Patients with spinal deformities often look to their general practitioners (GPs) for advice on management options. The SingHealth Duke-NUS Spine Centre shares the latest advances including minimally invasive techniques that offer benefits such as quicker recovery and increased patient acceptance.
INTRODUCTION
There have been many updates in the management of spinal deformity for both paediatric and adult populations. This article introduces new techniques which bring improved care and outcomes in the treatment of patients with spinal deformities.
Managing Paediatric Scoliosis
TRADITIONAL MANAGEMENT
Bracing
Traditionally, the commonest treatment for paediatric scoliosis has been bracing when there is significant residual growth of the spine. This is well-proven and supported by the Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST) in 2013.
Scoliosis-specific exercises
In patients who have scoliosis, it has also been shown that scoliosis-specific exercises are beneficial to improve posture and rotation in the three-dimensional deformity.
Schroth exercises (Figure 1) are one of the many therapies available for non-surgical management in addition to bracing.
Surgery
In patients who have a scoliosis curve with a cobb of more than 45 degrees, surgery is indicated and posterior deformity correction and fusion is the standard treatment (Figure 2).
However, traditional spinal fusion reduces the mobility of the remaining spine segments and can lead to some stiffness, especially when there is a lumbar spine curvature that needs a fusion.
A NEW SURGICAL TECHNIQUE: VERTEBRAL BODY TETHERING
Most recently, we have adopted vertebral body tethering, a motion preservation technique which allows the concave part of the spine to continue growing in patients who are deemed to have remaining growth potential, allowing the spine to straighten over time.
The use of a cord on the convex side of the curve (Figure 3) is effective in slowing down growth leading to gradual correction of the spinal deformity. This procedure is minimally invasive via a thoracoscopic approach. Patients tend to stay for two to three days and can resume activity at six weeks post-surgery with minimal limitation to mobility.
Patient outcomes
This has been an effective way of managing younger patients who are already surgical candidates based on the severity of the curve.
Our initial experience has shown that patients who underwent this non-fusion procedure were able to return to sports due to the preservation of thoracolumbar mobility. This surgical option allows this active population to live as normal a life as possible, as opposed to patients who had fusion surgery who may be limited in their activities due to stiffness of the spine.
Advantages
In summary, the advantages of vertebral body tethering in the treatment of scoliosis are:
Preserved motion of the spine to allow unrestricted sporting activities
Non-fusion option which allows for growth in the teenage population
Minimally invasive technique allowing rapid postoperative recovery and superior cosmesis
We certainly hope that the use of this technology coupled with early diagnosis and treatment will provide parents with more options in the management of adolescent idiopathic scoliosis. Whilst not all patients with scoliosis will be suitable for this surgery, further evaluation with a spine surgeon will determine whether they are candidates for this minimally invasive, non-fusion technique.
Managing Adult Spinal Deformities
With the rapidly ageing population, there has been greater interest in adult spinal deformity. It is estimated that at least 10% of the population has spinal deformity and recent advances in the use of minimally invasive and anterior and lateral technology have been instrumental in offering excellent outcomes for patients.
In considering the day-to-day activity of our older folk, posture plays an important role in functional movement.
Many of the elderly lose their lumbar lordosis as they age, which leads to increased pain in the upper back as the spine tries to compensate for the flattening of the lumbar spine.
DIAGNOSTIC MARKERS AND INVESTIGATIONS
Pelvic incidence (PI) is an important marker in determining the ideal lumbar lordosis and is measured on standing whole spine X-rays.
The sagittal vertical axis (SVA) is a marker of the extent of ‘stooping’ of the patient which has implications on their health-related scores.
Each deformity patient is analysed using the EOS X-ray, which is a low-dose X-ray to calculate the ideal lumbar parameters which form targets should there be a requirement to undergo spine surgery. Figure 5B demonstrates an adult patient who has both coronal and sagittal deformities.
A MINIMALLY INVASIVE DEFORMITY CORRECTION TECHNIQUE
When looking at adult deformities, three aspects are considered:
Presence of spinal stenosis (leg pain)
Back pain
Overall alignment
Since 2009, minimally invasive technologies have been utilised to help address all three aspects and have been successful in the patient-reported outcome scores.
Figure 6 shows the principle of minimally invasive deformity correction using an interbody cage which produces improvement in a spondylolisthesis of L3/4.
Similarly, this technology can also be used to treat scoliosis in adults using a minimally invasive approach (Figure 7).
Patient outcomes
To date, over 300 patients have benefited from this procedure. It has remained popular due to the minimally invasive nature of the surgery which produces a faster return to work and decreased blood loss during surgery.
KEY TAKEAWAYS FOR GPs
Adult spinal deformity is an epidemic that is underdiagnosed but often disabling to patients.
A greater understanding of spinal deformity has led to improvements in outcomes with surgical correction.
While often requiring major spinal surgeries in the past, minimally invasive techniques such as lateral approaches can now be used to successfully correct these deformities.
Additionally, patients have less surgical trauma with this strategy, allowing patients to recover faster and return to function earlier. This has also led to better patient acceptance of spine surgery for their deformities.
CONCLUSION
We hope that with a better understanding of spinal deformity, patients will understand the root cause of their disability and seek treatment early.
Deformity correction can now be achieved with minimally invasive techniques, allowing patients to overcome the stigma of major spine surgery and giving them the confidence to return to function after surgery.
Singapore General Hospital sees patients from age 10 and above, including scoliosis cases.
Dr Jiang Lei is a consultant with an interest in minimally invasive deformity surgery for paediatric and adult patients. He has research interests in spinal cord injury and recently completed his fellowship at Addenbrook’s Hospital, Cambridge. He is also the Research Chair of the SingHealth-Duke NUS Spine Centre. GPs who would like more information on this topic, please contact Dr Jiang at [email protected].
Associate Professor Reuben Soh is a Deputy Director of the SingHealth-Duke NUS Spine Centre. He has interests in paediatric and adult deformity and is a board member of the Asia Pacific Spine Society anterior column realignment focus group, the Society for Minimally Invasive Spine Surgery and the International Society for the Advancement of Spine Surgery. GPs who would like more information on this topic, please contact Assoc Prof Soh at [email protected].
GPs can call the SingHealth Duke-NUS Spine Centre for appointments at the following hotlines or click here to visit the website:
Singapore General Hospital: 6326 6060
Changi General Hospital: 6788 3003
Sengkang General Hospital: 6930 6000
KK Women's and Children's Hospital: 6692 2984
National Neuroscience Institute: 6330 6363
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