A few years ago, however, Kara received some news that threw her a curve. Her spine was twisting laterally at a rapid rate and would only get worse if it were left untreated.

“We knew that Kara had scoliosis since she was 12, but it was a mild case,” says her mother, Barbara. “When her menstrual cycle began, the scoliosis quickly became worse.”

The Mongiovis took Kara to see Dr. Sanjeev Sabharwal, a pediatric orthopaedic surgeon at University Hospital and an assistant professor of orthopaedics and pediatric orthopaedics at New Jersey Medical School. Scoliosis is measured by degrees; the higher the number, the more severe the condition. Kara’s X-rays showed a spinal curvature of 50 degrees. At that level, Dr. Sabharwal told the family, wearing an orthotic brace to halt the curve’s progression was not the best option. Surgery would be needed to straighten Kara’s crooked spine.

“I was a little scared and wondered how the scar would look on my back,” says Kara. “Mostly, though, I just wanted to have a straight back.”

Kara's surgery was successful and her recovery was surprisingly quick and uneventful, says her mother. An additional benefit of the surgery, Kara notes, is that it “added” two inches to her height–the result of straightening her spine.

Timing Is Everything

Scoliosis, a three-dimensional, sideways curvature of the spine, affects about 1 in 10 teenagers (mostly girls), although younger children and adults can also have the condition. Because scoliosis commonly develops during the adolescent growth period, the American Association of Pediatrics recommends screenings at ages 10, 12, 14, and 16. Pediatricians and family practitioners typically conduct scoliosis screenings at these ages during well-child checkups, and most public school systems offer free screenings.

That’s crucial, says Dr. Sabharwal, because the earlier scoliosis is detected, the more likely that surgery can be avoided. “When the curvature is mild–up to 20 degrees or so–we’ll watch the patient to see if the curve progresses,” he says. “With a moderate case, where the curvature is between 25 degrees and 40 degrees, we can use a brace that often keeps the curve from getting worse during a critical time–the adolescent growth spurt. Once a teen’s growth is complete, it is unlikely that a curvature will get worse.”

Although the majority of scoliosis cases are discovered and treated when the patient is an adolescent, sometimes the condition isn’t correctly diagnosed until adulthood. “Scoliosis is not always as easy to identify as people might think,” says Dr. Mitchell Reiter, assistant professor of orthopaedics at New Jersey Medical School and an orthopaedic surgeon at University Hospital. “If a person has two mild curves that balance each other out, it’s possible to miss the diagnosis.”

Unlike with children, scoliosis can be painful for adults, causing disabling lower back pain or pain that radiates to the legs. That doesn’t necessarily mean surgery is needed. University Hospital’s comprehensive, multidisciplinary approach of therapy, anti-inflammatory drugs, pain relievers, and spinal injections ranging from a local anesthetic to a nerve block, often effectively manages pain. Only in the most severe cases of adult scoliosis–when the curve exceeds about 50 degrees– is surgery recommended to help correct the deformity, says Dr. Reiter.

Special Cases, Special Care

Most scoliosis is “idiopathic” in origin, meaning that there’s no direct underlying cause for the condition. However, about 20 percent of scoliosis cases are linked to other conditions, such as muscular dystrophy, spinal muscular atrophy, cerebral palsy, and Down’s syndrome. Dr. Sabharwal has the training and experience to treat these complicated cases, which often need a different approach than would be used for adolescent idiopathic scoliosis.

These patients often have difficulty breathing after surgery due to muscular weakness in the chest. Typically, they would need a tracheostomy, which provides an airway or allows for removal of secretions in the lungs. Dr. John Bach, one of Dr. Sabharwal’s colleagues at University Hospital and Vice-Chairman of the Department of Physical Medicine and Rehabilitation, specializes in the rehabilitation of patients with neuromuscular disease. He has developed a non-invasive ventilation tool, a “coughilator,” that helps eliminate the need for a tracheostomy by teaching the patients, prior to surgery, how to breathe on their own once the surgery is completed, thus decreasing respiratory problems.

Matildelis Medina, who has muscular dystrophy, had an 80 degree curvature of the spine. She could sit in a wheelchair, but it took a great deal of positioning with pillows to keep her upright. Although she was only eight years old at the time, Dr. Sabharwal believed it was in her best interest to have surgery to straighten her spine. Using a customized rod, he was able to reduce Matildelis’ curvature down to less than 20 degrees. She can now balance herself independently, and her hands are freed to feed herself, use the computer, and do other tasks. “The surgery has changed Matildelis’ life,” says her mother. “She can sit for longer periods of time and do more things for herself.”

Bracing or Surgery?

Orthotic bracing can be quite effective in stopping the progression of a curve; only about 10 percent of braced patients will need surgery. There is a compliance factor–the brace typically is worn up to a maximum of 22 hours a day–but the braces available today are not the cumbersome version of several years ago. Most are made of lightweight plastic with a foam lining and fasten with Velcro. Some are underarm models, as compared to those that go all the way up to the neck. And although it might feel like forever to a teenager, most braces are worn for a year or less.

When the curve is at 40 degrees or more, surgery is often recommended. The procedure typically performed is called posterior spinal fusion with instrumentation, which means that the surgeon accesses the spine from the back. Bone from another part of the patient’s body is grafted onto the vertebrae; to hold the bone in place, two stainless steel rods are attached to the spine with hooks or pedicle screws.

Hooks and wires are the traditional choice, but with the advancements made in image-guided surgery, pedicle screws–which enter into the bone– are increasingly being used, notes Dr. Robert Heary, director of The Spine Center at University Hospital and an associate professor of neurological surgery at New Jersey Medical School. “With pedicle screws, a surgeon is able to attach the rods to a shorter section of the spine than typically is possible using hooks and wires. That allows the patient to retain more mobility,” he says.

This idea of shorter lengths of fusions is desirable and will lead to better results, says Heary. "One of the problems with conventional deformity surgery is related to very long fused segments years after the surgery has been performed. However," he cautions, "pedicle screws need to be precisely placed. Image-guided surgery enables the surgeon to do just that.”

With image-guided surgery, the patient has a CT scan performed a few days prior to the surgery. During the surgery, the information from the previous CT scan is loaded into a computer in the operating room. This system is called the Stealth™ surgical navigation system, and is one of several types used at University Hospital. During the surgery, the surgeon touches points on the patient which are matched to points on the computer. By doing this, the surgeon is able to develop a map where he can receive "real time" feedback from the computer during surgery. Once the patient's data has been received by the computer, the path for surgery and the surgeon's view of the area are much clearer and precise. The surgeon can then place metallic instrumentation (screws) into narrow places near vital structures (such as the spinal cord) that would have been too risky or unreachable before this technology was available.

For some patients, it’s not the surgery itself that is worrisome, but whether or not they will need a blood transfusion. University Hospital, with its University Center for Bloodless Surgery & Medicine, is committed to limiting blood loss during surgery and thus, eliminating or reducing the need for transfusion. During Kara’s surgery, a technique known as cell saver, or interaoperative blood salvage, was used to recover the blood she lost, clean it, and reinfuse it to her. She received only a half-pint of her own blood.

Bouncing Back

After a successful surgery–one where there is good fusion between the spine and the rod–the rehabilitation period begins. “The back muscles are weakened after surgery,” says Dr. Scott Nadler, associate professor of physical medicine and rehabilitation at New Jersey Medical School. “Our focus is on strengthening those muscles so there is less discomfort, but also on posture and proper balance. When the spine is curved, the person bears weight unevenly. Poor posture becomes a habit.”

At the start, therapy sessions are scheduled for about three times a week and are what Dr. Nadler describes as “functional” in nature, i.e., working toward a correct back alignment. As the patient progresses, there are weight-bearing exercises, such as squats, and ultimately, aerobic exercises, including walking, running, or swimming. Rehabilitation after surgery can take between two and six months, depending on the level of scoliosis the patient had and other individual factors.

A patient who wears an orthotic brace also needs physical therapy. “While muscle healing is not an issue as it is with surgery, the patient wears the brace up to 22 hours a day,” notes Dr. Nadler. “The goal here is to increase the strength of spinal musculature, with attention to flexibility and posture.”

Experience Matters

There’s no single, cookie-cutter approach to treating scoliosis – orthopaedic surgery, neurological surgery and physical medicine and rehabilitation all play important roles in providing the most effective treatment option. Regardless of what option is ultimately chosen, the goal is the same: straighten a crooked spine while retaining as much of the patient’s natural mobility as possible. “Scoliosis treatment is challenging, but the end results are well worth it,” says Dr. Heary. “Most of our patients are otherwise healthy teenagers who have a condition that can get worse without a brace or surgery. After treatment, it’s rewarding to know we’ve greatly improved their lives.