Scoliosis Treatment in the 21st Century

 

By Dr. Josh Woggon

 

"Progress lies not in advancing what is, but in advancing toward what will be."
-Khalil Gibran
 
How far have we truly come in providing people living with scoliosis better treatment options than were available one hundred years ago?
 
Scoliosis has been described in cave drawings, found in Egyptian mummies, and recognized in the first written treatises composed by the earliest Western and Eastern historical physicians.  It has been reported to be the most common spinal deformity afflicting children and adults, and to double the mortality rate in those it afflicts.  Yet for all of the history and gravity behind this condition, there exists a remarkable apathy towards it in our current cultures and healthcare systems around the world.
 
In the article, "A century of spine surgery: what can patients expect?" Martha Hawes PhD (author of Scoliosis and the Human Spine) and Joe O'Brien (President of the National Scoliosis Foundation) report that, since 1950, over 12,500 research articles have been published on the topic of scoliosis.  Of these, nearly half (5,721) deal specifically with scoliosis surgery.
 
Yet, for all of their efforts, researchers have failed to demonstrate any indications that spinal fusion provides superior long-term outcomes to living with scoliosis, and have failed to prove that there is any medical reason for a patient to undergo this surgery (see the sidebar to the left).  In Pennsylvania, insurance companies have recently begun denying reimbursement for spinal fusion as a treatment for scoliosis, on the justification that it fails to demonstrate any benefit other than cosmetic improvement, and, all-too-frequently, it fails to do that.  As stated in 2001 by Caroline Goldberg, "Surgery does not cure the disease of scoliosis, but rather replaces one deformity with another."
 
Scoliosis brace treatment was first introduced as a treatment for scoliosis in the seventh century; the Milwaukee brace was developed in 1945.  The purpose of bracing has not changed significantly since its inception; prevention of progression, rather than true correction, remains the only goal.  New genetic prognostic tests which can "risk-stratify" people with scoliosis into low, medium, or high risks of progression have recently been used to determine the true effect of bracing on influencing whether or not an individual will progress to the level where surgery is recommended.  These new methods have failed to demonstrate that current bracing strategies reduce the number of individuals who are at "high-risk" for progression that eventually progress to severe levels.  Yet the approach of most scoliosis specialists, when confronted with the fact that bracing does not work, insist that the answer is to build a better brace.  At the foundation of every failure is a flawed philosophy.
 
The "front-line" of defense against scoliosis continues to be ignorance.  When a case of scoliosis is first diagnosed, standard orthopedic practice is to relentlessly subject the adolescent to a series of x-rays that serve no purpose but to monitor the progression of the disease.  In the context of any other condition - whether it is the common cold or a case of cancer - it would make no sense to wait until a disease has progressed to more severe levels before initiating treatment.  Yet, when it comes to scoliosis, it is standard practice.
 
Current methods of scoliosis screening have been condemned for their inaccuracy and false findings, yet little effort has gone into developing new methods of detecting scoliosis.  Why search for the problem when there is no solution?  As the inefficacy of bracing becomes more and more widely recognized, many surgeons have opined that there is no reason to detect scoliosis early, and no reason to intervene in the condition until the deformity has progressed to surgical levels.
 
The system that is in place does not serve the best interests of the people living with scoliosis.  It is inefficient and impersonal, applying the same treatments without regard for physical function or the personal preferences of the patient.  The only objective outcome assessment used is Cobb angle; factors such as balance, lung function, ranges of motion, and muscle strength are often left out of clinical practice, for the simple fact that bracing & surgery are not expected to improve these outcomes.
 
The CLEAR Scoliosis Institute seeks to change the current paradigm for the management of scoliosis in the United States and around the world, by introducing treatment methodologies which recognize & address factors beyond the two-dimensional measurement that is Cobb angle.  A truly effective treatment results in a global improvement in the patient's quality of life - not simply a straighter spine.  The clinical improvements noted in their patients by the dozens of CLEAR-certified doctors around the world have attracted the attention of qualified research organizations, and led to the development of an independent research initiative spearheaded by Parker University.  It is the sincere desire of CLEAR Institute that the data collected & published as a result of this initiative will force a re-thinking of the current paradigm, and encourage intelligent decisions by healthcare policymakers.  Rather than reimbursing the costs of flawed treatment methods which do not improve long-term outcomes, reimbursement will be results-driven and reward treatment strategies which can demonstrate true correction, rather than simple management, of the condition of scoliosis.