Every year, the National Scoliosis Foundation receives letters and telephone calls from parents of young people who have been told they have a “mild” curvature of the spine. They are concerned and confused. They have been told that treatment is not presently necessary but may be in the future. Parents ask us, “are we to just stand by and watch our child become deformed?” To find out more about such curves, we interviewed Dr. William P. Bunnell, Chairman of the Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, California.
Q: Dr. Bunnell, we’ve been told that one in ten persons has scoliosis but we know that most curvatures will remain mild and never require treatment. What percent of curves remain mild?
A: Ninety-five percent of the curvatures will not require treatment.
Q: How does an orthopedist determine whether or not a curve is mild?
A: We begin with a physical examination that involves bending the patient forward so that we can see whether the curvature is causing a rotation of the spine and a rib deformity. We then may take an x-ray of the patient’s spine to determine precisely the nature and degree of the curvature.
Q: Which curves are considered mild?
A: We usually label a curve mild if it’s under 20 degrees. And if a curve is less than 10 degrees, we don’t even dignify it by calling it scoliosis. Instead, we might refer to it as a postural variation.
Q: What factors do doctors take into account in order to predict whether or not a mild curve will progress and require treatment?
A: One of those factors is skeletal maturity or bone age. The classic way of determining bone age is to take an x-ray of the patient’s wrist and then compare it to scores of other wrist x-rays that have been catalogued in a special book called The Greulich and Pyle Atlas. Such a comparison might reveal that a child who is chronologically fourteen actually has a bone age of thirteen. Another way to discover skeletal maturity is to simply look at the appearance of the pelvis on an x-ray; by doing so, we can tell whether or not the patient is near the end of growth. Menstrual history also helps us predict the chances of curve progression in a girl. We know that young girls grow rapidly during the year prior to their first period, and that’s when most girls’ curves get worse. On the other hand, if a youngster has had her first period, we know that she’ll continue to grow for one to two years after that, but at a reduced rate. Thus, we can say that if a patient’s curve is around 25 degrees, but she hasn’t had her first period yet, there’s a significant chance the curve will increase. The risk of progression is lower, however, if she’s already had her first period.
Q: Once a youngster has been diagnosed as having a mild curvature, what steps should he or she take?
A: It will depend upon the size of the patient’s curve and the growth status. A young patient (6-8 years old) with a very mild curve (15 degrees) might only need to be seen once every 6-12 months since the risk of progression is low. A pre-teen (11-12 years old) with a larger curve (25 degrees) will require much closer observation (every 3-4 months) because of the higher risk of curve progression. There is no need to restrict physical activities during this period, nor are physical exercises of any benefit in preventing curve progression.
Q: During the observation period, would you take x-rays each time you saw the patient, or could you use the Scoliometer?
A: Although an x-ray is the only way to be absolutely sure about whether or not a curve is progressing, I believe that the Scoliometer is effective in determining significant progression of mild curves. Its use easily reduces the need for x-ray (not clinical examinations) by 50%.
Q: Can anything be done to reduce a mild curve? What about exercise or manipulation?
A: There’s not an ounce of scientifically documented evidence that exercise or manipulation can reduce a curvature. There is a place for exercise in children who have poor posture; it can help create body awareness so they don’t slouch.
Q: If the patient is still growing and the mild curve does progress beyond 25 degrees, what type of treatment would you recommend?
A: I’d probably recommend a rigid brace of some sort, and my choice would depend on whether the patient had a single or double curve as well as the location of the curve(s) along the spine.
Q: Wouldn’t you consider electro-stimulation as a treatment?
A: Let me put it to you this way: Most doctors thought the electro-stimulation was going to be a fantastic idea, and so did patients. But now that we have subjected the research results to critical review, it appears that patients who were getting that type of treatment were statistically no better off than those who got no treatment at all.
Q: One final question. We know some youngsters who, despite the fact that their curves are well below 25 degrees, believe they are “deformed.” What would you say to that?
A: It’s my contention that mild curves are extremely prevalent in the population. In fact in 1988, I personally looked at 1,000 high school students and found only 16 youngsters who had perfectly straight spines. It’s important to realize that almost everybody has a little bit of irregular curvature. And that’s why it’s so important that we don’t treat everybody.