Young people with severe cerebral palsy or muscular dystrophy, for example, who are wheelchair dependent may require to have their spine stabilised so that they can maximise the use of their arms and hands. Indeed patients with muscular dystrophy should have their spines stabilised from top to bottom as soon as they go into a wheelchair. There is evidence that this not only enhances function but prolongs life.
For the vast majority of those with idiopathic scoliosis, however, it is necessary to consider the infant and the adolescent separately. Those with infantile scoliosis which progresses need to have plaster of paris jackets fitted so that the pressure on the ribs can untwist the spine. These jackets need to be replaced every two to three months, under a light anaesthetic, as a day case. This treatment programme is continued until the age of three when the infantile phase of rapid growth diminishes.
For the adolescent with idiopathic scoliosis there is, unfortunately, no evidence base to support any form of non-operative treatment. In the last fifty years or more valiant efforts have been made to control the deformity with various types of brace or plaster casts but the adolescent is recalcitrant to anything but operative treatment.
Because the deformity of idiopathic scoliosis is a matter of appearance and deformity and not organic health, then what matters is whether the patient and family accept the deformity or wish to undergo surgical treatment for it. Surgery being the only treatment modality that benefits such patients.
Surgery comprises the insertion of metal work to straighten the spine, then to set the spine in the correct position using bone grafts so that the spine solidifies rather like a fracture that heals. With modern instrumentation systems the corrections are excellent and the complications minimal. It is particularly rewarding to see a distressed and reclusive teenager returning to normal life as a result of having the deformity corrected. That is why we surgeons carry out this type of surgery.
Before surgery the Consultant Spinal Surgeon explains the operative process and the patient is assessed, health wise, by an experienced nursing sister trained in the pre-operative assessment of our patients. Various x-rays and scans need to be carried out as well as blood tests and chest function tests to make sure that the patient is fit for surgery.
The anaesthetist makes sure the patient is suitable for surgery and all the treatment team meet patients and family prior to surgical intervention.
Surgery is usually in the form of one operation on the back but sometimes, with particularly stiff curves a preliminary release procedure is necessary.
Anaesthesia and the surgical procedure take about half a day and then the patient goes to the High Dependency Unit (HDU) for the first few post op days where there is one to one nursing. The patient then returns to the ward and is gradually mobilised so that about ten days after surgery the patient can be discharged home (after having walked up a flight of stairs with two physiotherapists). We usually try and carry out surgery during the school holidays to minimise educational upset. For the first month at home the patient gradually regains strength and mobility and, if it is term time, can go back to school at this point (i.e. about six weeks after surgery). For the next six weeks there should be no lifting, carrying or bending but from three to six months after surgery normal activities can be resumed, So that six months on from surgery the patient is back to full normal physical activities.
The patient is then seen serially in the Outpatients Department to monitor their recovery and then seen annually until the end of their growth at which point the patients and family will be discharged from clinical care, having been with the spinal surgical team for possibly ten or even more years.
Most health regions (i.e. Yorkshire, Lancashire, London) have a dedicated spinal deformity treatment centre at one of their big hospitals and so patients will not have to travel far to get state of the art treatment. All spinal surgeons who carry out scoliosis work attend the national meetings of the major scoliosis societies in the U.K., Europe and America, and also familiarise themselves with the relevant literature by reading the appropriate spine journals. Treatment of scoliosis patients is a science as well as an art and you can be assured that in the UK we have all the necessary therapeutic knowledge, skills and expertise.