M.D. News, May 2004

Advances in Treating Scoliosis:
A Forward-Thinking Approach Looks at Long-Term Life Quality

By Tina Cauller

Scoliosis affects about 60 million people around the world, and is one of the most common diseases of the spine. Most have no troublesome symptoms, but for a small percentage of patients, the abnormal sideways curvature of the spine continues to progress. In the most severe cases, adult scoliosis patients may experience incapacitating pain and increasing deformity. In the most extreme cases, patients have difficulty breathing and can develop serious pulmonary effects, including right heart failure and early death.

It has long been considered important to identify and treat scoliosis as early as possible to maximize the effectiveness of treatment. In the U.S., public schools began screening programs to detect scoliosis in the 1950s. This screening was very helpful, and as a result, it is no longer as common to see immense spinal curves, especially in urban areas.

It is a misconception that scoliosis affects only young females. Despite the fact that scoliosis affects male and female patients at equal rates, the progressive form of the disease develops in women seven times more frequently than in men. The approach to treating all patients is the subject of much attention and research in the orthopedic community.

Alexis P. Shelokov, M.D., medical director of Consulting Orthopedists, is an orthopedic spine surgeon who specializes in the treatment of scoliosis in children and adults, as well as other forms of spinal deformity. According to Dr. Shelokov, "Traditionally, pediatric patients with scoliosis were treated at children's hospitals and discharged when they' reached age 18. This approach limited any potential for continuity of care and many are lost to follow-up, unless they developed symptoms as adults. Today, more adults with scoliosis are reporting later effects of scoliosis as a decreased quality of life due to the progression of their disease. As they age, some find that their activities are limited by daily debilitating pain. Many can be managed without surgery, but for a subpopulation whose curvature progresses, surgery may be the most effective treatment. The real challenge for the modem scoliosis surgeon is to integrate both pediatric and adult scoliosis treatment into a meaningful continuum."

Children with moderate curvatures are still managed primarily with bracing. Over the years, there have been many refinements and improvements in bracing technology and the results have been beneficial for the pediatric population.

Dr. Shelokov notes, "We have gotten much better at identifying and intervening at the appropriate time in the history of the spinal curve. It is crucial not to overtreat nor exacerbate any potentially damaging psychological effects of the disease. For a preteen or young adolescent in the critical stages of personality development, a maximally cosmetic bracing solution is important. Sometimes, we can use a brace that is worn only at night and avoid the need for surgery. As physicians, we must balance benign neglect with our desire to intervene. We need to recognize and avoid unintended consequences of treatment."
More severe curvature may require surgery to prevent progression. Advanced curves, which were once impossible to reliably correct, are now treated routinely. Curvatures of 100 120 degrees can be successfully corrected and fused with modem surgical procedures.

To minimize surgical risk, it is essential that spinal surgery be performed by an experienced surgical and nursing team. Although the incidence of accidental injury to the spinal cord during surgery is fairly low, about one in 100 nationally, patients still express understandable concern and apprehension about this frightening complication. Dr. Shelokov has been in practice for more than 12 years and has performed more than 6,000 spinal operations. He is one of just a few U.S. surgeons who regularly perform scoliosis revision surgery for children and adults who have had unsuccessful surgery in the past.

"At Medical Center of PIano, the staff has gained a special expertise in managing these patients and their extensive experience plays an important role in achieving successful outcomes." Dr. Shelokov notes. There are only a handful of centers in the United States, which have extensive experience and interest in managing in these difficult procedures. According to Dr. Shelokov, "Even in many major cities, there often is no group focusing solely on care of adults with scoliosis. As a result, many individuals who would benefit from these technical advances are unaware of the opportunity to get better."

In the 1990s, Dr. Shelokov became a leader in performing a minimally invasive procedure known as thoracoscopic surgery to treat children with scoliosis. This technique is also routinely used in the treatment of adult scoliosis at Consulting Orthopedists. The development of this enhanced technology allowed frontal access to the thoracic spine via a small incision. As Dr. Shelokov points out, "Besides the obvious cosmetic advantages if avoiding a six-inch scar, thoracoscopic surgery gets the surgeon in the center if the game. Un- fortunately, there is a steep learning curve with this procedure, so there may be only two or three surgeons in an urban center who perform thoracoscopic spine surgery, and even fewer who regularly operate on adults using this technique.

"Medical Center of PIano was one of the pioneering centers in this new minimally invasive procedure in the early 1990s," adds Dr. Shelokov. "Offering this alternative to patients has helped position Medical Center of Piano as a leader in spinal surgery."

Although Dr. Shelokov is experienced in treating adults, he genuinely enjoys his pediatric patients as well, and is particularly attuned to their needs. "Children's curves are more flexible and they heal more rapidly than adults. This translates into a lower rate of surgical complications than adults. Success in the pediatric population, however, depends upon an appreciation and focus on the underlying needs of children. A successful pediatric surgeon must like children, and understand what motivates them and their parents."

Dr. Shelokov describes a fundamental change in the rationale behind scoliosis treatment. Traditional medical wisdom held that surgery was the result of a failure to manage progression of the spinal curvature with other means. Experts believed that if the physician understood how and when to intervene with the appropriate brace, the curve would not progress and spinal surgery would not become necessary. Today, many experts believe that surgery may actually be the more conservative approach in certain cases.

Dr. Shelokov explains, "For some children, there are times when surgery is the more conservative choice. Today, with the advent of new and less invasive methods, we can sometimes perform a small operation and prevent larger curves from developing. We believe this earlier emphasis on intervention may avoid adding another individual to the adult population with symptomatic scoliosis."

Several factors have contributed to a changing environment in the field of spinal surgery. Advanced imaging methods like MRI allow surgeons to better identify disc and nerve problems. Advances in anesthesia and highly trained anesthesiologists have enabled surgeons to step outside old constraints. There are new surgical implants designed specifically for treating adult scoliosis. Fusion technology has been advanced light years with the emergence of bone morphogenic proteins. And, as Dr. Shelokov explains, "Middle age has shifted from 30 or 40 to perhaps 50 or 60 years old. People are living longer and are expecting and demanding a certain quality of life. As surgeons, our goal is to help transform patient expectations into reality whenever possible."

Dr. Shelokov has written and presented more than 40 medical and scientific papers, and is highly involved in research focused on a better understanding of scoliosis, its etiology and treatment. He notes, "We know now that scoliosis is a polygenetic inheritable disorder that affects collagen in a way that allows for progressive curvature." While basic research into the causation of scoliosis is important, Dr. Shelokov's main research interest is in the effectiveness of treatment. "We are studying individual patients' ability to recover lost pulmonary and cardiac function after surgery to correct scoliosis. We are also trying to more fully understand the psychological dimension of scoliosis pain by using psychometric testing to identify good candidates for surgery."
He adds, "We must continue to ask important long-term questions about adult intervention to determine its effects on longevity and life quality. We need to conclusively demonstrate whether pulmonary' hyper- tension can be managed or improved through surgery and the resulting change in chest wall configuration."

Dr. Shelokov meets biannually with the 35-member ISOLA Study Group, where deformity surgeons share and discuss their most difficult cases. He is enthusiastic about the power of this kind of knowledge sharing: "There is a renaissance taking place in terms of what can be done for patients with scoliosis."

Dr. Shelokov got involved in treating adults with scoliosis after finding that this population was underserved. He notes, "I feel incredibly fortunate to be involved in this particular area of medicine. because it is changing so rapidly, it is very exciting. It is extremely rewarding to participate in the creation of new roadmaps for treatment, and to offer new hope to people who have been considered outside the scope of effective treatment for so long."

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