve in a skeletally immature patient (Risser 0 to 2) with significant growth potential left, a conservative line of management in the form of bracing can be considered, rather than to rush into a potentially unnecessary major spinal surgery. We reviewed the literature spanning the last 20 years for the results of bracing in this specific group of patients. From the 9 studies selected, a group-specific data extraction was carried out. Three hundred and five patients with a 36 to 50 degrees scoliosis curve and Risser stages 0 to 2 were treated by bracing and the treatment was termed successful in 160 patients. Thus, more than half (52.5%) of the patients were successfully managed with a brace and were spared surgery. The current trend for management of these curves is early surgical intervention, the rationale being the ineffectiveness of bracing in preventing the progression of such a large curve and the difficulty in obtaining satisfactory correction by postponing surgery to a later date. On the basis of our results, we propose a conservative line of management for these curves, in contrast with current views, rather than to rush into a major spine surgery, expecting a favorable outcome with a well-supervised bracing program. If the curve progresses, surgery can always be considered later, keeping in mind the excellent correction obtained with the pedicle screw systems even for large curves of 70 to 100 degrees."

[Goldfinch]

This is an interesting article and is definitely a useful thing for the parents of patients to read. It appears that this Korean hospital is quite "trigger happy" with surgery - this isn't typical of the hospitals that I have worked in, but certainly may be the case elsewhere. Parents should know that a stable 35-50 degree curve isn't an emergency.

At my centre we try to hold surgery off for as long as possible. It is only indicated in curves that are obviously progressing despite bracing. If we can hold a curve by bracing we will, unless the child has cardiac or respiratory issues secondary to their curve (usually this only happens in much larger curves - above 80 degrees, more typically around 100 degrees). I would argue that 35-50 degrees isn't what we would term as "large" in a surgical sense, and we never fuse curves in the 30s. Curves that are progressing are a different ballgame; a child who has a 50 degree curve that has developed rapidly and has documented rapid progression will be placed on the surgical waiting list at once, because typically these children will have progressed a significant amount by the time their surgery date comes round (waiting times on the National Health Service can run to over a year). They do have the option of backing out of the surgery at any point, so if their curve miraculously stabilised then they could choose not to have it fused.

I should state here that the decision for surgery is not based purely on the Cobb Angle (as we have discussed elsewhere) but on individual factors and measurements that affect each particular case. Also, some of our consultants will not brace larger curves (ie 50+), because they believe they will progress anyway, and they wish to spare the child the trauma of years in a brace followed by inevitable fusion. In many cases the teenage patients themselves prefer the prospect of surgery over wearing a brace. It's very difficult to persuade them to wear one! I am following the news regarding Spinecor with great interest as I think this sort of innovation is the way forward.

[Dr Kalla]

Thanks for your input Goldfinch, valuable as always.

The situation is far different here in Asia. In Singapore the waiting time can be around a week and yes they have even recommended surgeries for cases even below 30 degrees. I believe that the surgeons here work very much on commission and a few bad apples appear very soon. Fortunately not all surgeons are the same here.

[Goldfinch]

That is terribly shocking :-( Surgery should never be rushed into so soon, least of all for such small curves. At my centre, even those with huge curvatures who are seen as a priority are given a good couple of months at least in order to digest the idea of having surgery, and to explore and research more about surgery and alternatives if they wish to. It is very important to me that patients feel comfortable and in control about their decision to have spinal fusion done. Hopefully more papers like this will be published in your part of the world!

[DrStitzel]

This further emphizes my point that the initial recommendation for surgery should not be made based off a phantom cobb angle threshold (40 degrees?). If the scoliosis fusion surgery is being done for medical reasons....as opposed to cosmetic reasons, the initial recommendation for the procedure should be entirely based off organic health measures (respiratory measures, cardiac out measures, ect.) with cobb angle being a secondary concern.....if considered at all since it (cobb angle) has a very poor coorelation with any organic health measures on an individual basis.