We asked some leading surgeons to answer a few frequently asked questions about scoliosis surgery. Here is what they had to say.
When would you normally recommend surgery?
How do you treat a rib prominence?
How much correction can I expect?
Where do you get your bone chips?
How much will my physical activities be restricted after surgery?
When would you normally recommend surgery?
When you were diagnosed with scoliosis, your surgeon would have told you your Cobb angle. The Cobb angle measures how severe your curve is. The higher your Cobb angle, the greater your curve. A lot of surgeons will recommend surgery if you have a Cobb angle of 40 to 45 degrees or higher. However, this may vary depending on the region or country where you live.
Dr Reinhard Zeller, The Hospital for Sick Children, Toronto, Ontario: I would recommend surgery if you have a Cobb angle of 50 degrees. However, if you have a lower Cobb angle but your trunk is really shifted to one side, I might also ask you to consider surgery.
Dr Ron El Hawary, The IWK Health Centre, Halifax, Nova Scotia: I would recommend surgery if your Cobb angle is 50 to 60 degrees or more.
Dr Douglas Hedden, Stollery Children’s Hospital, Edmonton, Alberta: Usually a Cobb angle of 50 degrees or higher. However, the decision to do surgery really depends on several factors. Your age is important. If you are young with a lot of growing to do, it is more likely that your curve will get worse as you get older. Therefore, if you are quite young, I would recommend surgery with a lower Cobb angle. Also important is how you have responded to other types of treatment. For example, if you have been wearing a brace for some time and your curve is still getting worse, I might recommend surgery. The type of scoliosis you have also affects my decision. Some types of scoliosis get worse faster than others and do not respond as well to bracing. The most important thing I consider is what you and your family think of your curve. If your curve is really affecting you and causing you problems, I might consider surgery.
Dr James Jarvis, Children’s Hospital of Eastern Ontario, Ottawa, Ontario: There are lots of things I consider when deciding to do surgery. These include your age and how mature you are, as well as the type of curve you have. If your curve is in your thoracic (mid) spine I may consider surgery with a lower Cobb angle. However, if your curve is in your lumbar (lower) spine, I would want to keep your back bones as mobile as possible, and so I will not do surgery unless your Cobb angle is higher. Also, if you have two curves but overall your spine is well-balanced, I am less likely to do surgery unless your Cobb angle is higher.
Dr Timothy Carey, Children’s Hospital of Western Ontario, London, Ontario: In general, if you are younger and your curve is in your thoracic (mid) spine, and your Cobb angle is more than 50 degrees, I will recommend surgery. If you are older and your skeleton is more mature, and your Cobb angle is between 50 and 60 degrees, I will talk with you and decide the best way to proceed. If you are older, more mature, and you have a Cobb angle greater than 60 degrees, I will recommend surgery. If you have a curve in your lumbar (lower) spine or thoracolumbar (mid and lower) spine, your curve pattern and symptoms become a big consideration. Generally, for these types of curves, I consider surgery if the Cobb angle is more than 50 degrees.
Dr Andrew Howard, The Hospital for Sick Children, Toronto, Ontario: When I recommend surgery, my aim is to prevent your curve from getting worse. If your curve is in your thoracic (mid) spine and your Cobb angle is less than 50 degrees, I am not likely to do this with surgery. However, if your Cobb angle is 55 to 60 degrees or higher, I would recommend surgery.
How do you treat a rib prominence?
When you bend over, does your ribcage stick out on one side of your back? This is called a rib prominence and it happens in some teens who have scoliosis. Rib prominence happens when ribs rotate due to spinal rotation. Here is how some leading surgeons try to correct rib prominence.
Dr Zeller: I use a technique called "direct vertebral derotation.” This is when I try to reduce the rotation (derotation) of the spine. This is done during the scoliosis surgery, and it usually allows me to correct the rib prominence. If you have an extremely severe rib prominence, or if you are older and you have a very rigid curve, I might need to shorten or remove one or two of your ribs. This technique is called a thoracoplasty, and again, it is only used when the rib prominence is really severe.
Dr El Hawary: I usually don’t treat a rib prominence any differently from a regular scoliosis surgery. However, if the rib prominence is severe, I would consider doing a thoracoplasty. I try to avoid this procedure though, because it comes with additional risks to the lungs.
Dr Hedden: I generally do a derotation of the spine during the scoliosis surgery. So this means I try to correct both the rotation and the curve in your spine during the same operation. This procedure is becoming more and more successful. Sometimes though, I may need to treat the scoliosis and the rib prominence in separate surgeries. The need to do these procedures separately has decreased. If your rib prominence is severe and I feel the scoliosis surgery and spine derotation are not enough, I may consider removing a part of your rib(s) on the side of your rib prominence. This can sometimes help to improve the appearance of your back. If the problem is on the opposite side with the chest having an appearance of being too flat, then cutting the ribs and overlapping them (to build up the area that is flat) can be beneficial. The need to do this is becoming increasingly rare.
Dr Jarvis: With today’s improved techniques, rib prominence can often be corrected as part of the scoliosis surgery. However, if the rib prominence is severe, I may use a thoracoplasty, either during scoliosis surgery or as a second surgery. In a thoracoplasty, I would remove a small portion of one of your ribs in such a way that the rib will grow back in an improved position.
Dr Carey: Historically, I have done thoracoplasty for severe rib prominence. However, treatment is getting better every year. With all the new instruments and techniques we now have available, I have not needed to do any thoracoplasties in the last year.
Dr Howard: I treat rib prominence during surgery, either with a spinal derotation or a thoracoplasty.
How much correction can I expect?
Dr Zeller: It depends on the stiffness of the curve. If you have a typical curve, I can usually correct it by about 66% to 70%. If your curve is over 90 degrees, I can usually correct it by about 50%.
Dr El Hawary: I can correct a typical curve by about 50%.
Dr Hedden: If you are of normal size with no underlying bone problem, I can usually correct the curve by about 70%.
Dr Jarvis: The amount of correction really depends on the type of curve and on your flexibility. I can usually make corrections by about 50% to 75% but again, the most important consideration is your trunk balance and safety.
Dr Carey: It depends on your curve pattern and certain tests I do before the surgery. Generally though, I can correct by at least 50%.
Dr Howard: It is hard to predict but generally I can correct by about 65%.
Where do you get your bone chips?
Bone chips are little pieces of bone that are added to your spine during the operation. The bone chips, also called a bone graft, slowly heal together with the bones in your back to form a solid mass of bone. Bone chips are usually taken from bone in other parts of your body, or from a bone bank. If bone chips are taken from a bone bank, it is called a bone transplant or allograft.
Dr Zeller: If your curve is in your thoracic (mid) spine, a thorough local decortication (removal of top layer of bone from bones in spinal column) provides enough bone. For severe curves, or for curves that involve the lower back, the bone chips are taken from part of your pelvic bone (around the back of your hip area).
Dr El Hawary: I usually get our bone chips from a bone bank. However, if you do not want to have a bone transplant, I can also obtain the bone chips from part of your pelvis (around the back of your hip area).
Dr Hedden: You might only need to have bone chips taken from the area of your body where the surgery is done. You might also need bone chips taken from the bone bank, but this comes with a higher risk of infection. Substitutes for bone chips are becoming more available.
Dr Jarvis: I generally will use bone chips taken from the area of your body where the surgery is performed. I may need to add more bone chips from your pelvis or from a bone bank.
Dr Carey: I use a combination of local harvested bone (from your spine) and bone chips from a bone bank. If you do not like the idea of getting a bone transplant from a bone bank, I may use bone from your pelvis instead (around the back of your hip area).
Dr Howard: We usually take bone from the area of your body where the surgery is done. We may add some bone chips from a bone bank. Sometimes we might use bone taken from your ribs or pelvis.
How much will my physical activities be restricted after surgery?
Dr Zeller: Now, more than ever, I can achieve very good results in terms of correcting your curve. I also have much better brace protection for you after surgery. However, your bones still need a lot of time before they fuse and become solid. I would recommend not doing any sports or carrying heavy loads for the first six months after surgery. After six months, I will do a check-up and review your X-rays, and I might authorize doing mild activities like swimming. After one year, you might be able to do more activities like running, ballgames, or jogging. I will not want you to participate in contact sports until 18 months to two years after surgery, once your X-rays show that your bones have completely fused.
Dr El Hawary: I usually ask teens to restrict their physical activities for nine to 12 months after surgery.
Dr Hedden: It varies from surgeon to surgeon, but we all recommend a gradual return to activity. I will most likely allow you to return to your daily activities for the first three months after surgery. From three to six months after surgery, I may allow gentle exercise such as swimming. After six months, I might suggest a return to non-contact sports such as tennis and golf. After one year, you may be able to return to unrestricted activity.
Dr Jarvis: You will most likely be able to return to school about one month after the surgery. You will be restricted from excessive bending and heavy lifting for at least the first two to three months. In general, I limit sports for six months and contact sports for one year. These guidelines may be shortened depending on the type of surgery I did and the instrumentation I used.
Dr Carey: In general, you should not bend or lift anything for the first six weeks after surgery. After that, you can begin to take a few gentle activities. You can start doing non-contact sports at around six months and contact sports at one year. I advise against high impact sports.
Dr Howard: You can usually expect to return to your normal activities after one year.
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