Scoliosis surgery is a highly invasive and permanent scoliosis treatment option that is generally reserved for severe scoliosis spine cases in adolescent and adult cases of idiopathic scoliosis.  Despite the many studies demonstrating poor long-term results of scoliosis fusion surgery, including chronic pain, psychological impairment and disability, the number of scoliosis patients opting for scoliosis surgery procedures continues to rise each and every year. 

There may be many reasons for the continued rise of scoliosis surgeries; more availability to health care coverage, increased societal pressure to eliminate physical spinal deformity, or a growing confidence in surgical procedures to provide an optimal solution, but to date, there is no significant reason to believe the poor long-term outcomes from updated scoliosis surgery procedures will be improved since they still ultimately result in multiple level spinal fusion.

A shocking 50 year follow-up on untreated scoliosis patients published in JAMA (Journal of the American Medical Association) in 2003 concluded, “Untreated adults with scoliosis are productive and functional at a high level at 50-year follow-up. Untreated scoliosis causes little physical impairment other than back pain and cosmetic concerns.  This is in sharp contrast with a 2002 long-term post scoliosis surgery study that found “40% of operated treated patients with idiopathic scoliosis were legally defined as severely handicapped persons”.  Essentially, the contrast between these two studies indicates the scoliosis patient is better off doing nothing than having scoliosis surgery.  Although, I must note that multiple studies have found that, while adolescent idiopathic scoliosis is not life-threatening, it will very often negatively impact one’s quality of life through-out adulthood.  With this being understood, I am not advocating for no treatment of scoliosis, but I feel it does suggest that we need to seriously entertain the idea that drastic measures like scoliosis surgery may be worse than the condition itself in the long-term outcomes for the patient.

Efforts to correct this glaring discrepancy have been undertaken in the form of earlier spinal fusion in children with early onset progressive scoliosis.  Here are the results from one such study, “Spinal deformity is apparently not well controlled by early fusion since revision surgery has been required in 24% to 39% of patients who underwent presumed definitive fusion in early childhood. Restrictive pulmonary disease, defined as forced vital capacity less than 50% of normal, occurs in 43% to 64% of patients who undergo early fusion surgery with those children who have extensive thoracic fusions and whose fusions involve the proximal thoracic spine at highest risk. Thoracic growth after early surgery is an average of 50% of that seen in children with scoliosis who do not have early surgery. Diminished thoracic spinal height correlates with decreased forced vital capacity…..The literature does not support routine definitive fusion of thoracic spinal deformity at an early age in children with scoliosis.”

So where did all of this go wrong?  The answer is, from the beginning.  The entire concept of fusing 6 to 12 vertebral levels of a person’s spine and not expecting a bio-mechanical disaster in the long run is simply delusional.  The simple fact that “There is no right way to do the wrong thing” still holds true as ever and scoliosis fusion surgery for the treatment of adolescent idiopathic scoliosis is no exception.

We need a better way.  We need a rehabilitation based scoliosis treatment system the pro-actively trains the brain’s automatic postural control centers and corrects neurological spinal feedback mechanisms.  But, here is the trick.  The rehabilitation stimulus needs to stimulate the brain to recognize the scoliosis spine alignment is incorrect and trigger the auto-correction message which is then sent to the spinal muscles.  Currently this can only be done through specialized scoliosis rehabilitation that actually alters where the brain subconsciously perceives the various major alignment points of the head, torso, and pelvis by having the patient wear lightly weighted hats, hip belts, and specially designed long lever arm torso weighting.  This creates a true “re-active” brain-muscle response that signals to the brain that something is wrong and provides the exact feedback it needs to self correct the scoliosis spine to a large degree.  This is in stark contrast to the “muscle memory” spinal feedback efforts in re-training the brain seen by some of the dynamic scoliosis braces on the market today.

The take home message about the future of scoliosis treatment is...."scoliosis treatment needs to start in the brain, not the spine."

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The current medical management of idiopathic scoliosis is fairly straight forward with 3: main recommendations:

~Smaller curves below 25 degrees monitor with no scoliosis treatment.

• ~Medium curves over 25 and less than 40 degrees, scoliosis brace treatment.

~Large curves over 40 degrees, multiple level scoliosis surgery.

The problem arises with parents of children who have entered the 40 degree zone when the typical orthopedic response is your child needs scoliosis surgery and many of these parents simply don’t want scoliosis surgery and feel that it is too invasive a procedure at this point. So what are the options? Is there a nonsurgical management plan for scoliosis? What are the real consequences of choosing not to do a multiple level scoliosis fusion surgery on a child with a 40 degree, 50 degree, 60 degree scoliosis?

The answer to these questions is going to be different based on the facts of the individual child’s clinical picture. If we look at options for nonsurgical management of larger curvatures we won’t find a whole lot of current literature or choices. Some of the more common but rather generic options are exercises, chiropractic, massage, and other alternative back care choices that don’t offer much in terms of addressing some of the more important aspects of larger scoliosis curvature. Many parents and children feel that addressing posture, function levels, breathing capacity, rib deformity, and pain are the major concerns with managing a larger scoliosis curvature.

The other concerns are often regarding the future health of their child. Will the scoliosis continue to progress? Are their cardiovascular or respiratory risks not just a shallower breathing pattern, but real tangible health concerns with a larger curvature? Can my daughter have children? What about sports?

As you can see there certainly is a plethora of questions facing a nonsurgical choice when it comes to scoliosis and probably why tens of thousands of scoliosis fusion surgeries are performed annually. It’s easier to swim downstream then to swim upstream especially when you have some of the most respected surgeons advising you to do the surgery.

Shedding light in regards to nonsurgical management of larger scoliosis curvature generally above 40 degrees is something that needs to be done and I hope the following information will help do this. Statistically the chances of cardiopulmonary or cardiac dysfunction that will actually affect the health of the individual with scoliosis are rare. Most experts feel that only in grossly severe curves over 100 degrees is the heart actually in danger of being affected. Pulmonary changes are more common but only occur in thoracic primary curves above 60 degrees in addition the thoracic kyphosis also must demonstrate significant losses in order for more noticeable changes in respiratory capacity to be measurable. The ability to have children both carry and deliver a baby to term without complications is often unaffected by larger scoliosis and in some reports more of a problem with multiple level spinal fusion surgeries. Most patients with a larger scoliosis remain fully functional and continue to live normal lives and other than some visual body asymmetry really are at no increased health risks.

It would be interesting to argue that there are potentially more health risks and complications with surgically treated scoliosis versus non surgically treated. Experts could argue that nonsurgical leaves you at risk for progression, pulmonary deficiencies pain whereas surgical intervention yields no improvement in pulmonary deficiencies or pain and adds functional losses in movement ability, stiffness, scarring, and host of other reported health issues. One thing surgery definitely provides is 250 billion dollars of revenue annually.

Moving forward a new nonsurgical treatment option created by a group of doctors known as CLEAR scoliosis treatment provides the best opportunity to manage a larger curvature. The main premise of CLEAR treatment is to decrease soft tissue resistance and then rehabilitate the neuromuscular system using advanced cantilever body weighting that helps the spine adapt and learn a new straighter position without creating immobility. Soft tissue adaptations that are present with larger curves involve muscle, tendons, ligaments, and discs. These tissues become more rigid and asymmetrical in larger curve formation. Advanced biomechanical equipment used produces cyclical loading and unloading combined with low frequency vibration to stimulate collagen elongation thus increasing spinal flexibility. Once the spine is unlocked where soft tissue has disengaged the neuromuscular retraining begins. A series of engineering measurements are taken to allow the doctor to create the appropriate weight leverage needed to cause the bodies neurological righting mechanism to shift the spine to a more stable balanced position when the weight is placed on the patient. This shift in spinal position used to rebalance and redistribute the bodies center of mass causes the spine to become straighter. When used repetitively for approximately 90 days follow up x-rays will demonstrate average scoliosis curve reductions between 30-50% with doctors that have clinical experience and advanced training so it is important who you choose for this type of care program.

Unlike physical therapy or chiropractic care this group of doctors are specifically trained in scoliosis bioengineering, require additional training, specific clinical equipment, and are required to take multiple exams to become eligible to provide CLEAR scoliosis treatment . So if I were a parent choosing a nonsurgical scoliosis management system I would choose these guys hands down. I would also consider for those parents who are planning on multiple level scoliosis fusion surgery to get a consultation with a CLEAR practitioner prior to undergoing surgery for scoliosis you may in fact see more benefit in a nonsurgical approach. When it comes to risks versus benefits the tide is turning in regards to nonsurgical versus surgical management for scoliosis.

“Idiopathic scoliosis” is term that has been present in recorded human history for almost 3,500 years, but the mystery of its “unknown cause” is slowly being discovered. As many experts have suspected for decades, breakthroughs in scoliosis genetic testing (Scoliscore) and the scoliosis blood test have uncovered sequences of genetic code that leave an individual “genetically pre-disposed” to the development of severe idiopathic scoliosis. However, since the condition doesn’t appear until adolescence in the vast majority of patients, the search for environmental influences that are connected to un-coordinated growth spurts is on-going.

Virtually all current idiopathic scoliosis research is pointing towards a neurological deficit/under-development in the automatic postural control centers of the brain stem as the root cause of the condition, but the factors that cause severe progression requiring scoliosis brace treatment and /or scoliosis surgery appear to be primarily environmental (bio-mechanical, bio-chemical, and specific activity related) driven.

Previous attempts in scoliosis treatment have entirely centered on treating the scoliosis spine itself and have almost entirely ignored the obvious neurological component of idiopathic scoliosis. Scoliosis brace treatment is a relatively simple minded approach to “guided growth” in which the spine is essentially forced into a straighter position (in the front view dimension only). The scoliosis spine growth mal-adapts to alter the bio-mechanical loading patterns provided by the scoliosis brace in an attempt to “out-smart” the developing pattern of the scoliosis spine. Unfortunately, this well-studied scoliosis brace treatment approach has been found very ineffective due to the inability for idiopathic scoliosis patients to comply with the 23 hour a day, 7 day a week, 365 day a year scoliosis brace treatment protocol and those whom do comply experience significant muscle atrophy (muscle weakening) and scoliosis brace dependency in which they need to be “weaned” out of the scoliosis brace over the course of weeks or months. In addition to not addressing the primary neurological cause of idiopathic scoliosis, recent research at the University of Vermont conducted on rat tails under simulated scoliosis brace conditions, suggests that scoliosis brace treatment may actually be causing permanent deformity to the scoliosis spine discs that could lead to further curve progression during adolescences or adulthood.

Scoliosis surgery is a “brute force” approach to scoliosis treatment and has under gone many advancements since its inception in 1865, but even to this day the scoliosis treatment goal remains the same…..complete multi-level spinal fusion. While most orthopedic surgeons make substantial efforts to limit the number of vertebral segments fused during scoliosis surgery, it generally includes at least 5-6 segments out of a total 24 moveable spinal vertebrae which completely immobilizes an approximately 25% portion of the patients entire spinal column. The long-terms (15-20 years post scoliosis surgery) are very poor in terms of chronic pain and quality of life measures. Dr. Robert Saulter of the Toronto Hospital for Sick Children summed up the relationship between chronic dysfunction and chronic pain with is famous quote, “Restoration of function is more important than the relief of pain”. Unfortunately for the idiopathic scoliosis patients whom undergo scoliosis surgery the chronic dysfunction (multiple level spinal fusion)will almost certainly lead to severe chronic pain at some point in their lifetime. This may be considered an acceptable trade off if the scoliosis surgery was a “life-saving” procedure, but the research conducted on the effects of scoliosis surgery has concluded the procedures is primarily indicated for cosmetic purposes and is not medically necessary. This is a generally accepted fact with in the scoliosis treatment community, because scoliosis surgery does not improve cardiac function, pulmonary function, eliminate pain, or improve the adolescent idiopathic scoliosis patient’s quality of life in the long-term follow up studies. It should be noted, that a fused scoliosis spine from scoliosis surgery is every bit (or more) dysfunctional that an un-treated scoliosis spine. Perhaps most importantly, scoliosis surgery is not and will not lead to a cure for scoliosis since it still fails to address the underlying neurological deficit/ under-development that is the root cause of idiopathic scoliosis.

The concept of re-training the automatic postural control centers of the brain stem actually dates back several hundred years (if not much further back) to a time when young girls aspiring to become debutants practiced good posture by walking around balancing books on top of their heads (which is not a suggested scoliosis treatment). By making the head (temporarily) artificially heavier with the book, they essentially changed where their body neurologically perceived the center mass of their skull and caused their “body schema” (the neurological “set point” for normal spinal posture) to react to the perceived postural change. Over time the repeated re-training of the young girl’s automatic postural control centers in her brain stem resulted in a permanent change in the “body schema” and the improved posture simply, became “the new normal”. These very same principles (in a much more effective and advanced application) can be applied to scoliosis treatment and permanently alter the natural course of the idiopathic scoliosis condition by treating the root cause of the condition. The future of scoliosis treatment will be found in treating the scoliosis spine, by treating the automatic postural control centers in the brain stem first.

Don't let a lifetime be defined by idiopathic scoliosis

Now that genetic pre-disposition testing for scoliosis progression risk is available; An Early Stage Intervention Program has also been developed to provide scoliosis patients a non-bracing, non-surgical treatment option that allows them to take immediate action in the prevention of the next stage of the standard treatment process (scoliosis bracing or scoliosis fusion surgery).

While it is not the intention of CLEAR Institute to condemn the efforts of sincere and caring medical professionals who have dedicated their lives to helping individuals with scoliosis. We would, however, like to add to the current list of options; to educate those who are personally involved with scoliosis about what the research says; and, to empower these individuals to make their own decision regarding their own spine, and their own life.

The three medically-sanctioned methods of scoliosis treatment - observation, bracing, and surgery - have been around for decades. A great deal of research has been done on the risks & benefits of each option. However, the general conclusion of this research suggests that a new paradigm is desperately needed as there are many conflicts and inadequacies present in the current model.

Observation Only or the “watch & wait” stage

Once an individual has been diagnosed with scoliosis, no treatment is initially prescribed, and no action is immediately taken, until the Cobb angle has progressed to 25 degrees (which is an arbitrary figure. There is no clinical significance to this number). At this point, bracing is typically prescribed. This period, which is termed "watch & wait," consists only of regular visits to an orthopedic surgeon, where full-spine x-rays are taken consistently to gauge the progress of the patient's condition.

Scoliosis brace treatment (Generally recommended for curvatures 25 degrees and larger)
If there ever was a time when a patient could benefit most greatly from chiropractic, therapeutic exercise, or non-surgical intervention, it would undoubtedly be during the mild stages of the disease - before the muscles & tissues of the body have been deformed by months or even years of compensating for the abnormal twisting & bending of the spine.

Scoliosis bracing dates back to approximately 650 AD, when Paul of Aegina suggested bandaging scoliosis patients with wooden strips. The first metal brace was developed by Ambroise Pare in the 16th century. Today, there is a bewildering assortment of braces in use, ranging from the venerable and bulky Milwaukee brace, to the traditional TLSO (thoraco-lumbar-sacral orthosis) braces such as the Boston and the Wilmington brace. There are "part-time" braces, designed to be worn at night: the Providence brace, and the Charleston brace. There are also "dynamic corrective braces" which may use soft, elastic materials and claim to be able to do more than simply stabilize the progression of scoliosis. An example of a dynamic corrective brace would be the SpineCor brace, developed at the Sainte-Justine Hospital in 1992, or the Copes brace, developed by Arthur Copes to be used in conjunction with his STARS (Scoliosis Treatment Advanced Recovery System) rehabilitation protocol.

This dizzying variety is further complicated by the fact that not every doctor prescribes the braces to be used in the same manner, and not every patient may follow their doctor's recommendations to the same extent. As a result, research is often conflicting (to say the least) in regard to the true effectiveness of bracing in scoliosis treatment. Some studies have shown very little difference between patients who wore the brace for the prescribed time, and those who wore it barely, if at all. Others have demonstrated patients who have been successfully stabilized for years by wearing a bracing constantly; yet, there are also studies on patients who wore the brace for 23 hours out of every day, seven days a week, and continued to worsen. In every case, all corrective benefit is lost very quickly once the patient stops wearing the brace, and the general consensus is that bracing may prove helpful for some, but not for others.

Scoliosis surgery (Generally recommended of curvatures 40 degrees and larger)
Those patients for whom bracing fails to prevent the progression of their scoliosis are left with only one option: surgery. Those who are confronted with this choice may be told that having a metal rod fused to their spine will not impair their daily activities, and will reduce the rib arch & improve their cosmetic appearance. However, research has consistently shown that surgery - which primarily focuses upon the sideways bending, and does little to address the rotation of the spine (and hence the rib protrusion) - will actually cause the rib arch to worsen (Chen 2002, Goldberg 2003, Hill 2002, Pratt 2001, Weatherly 1980, Wood 1991, Wood 1997).

Scoliosis surgery, like most highly-invasive procedures, carries with it the ever-present risk of death. Although mortality rates of less than one percent are claimed, no surgeon can completely eliminate this possibility. There is also the danger of neurological damage, resulting in the loss of sensation or motor function to the arms & legs (paraplegia or quadraplegia). This has become a greater concern in recent years, as surgeons strive for greater corrections in their patients, and place more stress upon the nerves running through the spinal column.

The rate of hardware failure is virtually 100% over the course of a normal lifetime. It may occur immediately after the surgery or several years later, but one or more components of the hardware placed inside the body is highly likely to fail or break. The author of one study stated, "One would expect that if the patient lives long enough, rod breakage will be a virtual certainty". Another study found that amongst seventy-four patients who underwent the surgery, pseudoarthrosis (failed fusion) occurred in 27% of patients within a few years after the procedure.

The truth of the matter is that scoliosis is an abnormality of the spine which involves much more than merely a sideways curve. Yet the "effectiveness" of surgery is measured only by the degree to which it can reduce the lateral deviation through the application of brute force, and a fused spine is every bit as abnormal and dysfunctional as a scoliotic spine.

We can alter the natural course of this disease by identifying which patients are at the highest risk for severe progression via genetic testing (Scoliscore) and by implementing an aggressive, non-invasive Early Stage Scoliosis Intervention program that re-trains the brains involuntary postural controls centers before the spinal curvature reaches the 30 degree "buckling" point