Frequently asked questions about scoliosis

Why does scoliosis develop most often in late childhood?
And why is it more common in girls? Scoliosis most often develops in late childhood because of the association between growth and progressive scoliosis curves. Although scoliosis can develop at any age, including infantile (age birth- 3), Juvenile (age 3-10), adolescent (age 10-18) and adult (> age 18), the most common time to detect curves are in late childhood/early teen years. Thus, the most common form seen, Adolescent Idiopathic Scoliosis (AIS), is detected between ages 10 and 18, often just before or after puberty and the associated adolescent growth spurt. Small curves (10-20 degrees) are nearly equally found in boys and girls, but larger curves which often need treatment (those > 40 degrees) are seen in females to males in a 9:1 ratio. It is a bit unclear why that is the case, it may certainly be a genetic tendency, and/or something relating to hormonal alterations or connective tissue adaptations for the potential for childbirth in females.
What causes some children to develop scoliosis while others do not?
Is it simply genetic or are there other factors involved? Although there are many potential etiologic factors implicated for idiopathic scoliosis development, the genetic aspects are probably the most influential. Multiple genetic studies have confirmed strong family relations including studies of identical vs paternal twins. Other factors such as various hormones, equilibrium and balance issues have been promoted as well, but none are conclusive. The genetic factors are strong but highly complex, multigene interactions that are still being actively investigated, including here at Washington University by Dr Matt Dobbs of the Department of Orthopedic Surgery.
What causes adults to develop scoliosis?
Adults can develop scoliosis as a result of slow progression of childhood curves that were untreated, or as curves that develop on their own from aging of the spine, usually in the lower (lumbar) region and termed "de novo" adult lumbar scoliosis. These de novo curves result from progressive degeneration of the joints in the back of the spine along with degeneration of the discs supporting the front of the spine. Although this natural aging process occurs in everyone, only certain people will develop a corresponding scoliosis with the process.
At what point is a brace needed to treat scoliosis?
Bracing is indicated only for children and teens that are still growing in order to attempt to slow or stop the scoliosis progression during the remainder of the child's skeletal growth. It is also only indicated for mild to moderate curves in the 20-40 degree range and appears less effective in males and those with larger body habituses.
Beyond bracing, what are the treatment options? Are minimally invasive procedures becoming more common?
There are 3 standard treatments for scoliosis in Children: Observation, Bracing (as above) and surgery. Observation is indicated for small curves (< 20 deg, no matter what the age), and curves < 45-50 degrees in those who are skeletally mature. Surgery is indicated for curves > 40-45 degrees in those with growth remaining, and >45-50 degrees for those who are done growing (skeletally mature). For adult patients, there is really no good indication for bracing except for the rare circumstance of helping patients with lumbar pain, postural changes for temporary pain relief. Observation with physical therapy, aerobic activities etc are indicated for a vast majority of patients with smaller curves and minimal symptoms. Active non-surgical treatment such as epidural steroid or nerve root injections are indicated in the subset of adults who have spinal stenosis (narrowed spinal canal) and/or pinched nerves in the lumbar spine. Surgery is reserved for those adults with previously untreated adolescent scoliosis with continued curve progression in adulthood to curves > 50-60 degrees in the thoracic or lumbar spine, or for those denovo curves > 30-40 degrees in the lumbar spine in which the patient is symptomatic.
Can scoliosis cause related problems with blood flow or organ systems?
Scoliosis can cause restricted pulmonary disease when affecting the thoracic spine, and even suboptimal cardiac function in the very severe curves > 90-100 degrees. For curves affecting the lumbar spine, spinal stenosis and/or pinched nerves can cause lower extremity pain/disability. Also, for those patients whose spine is collapsing, the trunk can shorten with the rib cage resting on the pelvis making breathing more difficult and often impairing GI function as well. Also, the psychosocial aspects of living with a progressive disfiguring spinal deformity cannot be ignored and impaired quality of life parameters are documented in the literature for various subsets of adult scoliosis patients.

K. Daniel Riew on neck pain

Learn more about Dr. Riew and neck and back pain on our website at http://ortho.wustl.edu/

Physiatry 'Missing Link' in Orthopedics

In her office at the new Washington University Orthopedics and Barnes-Jewish Hospital Outpatient Orthopedic Center in Chesterfield, Heidi Prather, D.O., first lowers her eyes, then looks at the ceiling for a moment as she recalls her decision to go into physical medicine and rehabilitation as a specialty and to focus a part of her practice primarily on women.
“I’ve never told this story,” she says. “My mentor during residency, who happened to be male, once looked at me and said, ‘Since you’re going into academic medicine, you’d better figure out these things about women because we men aren’t going to.’ That’s honestly when I thought, ‘OK, that can be my issue.’”
That was during her residency at the Rehabilitation Institute of Chicago, which is home to the Northwestern University Feinberg School of Medicine’s Department of Physical Medicine and Rehabilitation. Her mentor, Joel M. Press, M.D., says he was mostly telling her things she already knew.
“She always understood that it’s about the patient,” says Press, director of the Rehabilitation Institute’s Spine and Sports Rehabilitation Center in Chicago. “By focusing on patient needs, both women and men, she’s become a leader in our field. She’s also been able to build one of the best musculoskeletal fellowship programs around and helped improve the already outstanding reputation of Washington University Orthopedics.”
Prather, an associate professor of physical medicine and rehabilitation, is the first woman president of the Physiatric Association of Spine, Sports and Occupational Rehabilitation. In that capacity, she’s getting a chance to raise awareness nationally among physiatrists (those who specialize in physical medicine and rehabilitation) regarding issues involving women and injuries.
She says when treating an injured woman, doctors — and physiatrists in particular — must consider the continuum of the lifecycle for women and where the woman is along that timeline when she experiences an injury or impairment.
“There are pre-pubertal women versus post-pubertal,” she explains. “Then there’s before babies, during pregnancy, immediately post-partum, pre-menopausal, post-menopausal and aging. Where a woman is on that timeline will greatly influence her musculoskeletal function. Men simply don’t undergo the same kinds of changes.”
For example, when a pre-menopausal woman has a compression fracture of the spine, Prather immediately worries about early osteoporosis. A similar fracture in an older woman also might be due to weakened bones, but determining the cause of such a fracture — an important factor in determining treatment and rehabilitation — is especially urgent for a woman of 40.
“I might easily see what the problem is, but figuring out why a woman has the problem is key,” she says. “If I don’t learn the cause, there’s a good chance she may face that same problem in the future.”
Music and tennis
Prather herself has been happy to avoid injuries lately. Because she’s been injury-free, she’s been running quite a bit. She says she rarely exercises when injured.

Heidi Prather, D.O.  Born: May 20, 1965, Kansas City, Mo. Education: Bachelor of arts with honors, biology and chemistry, 1987, Drury College; D.O., University of Health Sciences College of Osteopathic Medicine, 1991 University position: Associate professor of physical medicine and rehabilitation, Washington University Orthopedics Family: Son, Ethan Bradley (10); daughter, Emma Bradley (6); husband, Jeffrey Bradley, M.D.; mother, Becky Prather; father, Carl Prather; sister, Gretchen Evans

“I don’t overdo it because when I work with my patients, I see what can happen,” she says. “I’m pretty good when I’m hurt. I rest, and then I usually go around and ask other physicians and physical therapists to look at me. I find it’s usually better to trust someone else than to try to diagnose yourself.”
She grew up in Kansas City in a family of musical tennis players. Her father, Carl Prather, was a band director. Her mom, Becky, played drums. Heidi herself took up the trumpet and attended Drury College in Springfield, Mo., on a music scholarship, playing in the symphonic band and other musical groups, including the professional symphony in Springfield. But she never wanted music to be “work,” hoping instead to use it as an outlet.
These days, she plays piano to relax after long nights of dictation. She’d like to return to music more seriously someday, but that will have to wait until her kids Ethan, 10, and Emma, 6, are a little older. Much of her spare time these days is spent as a “soccer mom,” attending games and practices and taking turns shuttling them to Tae Kwon Do and dance lessons with her husband, Jeffrey D. Bradley, M.D., associate professor of radiation oncology at the Siteman Cancer Center.
She calls herself the least talented tennis player in the family, but she still managed to compete at Drury. Her younger sister, Gretchen, was the star, however, and still competes in sanctioned tournaments, recently playing in a national event.
In addition to running, Prather also rode her bike across Missouri this summer, accompanying her mentor, Joel Press. She was with him for 213 miles of his cross-country bike trip called the Ride for Rehab. Missouri was only a small portion of his total trip, but Prather made enough of an impression to receive official recognition as the Ride for Rehab’s “top female physiatrist rider without twins.”

By: Jim Dryden

Read the original article here:
Keeping dancers on their toes | Newsroom | Washington University in St. Louis

Spine Disorders Complicate Hip Arthroplasty

Patients undergoing total hip arthroplasty (THA) who have coexistent lumbar spine disorders (LSDs) do not report as much improvement in pain and function after arthroplasty compared with patients without lumbar disorders.

(HealthDay News) — These are the findings according to a study published in the May issue of The Spine Journal.
Heidi Prather, D.O., from the Washington University School of Medicine in St. Louis, and colleagues retrospectively examined 3,206 patients who underwent THA from 1996 to 2008. To identify which patients were also evaluated by a spine specialist, the International Classification of Diseases, Ninth Revision billing codes for LSDs were cross-referenced with patients who had undergone a THA. Functional outcomes were measured using the modified Harris Hip Score (mHHS) and University of California Los Angeles (UCLA) hip questionnaire, and physician medical charges were assessed.
The researchers found that a higher number of LSD patients were significantly older (64.5 years) compared with patients treated with THA alone (58.5 years). Compared with the THA + LSD group, patients in the THA alone group had significantly greater improvement in the mHHS, UCLA score, and pain. On average, patients in the THA + LSD group incurred significantly more in charges per episode of care ($2,668) and significantly more days per episode of care, compared to patients with THA alone.
"Patients undergoing THA alone had greater improvement in function and pain relief with fewer medical charges as compared with patients undergoing a THA and treatment for an LSD," the authors write.

Read the original article in MD News here:
MD News - Coexistent Lumbar Disorders Complicate Hip Arthroplasty

Spinal Tumor Recovery

Mary Martinez is back to bowling and golfing and is “doing fantastic,” though she says she’s under doctor’s orders not to lift refrigerators or break up concrete. Just one year ago, the 60-year-old Martinez was treated for lung cancer that had metastasized to her spine, and Jacob Buchowski, MD, MS, had to implant two artificial vertebrae to replace those that had been consumed by cancer.
Martinez, whose nickname at Barnes-Jewish Hospital was “the sledgehammer lady,” first learned that something was wrong when her back made an audible “pop” while she was wielding a sledgehammer to break up an old walk around her swimming pool. Excruciating pain below her shoulder blade radiated down her arm and made her left side ineffective.
Based on the advice of her chiropractor, Martinez underwent an MRI when X-rays were negative and three weeks of chiropractic treatment did nothing to relieve the pain. The scans revealed a lesion on her lung, which Martinez, a long-time smoker, says matter-of-factly didn’t surprise her. It took exploratory surgery to find the cancer’s metastasis to the spine.
Eventually, Martinez was referred to a Siteman Cancer Center oncologist, but the disease was unresponsive to chemotherapy, and surgery on both her lungs and her spine was scheduled for St. Patrick’s Day of ’08.
In a complex, day-long surgery, Buchowski and colleagues removed the entire tumor which originated in the lung and invaded two thoracic vertebrae. The extent of tumor involvement made it necessary to reconstruct the spine with a metal cage, screws, and rods.
Although the need for radiation prior to surgery made wound healing difficult and Buchowski had to schedule plastic surgery by a colleague, the problem was completely resolved. Martinez, a former Illinois special education teacher, says now that she is “not quite the Energizer Bunny,” but is grateful to be active again and lucky that the sledgehammer incident introduced her to Buchowski.
“I did my research on the Internet, and he was the right man for the job. He always made me feel very secure, and always told me the truth, including that my surgery would last about 10 hours. I’m very thankful that Dr. Buchowski could help me.”

Can acupuncture treat back pain?

Acupuncture has relatively good evidence in the literature for treatment of chronic nonspecific low back pain. Several studies show that it can work better than ususal care which includes medications or physical therapy. Interestingly, randomized controlled trials did not show acupuncture to be superior to a sham acupuncture procedure. Acupuncture treatments usually consist of weekly visits, and it may take up to 5 session before noticing a benefit. Because of the out-of-pocket expense, acupuncture is often not the first line of treatment for low back pain. Patients I treat have usually failed all other treatments. Despite this, I am still able to get some results in this difficult population. Due to its good safety profile and minimally invasive nature, I think acupuncture is a good option for anyone that wants to try a more alternative approach to low back pain.

By: Chi- Tsai Tang, MD

Read more about Dr. Tang at: http://ortho.wustl.edu/content/Patient-Care/2717/FIND-A-PHYSICIAN/Listing-of-Faculty/Chi-Tsai-Tang-MD/Bio.aspx

Heidi Prather on Low Back Pain

Dr. Prather, one of our physiatrists, discusses the common causes and remedies for low back pain:



To read more about Dr. Prather please visit: http://ortho.wustl.edu/content/Patient-Care/2711/Find-a-Physician/Listing-of-Faculty/Heidi-Prather-DO/Bio.aspx

Modern Acupuncture

The use of acupuncture was first documented more than 2000 years ago. During the 6th century, improved transportation within Asia led to Chinese medicine spreading across Asia. Today, acupuncture remains a crucial part of the Japanese and Chinese health care system, offered alongside modern medicine. Acupuncture began to gain western attention after President Nixon visited China in 1972 where he witnessed acupuncture being performed. Today in America, acupuncture has grown into a common form of pain managemnt in may clinics and hospitals. It is estimated that 15 million Americans or roughly 6 % of the American population, has visited an acupuncturist for a variety of symptoms including chronic pain, fatigue, nasea, arthritis and digestive problems. In 1995, the FDA classified acupuncture needles as medical instruments and assured their effectiveness. Then in 1997, the NIH recommended that insurance companies begin to provide full coverage for the treatment of certain conditions using acupuncture.

Dr. Tang, a physiatrist, uses medical acupuncture to treat different forms of pain.
You can request an appointment online here: http://ortho.wustl.edu/full/forms/MakeAnAppt.aspx

Medical Massage

Medical Massage is massage and/ or myofascial release that is directed to a specific injury or painful area. The patient will present with a specific diagnosis and the treatment is geared towards that diagnosis. The massage therapist will work on the fascia (connective tissue) and the muscles that they feel are contributing to the pain and dysfunction. An assessment including a postural analysis will be performed. Pain levels and function improvements are often the standard measurement for patient progress. Myofascial release and massage are often used in combination to relieve pain and dysfunction. Myofascial release is gentle stretching of the fascia including techniques such as cross hand release, skin rolling, trigger point pressure and scar release. Massage includes deep tissue work to relieve tight muscles. The combination of the above treatments can be extremely helpful in relieving pain and improving function.

By: Amy Smoot, LMT
BJWCH STAR Center

Fellowship Trained Surgeons

After an orthopedic surgeon completes their 5-year residency training, they choose a sub-specialty within orthopedic surgery to focus on throughout their career. They apply for a 1-year fellowship program in their area of interest, and upon completion, they are "fellowship-trained" in their domain. Fellowship-trained surgeons can go into academic practice or private practice. By hiring orthopedic surgeons who are fellowship-trained, we ensure that each of our surgeons have extensive expertise in their area of interest.

Acupuncture as a form of treatment

The most common condition I treat with acupuncture is probably chronic lower back pain that has been unresponsive to other treatments, and the most common diagnosis is spinal stenosis. Acupuncture ends up providing some benefit for about half of these patients. Acupuncture is also useful for numerous other conditions such as neck pain, myofascial (muscle related) pain, stress related conditions, headaches, and knee and hip pain due to arthritis. I am also personally interested in using acupuncture to treat sports-related injuries.

By: Chi- Tsai Tang, MD

Washington University Orthopedics - Spine Center

The Spine Center, conveniently located at our Orthopedic Outpatient Center in Chesterfield, provides comprehensive, specialized care to patients with acute back pain and neck pain. We are committed to seeing patients as soon as possible, and in most cases, appointments are given within 48 hours of your initial phone call.

76 percent of Americans suffer from acute back pain at some time during their lives. The focus of our center is to see patients early in the development of their symptoms and to provide a specific diagnosis and treatment plan. In addition to individualized treatment plans, rehabilitation also includes education regarding body mechanics specific to a patient’s lifestyle.

Back Pain Prevention Tips

Many of us suffer from back pain on a day-to-day basis. An estimated 60 to 90 percent of Americans experience at least one back injury during their lifetime. Of these people, half will experience recurring episodes of back pain. Most back problems develop over a span of years as a result of different factors - your exercise, how you sleep or sit and your diet. Here are a couple of helpful tips that may help prevent back pain:

• Exercise to keep your back strong. Aerobic conditioning and strength training can stem off lower back pain.
• Make an effort to sit and stand upright. Sitting or standing, you should put forth effort to keep good posture. To do this, try to ensure that your ears, shoulders and hips are aligned.
• Protect your back while sleeping. If you sleep on your side, sleep with a pillow in between your knees. If you sleep on your back, try to put a pillow underneath your lower back. Ensure your mattress also has proper support.
• Eat a healthy diet. Try to consume foods with vitamin D (found mostly in fish and soy products) and calcium, which helps to prevent osteoporosis.

Meet Carol, a patient of Dr. Bridwell's with scoliosis:

Our Residency Program

Resident physicians are graduates of medical school (MD), and are still completing training in their specialized field of medicine. Orthopedic Surgery is a specialty within the field of medicine, and each year, Washington University accepts 6 new resident physicians into their five-year training program.

Learn more about our program: http://ortho.wustl.edu/flipbook/OrthoLinkedIn11/index.html