THORACIC OUTLET SYNDROME
Thoracic outlet syndrome is a condition characterized by pain in the neck and shoulder, numbness/tingling of the fingers, and weakening of the grip.
Causes of Thoracic Outlet Syndrome
Thoracic outlet syndrome is a rare condition caused by compression of blood vessels and nerves in the area of the clavicle (collar bone). This compression is caused by the presence of an extra cervical rib (above the first rib) or an abnormal tight fibrous band connecting the spinal vertebra to the rib.
People with long necks and droopy shoulders may be predisposed to develop this condition because of extra pressure on their nerves and blood vessels
Information about Thoracic Outlet Syndrome
The thoracic outlet is an area at the top of the rib cage, between the neck and the chest. Several anatomical structures pass through this area, including the esophagus, trachea, and nerves and blood vessels that lead to the arm and neck region. The area contains the first rib, collar bone (clavicle), the arteries beneath the collar bone (subclavian artery), which supply blood to the arms, a network of nerves leading to the arms (brachial plexus), and the top of the lungs.
Pain and other symptoms occur when the nerves or blood vessels in this area are compressed. The likelihood of blood vessels or nerves in the thoracic outlet being compressed increases with increased size of body tissues in this area or with decreased size of the thoracic outlet. The pain of thoracic outlet syndrome is sometimes confused with the pain of angina that indicates heart problems. The two conditions can be distinguished from each other because the pain of thoracic outlet syndrome does not appear or increase when walking, while the pain of angina does. Also, the pain of thoracic outlet syndrome usually increases if the affected arm is raised, which does not happen in cases of angina.
There are three types of thoracic outlet syndrome:
True neurogenic thoracic outlet syndrome is caused by a compression of the nerves in the brachial plexus. Abnormal muscle or other tissue causes the problem.
Arterial thoracic outlet syndrome is caused by compression of the major artery leading to the arm, usually by a rib.
Disputed thoracic outlet syndrome describes patients who have chronic pain in the shoulders and arms and have no other disease or syndrome, but the underlying cause cannot be accurately determined.
Thoracic outlet syndrome is most common in women who are 35-55 years of age.
Symptoms of Thoracic Outlet Syndrome
Discomfort in the last 3 fingers and inner forearm
Numbness
Pain
Tingling
Pain and tingling in the neck and shoulders (may be worsened by carrying something heavy, such as a suitcase)
Weakness and wasting of the muscles of the hand
Compression of blood vessels or nerves in the thoracic outlet causes pain and/or abnormal nerve sensations. Compression usually occurs at the location where the blood vessels and nerves pass out of the thoracic outlet into the arm.
There are several factors that contribute to a person developing thoracic outlet syndrome. Poor posture is a major cause and is easy to treat. A person's physical makeup also can cause thoracic outlet syndrome. For example, abnormalities of certain anatomical structures can put pressure on blood vessels or nerves. Typical abnormalities that can cause problems are malformed ribs and too narrow an opening between the collar bone and the first rib.
The main symptom is pain in the affected area. The patient can also develop weakness in the arm and hands, tingling nerve sensations, and a condition called Raynaud's syndrome. In Raynaud's syndrome exposure to cold causes small arteries in the fingers to contract, cutting off blood flow. This causes the fingers to turn pale. In very severe cases of blood vessel compression, gangrene can result. Gangrene is the death of tissue caused by the blood supply being completely cut off.
In the case of arterial thoracic outlet syndrome, the artery beneath the collar bone leading to the arm is compressed causing the artery to increase in size. Blood clots (thrombi) may form in the blood vessel. When blood vessels are compressed, the hands, arms, and shoulders do not receive proper blood supply. They can swell and turn blue from a lack of blood.
In the case of true neurogenic thoracic outlet syndrome, the nerves most affected are those of the network of nerves supplying the chest, shoulder, arm, forearm, and hand (brachial plexus). When a nerve is affected in thoracic outlet syndrome it produces a tingling sensation (paresthesia). It can also cause weakness in the hand and reduced sensation in the palm and fingers.
Diagnosis of Thoracic Outlet Syndrome
There are no specific diagnostic tests for thoracic outlet syndromes. The diagnosis is made by ruling out other diseases and by observing the patient. Two non-specific tests that can suggest the presence of thoracic outlet syndrome are the Adson's test and the Allen test. In the Adson test, the patient takes a deep breath and tilts his or her head back and turns it to one side. The physician tests to see if the strength of the patient's pulse is reduced in the wrist on the arm on the opposite side of the head turn. In the Allen test, the arm in which the patient is experiencing symptoms is raised and rotated while the head is turned to the opposite side. The physician tests to see if the pulse strength at the wrist is reduced. If the strength of the pulse is reduced in either of these two tests it indicates compression of the subclavian artery.
Occasionally, examination with a stethoscope may reveal abnormal sounds in affected blood vessels. X rays can reveal constrictions in blood vessels if a special dye is injected into the blood stream to make the blood vessels visible (angiography).
Certain tests are available to help with the diagnosis of nerve compression. These include the nerve conduction velocity test and somatosensory evoked potential test. In the nerve conduction velocity test, electrodes are placed at various locations on the skin along a nerve that is being tested. A mild electrical impulse is delivered through an electrode at one end of the nerve and the electrical activity is recorded by the other electrodes. The time it takes for the electrical impulse to travel down the nerve from the stimulating electrodes to the recording electrodes is used to calculate the nerve conduction velocity. This can be used to determine if any nerve damage exists.
In a somatosensory evoked potential test, electrodes are placed on the skin at the scalp, neck, shoulder, and wrist. A mild electrical impulse is delivered at the wrist, and a recording is made of the response by the brain and spinal cord. This test also can determine the presence of nerve damage.
Treatment of Thoracic Outlet Syndrome
The main treatment for thoracic outlet syndrome is physical therapy. Exercises aimed at improving the posture of the affected person are also useful. In some cases, surgery can be performed to remove the cervical rib if this is causing the problem and physical therapy has failed to work. However, surgery is generally not used to treat thoracic outlet syndrome.
STILL'S DISEASE
Still's disease is a disorder featuring inflammation that is characterized by high spiking fevers, evanescent (transient) salmon-colored rash and/or arthritis. Still's disease was first described in children, but it is now known to occur, much less commonly, in adults (in whom it is referred to as adult-onset Still's disease).
Causes of Still's disease
The cause of Adult Still's disease is unknown. The condition rarely occurs in adults. It is more common in children, where it is called Systemic Juvenile Rheumatoid Arthritis. No risk factors for the disease have been identified.
Symptoms of Still's disease
Almost all patients will have fever, joint pain, sore throat, and a rash. The fever usually comes on quickly once per day, most commonly in the afternoon or evening. The rash is typically salmon pink colored and comes and goes with the fever.
Another common symptom is joint pain and inflammation (warmth and swelling of the joint). Usually, several joints are involved at the same time.
Additional symptoms include swollen lymph nodes (glands), pain with a deep breath (pleurisy), abdominal pain and swelling, and weight loss.
Diagnosis of Still's disease
The physical exam may show the fever, rash, and arthritis. Other signs include enlargement of the lymph nodes, liver, or spleen. Also, the presence of changes in the sound of the heart or lungs may indicate pericarditis or pleurisy.
Blood tests that can be helpful in diagnosing Adult Still's Disease include:
Elevation in the ESR (sedimentation rate)
Elevation in the White Blood Cell count
Elevation in liver function tests
Decrease in the Red Blood Cell count
Very high elevation in the Ferritin level
Negative rheumatoid factor and ANA test
Other tests may include:
joint X-rays
chest X-ray that may show pericarditis or pleural effusion
abdominal X-ray, CT scan or ultrasound for liver and spleen enlargement
Adult Still's Disease can only be diagnosed after other diseases are excluded. It may require many medical tests before a final diagnosis is made.
Treatment of Still's disease
The symptoms of arthritis are generally controlled with adequate doses of salicylates (aspirin) or nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen. Prednisone may be used for more severe cases. In the disease becomes chronic immunosuppressive medications might be needed. These may include methotrexate or new biologic therapies.
Expectations (prognosis)
Studies show that about 20% of patients have all of the symptoms go away in a year and never come back. About 30% of patients have all of the symptoms go away, but they come back several times over the next years. The rest of the patients (about 50%) will develop a chronic arthritis.
Complications
arthritis
liver disease
spleen enlargement
pericarditis
pleural effusion
Calling your health care provider
Call for an appointment with your health care provider if symptoms are present that are suggestive of Adult Still's disease.
Call your health care provider if cough, difficulty breathing, or other symptoms develop in a person with Adult Still's.
SPINAL STENOSIS
Spinal stenosis is narrowing of the spinal canal. This can develop as you age from drying out and shrinking of the disk spaces. (80% of the disks are made up of water) If this happens, even a minor injury can cause inflammation of the disk and put pressure on the nerve. You can feel pain anywhere along your back or leg(s) that this nerve supplies.
Information about Spinal Stenosis
Spinal stenosis mainly affects middle-aged or elderly people. It may be caused by osteoarthritis or Paget's disease or by an injury that causes pressure on the nerve roots and/or the spinal cord itself.
Spinal stenosis is a progressive narrowing of the opening in the spinal canal. The spine is a long series of bones called vertebrae. Between each pair of vertebra is a fibrous intervertebral disk. Collectively, the vertebrae and disks are called the backbone. Each vertebra has a hole through it. These holes line up to form the spinal canal. A large bundle of nerves called the spinal cord runs through the spinal canal. This bundle of 31 nerves carries messages between the brain and the various parts of the body. At each vertebra, some smaller nerves branch out from these nerve roots to serve the muscles and tissue in the immediate area. When the spinal canal narrows, nerve roots in the spinal cord are squeezed. Pressure on the nerve roots causes chronic pain and loss of control over some functions because communication with the brain is interrupted. The lower back and legs are most affected by spinal stenosis. The nerve roots that supply the legs are near the bottom of the spinal cord. The pain gets worse after standing for a long time and after some forms of exercise. The posture required by these physical activities increases the stress on the nerve roots. Spinal stenosis usually affects people over 50 years of age. Women have the condition more frequently than men do.
Cervical spinal stenosis is a narrowing of the vertebrae of the neck (cervical vertebrae). The disease and its effects are similar to stenosis in the lower spine. A narrower opening in the cervical vertebrae can also put pressure on arteries entering the spinal column, cutting off the blood supply to the remainder of the spinal cord.
Symptoms of Spinal Stenosis
Pain in the buttocks, thighs or calves that is worse with walking or exercise
Numbness in the buttocks, thighs or calves, that is worse with standing, walking or exercise
Back pain that radiates to the legs
Weakness of the legs
Neck pain
Leg pain
Difficulty or imbalance when walking
Spinal stenosis causes pain in the buttocks, thigh, and calf and increasing weakness in the legs. The patient may also have difficulty controlling bladder and bowel functions. The pain of spinal stenosis seems more severe when the patient walks downhill. Spinal stenosis can be congenital, acquired, or a combination. Congenital spinal stenosis is a birth defect. Acquired spinal stenosis develops after birth. It is usually a consequence of tissue destruction (degeneration) caused by an infectious disease or a disease in which the immune system attacks the body's own cells (autoimmune disease). The two most common causes of spinal stenosis are birth defect and progressive degeneration of the tissue of the joints (osteoarthritis). Other causes include improper alignment of the vertebrae as in spondylolisthesis, destruction of bone tissue as in Paget's disease, or an overgrowth of bone tissue as in diffuse idiopathic skeletal hyperostosis. The spinal canal is usually more than 11.5 millimeters in diameter. A smaller diameter indicates stenosis. The diameter of the cervical spine ranges is 15-25 millimeters. Any opening under 13 millimeters in diameter is considered evidence of stenosis. Acquired spinal stenosis usually begins with degeneration of the intervertebral disks or the surfaces of the vertebrae or both. In trying to heal this degeneration, the body builds up the spinal column. In the process, the spinal canal can become narrower.
Diagnosis of Spinal Stenosis
The physician must determine that the symptoms are caused by spinal stenosis. Conditions that can cause similar symptoms include a slipped (herniated) intervertebral disk, spinal tumors, and disorders of the blood flow (circulatory disorders). Spinal stenosis causes back and leg pain. The leg pain is usually worse when the patient is standing or walking. Some forms of spinal stenosis are less painful when the patient is riding an exercise bike because the forward tilt of the body changes the pressure in the spinal column. Doppler scanning can trace the flow of blood to determine whether the pain is caused by circulatory problems. X-ray images, computed tomography scans (CT scans), and magnetic resonance imaging (MRI) scans can reveal any narrowing of the spinal canal. Electromyography, nerve conduction velocity, or evoked potential studies can locate problems in the muscles indicating areas of spinal cord compression.
Treatment of Spinal Stenosis
Mild cases of spinal stenosis may be treated with rest, nonsteroidal anti-inflammatory drugs (such as aspirin) and muscle relaxants. Spinal stenosis can be a progressive disease, however, and the source of
pressure may have to be surgically removed (surgical decompression) if the patient is losing control over bladder and bowel functions. The surgical procedure removes bone and other tissues that have entered the spinal canal or put pressure on the spinal cord. Two vertebrae may be fused, to eliminate improper alignment, such as that caused by spondylolisthesis. For surgery, patients lie on their sides or in a modified kneeling position. This position reduces bleeding and places the spine in proper alignment. Alignment is especially important if vertebrae are to be fused. Surgical decompression can eliminate leg pain and restore control of the legs, bladder, and bowels, but usually does not eliminate lower back pain. Physical therapy and massage can help reduce the symptoms of spinal stenosis. An exercise program should be developed to increase flexibility and mobility. A brace or corset may be worn to improve posture. Activities that place stress on the lower back muscles should be avoided.
Prognosis of Spinal Stenosis
Surgical decompression does not stop the degenerative processes that cause spinal stenosis, and the condition can develop again. Nevertheless, most patients achieve good results with surgical decompression. The patient will probably continue to have lower back pain after the surgical procedure.
SHOULDER ARTHRITIS
An inflammation of the shoulder joint can cause pain and restricted joint movement
Arthritis is a degenerative disease caused by either wear and tear (osteoarthritis) or an inflammation (rheumatoid arthritis) of one or more joints. Arthritis not only affects joints; it may secondarily affect supporting structures such as muscles, tendons, and ligaments.
Symptoms of shoulder arthritis
The usual signs of arthritis of the shoulder are pain, particularly over the acromioclavicular (AC) joint, and a decrease in shoulder motion. A doctor may suspect the patient has arthritis when there is both pain and swelling in the joint.
Diagnosis of shoulder arthritis
The diagnosis may be confirmed by a physical examination and x rays. Blood tests may be helpful for diagnosing rheumatoid arthritis, but other tests may be needed as well. Analysis of synovial fluid from the shoulder joint may be helpful in diagnosing some kinds of arthritis. Although arthroscopy permits direct visualization of damage to cartilage, tendons, and ligaments, and may confirm a diagnosis, it is usually only done if a repair procedure is to be performed.
Treatment of shoulder arthritis
Most often osteoarthritis of the shoulder is treated with nonsteroidal anti-inflammatory drugs such as aspirin or ibuprofen. (Rheumatoid arthritis of the shoulder may require physical therapy and additional medicine, such as corticosteroids.)
When conservative treatment of osteoarthritis of the shoulder fails to relieve pain or improve function, or when there is severe deterioration of the joint causing parts to loosen and move out of place, shoulder joint replacement (arthroplasty) may provide better results. In this operation, a surgeon replaces the shoulder joint with an artificial ball for the humerus and a cap (glenoid) for the scapula.
Passive shoulder exercises (where someone else moves the arm to rotate the shoulder joint) are started soon after surgery. Patients begin exercising on their own about 3 to 6 weeks after surgery. Eventually, stretching and strengthening exercises become a major part of the rehabilitation program. The success of the operation often depends on the condition of rotator cuff muscles prior to surgery and the degree to which the patient follows the exercise program.
SHOULDER IMPINGEMENT
What is Shoulder Impingement?
Impingement refers to mechanical compression and/or wear of the rotator cuff tendons. The rotator cuff is actually a series of four muscles connecting the scapula (shoulder blade) to the humeral head (upper part of the shoulder joint.) The rotator cuff is important in maintaining the humeral head within the glenoid (socket) during normal shoulder function and also contributes to shoulder strength during activity. Normally, the rotator cuff glides smoothly between the undersurface of the acromion and the humeral head.
How Does Shoulder Impingement Occur?
Any process which compromises this normal gliding function may lead to mechanical impingement. Common causes include weakening and degeneration within the tendon due to aging, the formation of bone spurs and/or inflammatory tissue within the space above the rotator cuff (subacromial space), and overuse injuries. Overuse activities that can lead to impingement are most commonly seen in tennis players, pitchers and swimmers.
How is Shoulder Impingement Diagnosed?
The diagnosis of shoulder impingement can usually be made with a careful history and physical exam. Patients with impingement most commonly complain of pain in the shoulder, which is worse with overhead activity and sometimes severe enough to cause awakening in the night. Manipulation of the shoulder in a specific way by your doctor will usually reproduce the symptoms and confirm the diagnosis. X-rays are also helpful in evaluating the presence of bone spurs and/or the narrowing of the subacromial space. MRI (magnetic resonance imaging), a test that allows visualization of the rotator cuff, is usually not necessary in cases of shoulder impingement, but may be used to rule out more serious diagnoses.
How is Shoulder Impingement Treated?
The first step in treating shoulder impingement is eliminating any identifiable cause or contributing factor. This may mean temporarily avoiding activities like tennis, pitching or swimming. A non-steroidal anti-inflammatory medication may also be recommended by your doctor. The mainstay of treatment involves exercises to restore normal flexibility and strength to the shoulder girdle, including strengthening both the rotator cuff muscles and the muscles responsible for normal movement of the shoulder blade. This program of instruction and exercise demonstration may be initiated and carried out either by the doctor or a skilled
physical therapist. Occasionally, an injection of cortisone may be helpful in treating this condition.
Is Surgery Necessary?
Surgery is not necessary in most cases of shoulder impingement. But if symptoms persist despite adequate non-surgical treatment, surgical intervention may be beneficial. Surgery involves debriding, or surgically removing tissue that is irritating the rotator cuff. This may be done with either open or arthroscopic techniques. Outcome is favorable in about 90% of the cases.
SCOLIOSIS
Abnormal curvature in the spine is known as scoliosis, and generally begins just at the onset of puberty and progresses during the period of rapid growth. Most junior high schools routinely screen for scoliosis because, if caught early, progressive spine curvature can be prevented. Scoliosis affects girls much more frequently than boys.
There are three general causes of scoliosis: congenital, usually related to a problem with the formation of vertebrae or fused ribs during prenatal development; neuromuscular (poor muscle control or muscular weakness or paralysis due to diseases like cerebral palsy, muscular dystrophy, spina bifida and polio); and idiopathic (of unknown cause), which appears in a previously straight spine.
The idiopathic form in adolescents is the most common and may have a genetic predisposition. Most cases occur in girls and curves generally worsen during growth spurts. There are also infantile and juvenile forms that are less common and affect a similar number of boys and girls.
Scoliosis may be suspected when one shoulder appears to be higher than the other, or the pelvis appears to be tilted. It is often unnoticeable to an untrained observer, however.
Routine scoliosis screening is now done in junior high school/middle school and many early cases are detected that previously would have gone undetected until they were more advanced.
There may be fatigue in the spine after prolonged sitting or standing. Pain will become persistent if irritation of ligaments results. The greater the initial curve of the spine, the greater the chance for progression of the condition after growth is complete. Severe scoliosis (curves in the spine greater than 100 degrees) may cause breathing (respiratory) problems.
More information about Scoliosis
When viewed from the rear, the spine usually appears perfectly straight. Scoliosis is a lateral (side-to-side) curve in the spine, usually combined with a rotation of the vertebrae. (The lateral curvature of scoliosis should not be confused with the normal set of front-to-back spinal curves visible from the side.) While a small degree of lateral curvature does not cause any medical problems, larger curves can cause postural imbalance and lead to muscle fatigue and pain. More severe scoliosis can interfere with breathing and lead to arthritis of the spine (spondylosis).
Approximately 10% of all adolescents have some degree of scoliosis, though fewer than 1% have curves which require medical attention beyond monitoring. Scoliosis is found in both boys and girls, but a girl's spinal curve is much more likely to progress than a boy's. Girls require scoliosis treatment about five times as often. The reason for these differences is not known.
Symptoms of Scoliosis
the spine curving abnormally to the side (laterally)
shoulders and/ or hips appearing uneven
backache or low back pain
fatigue
Note: Kyphoscoliosis also involves abnormal front-to-back curvature, with a "rounded back" appearance.
Four out of five cases of scoliosis are idiopathic, meaning the cause is unknown. While idiopathic scoliosis tends to run in families, no responsible genes had been identified as of 1997. Children with idiopathic scoliosis appear to be otherwise entirely healthy, and have not had any bone or joint disease early in life. Scoliosis is not caused by poor posture, diet, or carrying a heavy bookbag exclusively on one shoulder.
Idiopathic scoliosis is further classified according to age of onset:
Infantile. Curvature appears before age three. This type is quite rare in the United States, but is more common in Europe.
Juvenile. Curvature appears between ages 3 and 10. This type may be equivalent to the adolescent type, except for the age of onset.
Adolescent. Curvature appears between ages of 10 and 13, near the beginning of puberty. This is the most common type of idiopathic scoliosis.
Adult. Curvature begins after physical maturation is completed.
Causes are known for three other types of scoliosis:
Congenital scoliosis is due to congenital birth defects in the spine, often associated with other organ defects.
Neuromuscular scoliosis is due to loss of control of the nerves or muscles which support the spine. The most common causes of this type of scoliosis are cerebral palsy and muscular dystrophy.
Degenerative scoliosis may be caused by degeneration of the discs which separate the vertebrae or arthritis in the joints that link them.
Scoliosis causes a noticeable asymmetry in the torso when viewed from the front or back. The first sign of scoliosis is often seen when a child is wearing a bathing suit or underwear. A child may appear to be standing with one shoulder higher than the other, or to have a tilt in the waistline. One shoulder blade may appear more prominent than the other due to rotation. In girls, one breast may appear higher than the other, or larger if rotation pushes that side forward.
Curve progression is greatest near the adolescent growth spurt. Scoliosis that begins early on is more likely to progress significantly than scoliosis that begins later in puberty.
More than 30 states have screening programs in schools for adolescent scoliosis, usually conducted by trained school nurses or gym teachers.
Diagnosis of Scoliosis
Diagnosis for scoliosis is done by an orthopedist. A complete medical history is taken, including questions about family history of scoliosis. The physical examination includes determination of pubertal development in adolescents, a neurological exam (which may reveal a neuromuscular cause), and measurements of trunk asymmetry. Examination of the trunk is done while the patient is standing, bending over, and lying down, and involves both visual inspection and use of a simple mechanical device called a scoliometer.
If a curve is detected, one or more x rays will usually be taken to define the curve or curves more precisely. An x ray is used to document spinal maturity, any pelvic tilt or hip asymmetry, and the location, extent, and degree of curvature. The curve is defined in terms of where it begins and ends, in which direction it bends, and by an angle measure known as the Cobb angle. The Cobb angle is found by projecting lines parallel to the vertebrae tops at the extremes of the curve; projecting perpendiculars from these lines; and measuring the angle of intersection. To properly track the progress of scoliosis, it is important to project from the same points of the spine each time.
Occasionally, magnetic resonance imaging (MRI) is used, primarily to look more closely at the condition of the spinal cord and nerve roots extending from it if neurological problems are suspected.
Treatment of Scoliosis
Treatment decisions for scoliosis are based on the degree of curvature, the likelihood of significant progression, and the presence of pain, if any.
Curves less than 20 degrees are not usually treated, except by regular follow-up for children who are still growing. Watchful waiting is usually all that is required in adolescents with curves of 20-30 degrees, or adults with curves up to 40 degrees or slightly more, as long as there is no pain.
For children or adolescents whose curves progress to 30 degrees, and who have a year or more of growth left, bracing may be required. Bracing cannot correct curvature, but may be effective in halting or slowing progression. Bracing is rarely used in adults, except where pain is significant and surgery is not an option, as in some elderly patients.
Two general styles of braces are used for daytime wear. The Milwaukee brace consists of metal uprights attached to pads at the hips, rib cage, and neck. The underarm brace uses rigid plastic to encircle the lower rib cage, abdomen, and hips. Both these brace types hold the spine in a vertical position. Because it can be worn out of sight beneath clothing, the underarm brace is better tolerated and often leads to better compliance. A third style, the Charleston bending brace, is used at night to bend the spine in the opposite direction. Braces are often prescribed to be worn for 22-23 hours per day, though some clinicians allow or encourage removal of the brace for exercise.
Bracing may be appropriate for scoliosis due to some types of neuromuscular disease, including spinal muscular atrophy, before growth is finished. Duchenne muscular dystrophy is not treated by bracing, since surgery is likely to be required, and since later surgery is complicated by loss of respiratory capacity.
Surgery for idiopathic scoliosis is usually recommended if:
The curve has progressed despite bracing
The curve is greater than 40-50 degrees before growth has stopped in an adolescent
The curve is greater than 50 degrees and continues to increase in an adult
There is significant pain.
Orthopedic surgery for neuromuscular scoliosis is often done earlier. The goals of surgery are to correct the deformity as much as possible, to prevent further deformity, and to eliminate pain as much as possible. Surgery can usually correct 40-50% of the curve, and sometimes as much as 80%. Surgery cannot always completely remove pain.
The surgical procedure for scoliosis is called spinal fusion, because the goal is to straighten the spine as much as possible, and then to fuse the vertebrae together to prevent further curvature. To achieve fusion, the involved vertebra are first exposed, and then scraped to promote regrowth. Bone chips are usually used to splint together the vertebrae to increase the likelihood of fusion. To maintain the proper spinal posture before fusion occurs, metal rods are inserted alongside the spine, and are attached to the vertebrae by hooks, screws, or wires. Fusion of the spine makes it rigid and resistant to further curvature. The metal rods are no longer needed once fusion is complete, but are rarely removed unless their presence leads to complications.
Spinal fusion leaves the involved portion of the spine permanently stiff and inflexible. While this leads to some loss of normal motion, most functional activities are not strongly affected, unless the very lowest portion of the spine (the lumbar region) is fused. Normal mobility, exercise, and even contact sports are usually all possible after spinal fusion. Full recovery takes approximately six months.
Alternative treatment for Scoliosis
Although important for general health and strength, exercise has not been shown to prevent or slow the development of scoliosis. It may help to relieve pain from scoliosis by helping to maintain range of motion. Good nutrition is also important for general health, but no specific dietary regimen has been shown to control scoliosis development. In particular, dietary calcium levels do not influence scoliosis progression.
Chiropractic treatment may relieve pain, but it cannot halt scoliosis development, and should not be a substitute for conventional treatment of progressing scoliosis. Acupuncture and acupressure may also help reduce pain and discomfort, but they cannot halt scoliosis development either.
Prognosis of Scoliosis
The prognosis for a person with scoliosis depends on may factors, including the age at which scoliosis begins and the treatment received. More importantly, mostly unknown individual factors affect the likelihood of progression and the severity of the curve. Most cases of mild adolescent idiopathic scoliosis need no treatment and do not progress. Untreated severe scoliosis often leads to spondylosis, and may impair breathing.
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