Not all those with scoliosis need an operation – that’s the main message that consultant orthopaedic surgeon Paul Connolly would like readers to be aware of.

A surgeon at the Cappagh National Orthopaedic Hospital as well as Temple Street and the Mater Hospitals, he sees many young patients with the condition known as idiopathic adolescent scoliosis.

“This condition is very common in Ireland with approximately two in every 100 people affected. Idiopathic is a fancy way of saying we don’t know what causes it but we do know that there is often a genetic link,” he says.

Children who present with the condition are x-rayed and monitored for several months initially.

“If the scoliosis is progressing, ie if the curve of the spine is getting bigger and is hitting the surgical (size) range, we will discuss spinal fusion surgery with the family,” he says. “Bracing, however, may be an option early on in a younger patient.”

The condition is often noticed during school check-ups or by parents during holiday-time, he says, after children have gone through their adolescent growth spurt.

“Parents might see it during the summer holidays when kids are in bathing suits. They’d notice a curved back or asymmetry – that one shoulder or hip appears higher than the other. It’s at that stage they talk to their GP.”

Treatment options - brace

A decision about surgical intervention usually occurs if the curve reaches 50 or 60 degrees, or when a curve progresses quickly with growth, he states. As mentioned, a brace may also be an option.

It is a thermoplastic moulded device, usually made in Cappagh in the orthotics department.

“They take a moulding and fabricate one. When worn, the brace pushes on the ribs and pelvis to try and push against the curve that is present.”

A brace can be a time-buyer, he says: “It won’t straighten out the curve but it may delay the need for surgical intervention until the children are a bit older and more skeletally mature, or in some cases it halts curve progression.

It would be an option for a patient of nine, 10 or 11 years of age who is premenarchal (pre-puberty), skeletally immature and where the curve is not more than 20-40 degrees.

When the child gets to 14 or 15 years of age and if the curve has increased to 50 or 60 degrees, then we would discuss surgery with them if that is something they want to do.”

A brace is usually worn under clothes, ideally for 20 hours a day, he adds.

“It can be taken off for hygiene purposes but children are asked to sleep in it and go to school in it. It’s a big ask for a child and their family to go through bracing. Some say there is no way I’m going down that route and in that case we don’t do it. Equally though, some families are keen to avoid surgery if at all possible and research has shown that braces can be beneficial. Brace use tends to be very user-dependent but some people do quite well with them.”

Chances of getting it worse

But is it inevitable that the curvature will get worse for every affected child?

“If you have a large curve when you’re ten or eleven years of age, then yes, in 90% of cases the curve will progress. If you get to 15 or 16 years of age though, and your curve is 20-40 degrees, then there is a good chance you mightn’t need an operation because a lot of your growth has already occurred.”

Patients can be lucky, he adds.

“If someone presents at the age of 17 with a 30 degree curve, we wouldn’t operate unless the patient and family really wanted something done. It is a big operation for a child to go through after all, and it’s not risk free.”

The operation involves a skin incision being made down the middle of the back and implants being inserted.

“This involves a variety of screws and hooks being put in to hold on to the bone and then a rod inserted that we manipulate in order to straighten the spine during the surgery.

“We want the spine to fuse and what we’re doing is using the implants to straighten it out and hold it in its correct position until the fusion has taken place. Local bone is used in order to achieve a fusion. We monitor the spinal cord all the time during the procedure to make the operation as safe as possible,” he says.

By and large it’s a fairly safe procedure, he adds.

“In Cappagh Hospital, the risk is within international norms but like any operation, there are potential complications. Paralysis is rare, probably 0.2% to 0.5% but it is potentially devastating. Infection would occur in about one in 100 cases also.”

Recovery takes about six months

Recovery generally takes about four to six months, with adolescents able to return to contact sports then. Spinal fusion surgery can have some implications for the future, however.

“That’s because you are making that portion of the back rigid. This can lead to them getting wear and tear symptoms in their lower back, so the incidence of low back pain in that group is a little bit higher than average.”

Types of scoliosis

There are other types of scoliosis – early onset scoliosis and congenital scoliosis, scoliosis associated with syndromes. These types of scoliosis affect young children and are diagnosed early by x-ray. They are often part of other conditions like cerebral palsy, spina bifida or some forms of muscular dystrophy.

Tests are done on all suspected scoliosis patients to eliminate the presence of these conditions.

Profile

Ciara Brewer is 15 and from Clonee, Co Meath. She had surgery to straighten her spine in December 2013 at the Cappagh Hospital and she hasn’t looked back since.

PE and Irish dancing were possible again for her just nine months after the operation, and she speaks highly of her overall experience in terms of care. Yet, 2013 was a very difficult year for her and her family after her dad, Paul, noticed the curvature in her spine when Ciara was playing the concertina one day.

“She was sitting in a chair,” says her mother, Barbara, “and had her hair up in a bun and her dad thought her back was sticking out a bit. He asked her to sit up but she said she was sitting up.”

The couple’s concern quickly brought them all to their GP.

“There was no family history of it and Ciara had no problems when she was born so it was a big shock to find ourselves referred to Temple Street hospital that afternoon. You don’t think the worst case scenario is going to happen to you but it did,” says her mum.

After several medical opinions, the consensus was that, yes, Ciara would need spinal fusion surgery, probably within a year.

“We were just so upset about it, and for Ciara as well, it was a big deal in the family – very hard.”

By the following September, the scoliosis was having a major impact on Ciara.

“I couldn’t breathe properly by then as my ribs were crushing my lungs so I couldn’t do Irish dancing or swimming,” she says. “My shoulders and hips were uneven too and ribs were sticking out in different places.”

Ciara liked the fact that hospital staff talked her through the whole process prior to the operation. “That helped a lot,” she says. “The day after the operation was a bit strange though. When I stood up at first it felt like my whole body had been rearranged.”

Ciara was home within a week and back to school in January but it was May before she was feeling well again and the following September before she could carry books or get back to PE.

Ciara was so interested in the x-ray side of her experience that she is now considering a career in radiography.

“She thought the job was cool so we’ll see what happens,” says her mum, and she pays tribute to the hospital: “The operation is like an engineering feat really. The doctors are so skilled. You don’t realise what these doctors are able to do but it’s all in a day’s work to them.”

The future means regular monitoring for Ciara.

“Obviously we’ll always be worried about Ciara, but really she was so good and so positive throughout the whole thing. Having scoliosis hasn’t stopped her doing anything. It was hard for me to look at the x-ray after, to see what was in there – but we’re so happy with the care she has had.”

Ciara has two siblings, Grace (10) and Joseph (14), and her parents will be keeping a close eye on them because of Ciara’s experience.

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Cappagh National Orthopaedic Hospital is Ireland’s major centre for elective (planned) orthopaedic surgery.

Over 20,000 patients are treated there each year and orthopaedic services include major joint replacement (ankle, hip, knee, shoulder, elbow and wrist), spinal surgery, primary bone tumour service, paediatric orthopaedics and sports injuries.

Money is currently needed to buy navigation assisted systems and software for scoliosis corrective surgery. It will cost €500,000. The new software will help tackle existing waiting lists for spinal surgery and allow surgeons to undertake complex spinal surgeries with dramatically reduced risk.

This service development will be a first for Ireland and will benefit many adolescents who have scoliosis. For more information or to donate, see the Cappagh Hospital Foundation website www.chf.ie or telephone 01-834 0325.

See www.scoliosis-ireland.ie for further information on scoliosis.