My reporting for Monday's Los Angeles Times includes the statistic, derived from one study, that a solid majority of healthy people over age 60 have scoliosis of the spine. In the patient population I commonly see in St. Louis, at the university where Larry Lenke and Keith Bridwell work, most of the patients who've gone on to have surgery for their scoliosis are in their 60's to 80's.
Yet most of us only think of scoliosis as a childhood growth problem (remember lining up shirtless to bend over in the middle school gym?) Adolescent idiopathic scoliosis can be treated, sometimes, by bracing. Judy Blume's 13-year-old character Deenie Fenner learned to cope with an unsightly and unwieldy brace she would have to wear until age seventeen. I talked with Stuart Weinstein, chair of orthopedics at the University of Iowa and former president of AAOS, and learned that at one time, bracing and surgery went hand in hand for the toughest childhood cases that resisted bracing alone. When Weinstein began practicing in 1976, children spent two weeks in the hospital in traction, stretching their curvature out before having a cast applied. Surgery was done through the cast, effectively a total contact brace, in a window cut into the cast. Two weeks later this cast was removed and another, extending from the neck down to the hips was applied to last six to nine months.
The days of casting the entire torso are over, but braces may need to stay on 18 hours of the day or more to work (orthotists are starting to rig up sensors to tell if wily teens are really following their prescriptions). Dr. Weinstein doesn't believe there's much evidence for the practice, and after decades of this arduous therapy, the NIH is just now funding a $4.9 million investigation into bracing efficacy, headed by Weinstein. One problem with Weinstein's study: it doesn't compare specific types of braces to one other, but lumps them all in together. Each medical center uses the local orthotists who in turn use their own preferred models.
With skeletally mature spines, adults cannot expect to improve or stop their curves with bracing, though some use braces for pain relief. Hans Rudolph Weiss told me that patients like the one in my story "would also have no more pain or less pain," with a brace of his own design instead of surgery. "And the second thing is, in the future, after this painful segment is stabilized, pain will arise below it," he contends. A non-surgical orthopedist practicing in Germany's Rhineland, Weiss argues passionately and questions the financial motivations of surgeons who lead the field's major organizations and journals. Non-practitioners like University of Arizona botanist Martha Hawes also enliven the treatment debate. Professor Hawes is documenting her personal case in a series of reports, in which she says she benefited from deep tissue massage and physical therapy.
Some critics question the essential concept shared by both the open and minimally invasive procedure, asking if "correction" can happen when the spine has lost a major function, its motion. Their school of thought features a deep distrust over surgeons' ability to objectively consider the efficacy of nonsurgical treatments. "99.9 percent of patients don't need surgery, so my view is that the 0.1 percent who do should go to the surgeons; the rest of them need somebody else to go to first," Hawes told me.
The SRS, a largely domestic body whose board is made up entirely of orthopedic surgeons, is the frequent target of ire for a European-based collection of mostly nonsurgical practitioners called the Society on Spinal Orthopaedic and Rehabilitation Treatment (SOSORT). In 2006 SOSORT founded an online journal, Scoliosis, to showcase conservative scoliosis treatments such as physical therapy and bracing. It is an alternative outlet to the more surgically focused, and more prestigious traditional journals like Spine and the Journal of Bone and Joint Surgery.
"If someone has a technique that works, then we're all interested in learning about it and applying it appropriately," says David Polly, an SRS board member. "If the patient's goal is prevention of deformity progression in the adult years, there's not an alternative strategy to surgery right now." Polly added that no data exists showing bracing or physical therapy stops curve progression in adults. "Data of low quality and small numbers suggests that there have been some patients who have achieved some symptomatic benefit from brace treatment. It has nothing to do with belief or disbelief in a technique, it's 'where's the data' and if there is compelling data in reasonable quality peer-reviewed journals then over time it gains attention and interest and then dissemination."
More worrying to me than the current tussle over treatments is the apparent uptick in scoliosis in developed countries that correlates nicely with increasingly sedentary lifestyles. Studies in healthy adults have proven that the sitting position causes the greatest increase in disc pressure, part of the wear and tear leading to the "degenerative disc disease" present in just about everyone by middle age. I'm concerned that the rate of adult scoliosis will speed up even further thanks to childhoods spent hunched over in front of video games and adulthoods spent hunched over in front of computers. We should do more of our daily work standing and moving about - something I currently get no shortage of, pacing up and down the hospital wards. I'm frustrated to hear about employers who won't accommodate the human body, especially when I know Medicare might end up paying for $100,000 worth of spine fusion surgery, weight loss surgery and diabetic complications that could conceivably be prevented, to the best of our knowledge, by simple solutions like the treadmill desk. TrekDesk is one of the many commercial outfits exploiting James Levine's work at Mayo Clinic, where he is meticulously proving what we already know intuitively: humans weren't meant to sit on our butts all day. Myself, I agree with Lyndon Johnson's attitude that if you can get work done in the pool, why not?