Because the National Scoliosis Foundation receives constant inquiries from individuals asking whether pain is a symptom of idiopathic scoliosis, we interviewed Dr. Robert Winter, internationally know for work in surgical and non-surgical treatment of spine deformity. Dr. Winter is the author of numerous textbooks, papers, and chapters of surgical textbooks. He is a frequent speaker at national and international orthopaedics conferences. He is also a founding member and past president of the Scoliosis Research Society, President of the Minnesota Spine Center, Chief of Spine Service at Gillette Children’s Hospital, and Clinical Professor of Orthopaedic Surgery at the University of Minnesota.
Q: Dr. Winter, is pain a symptom of scoliosis in the adolescent?
A: Very rarely. In fact, if a typical 12 to 14 year old adolescent with scoliosis visits our clinic and her main complaint is “I hurt,” we would be concerned, because most patients of that age simply don’t hurt. We would wonder (1) Why is this girl different from the usual patient? and (2) Is there something else going on besides scoliosis? Then we would order a variety of tests to find out whether she has a bone infection, a bone tumor, a spinal cord tumor, or some other type of problem.
Q: Let’s say the patient mentioned above undergoes various test, and you find that she has no abnormal condition other than scoliosis. What might be causing her pain?
A: Some adolescents with scoliosis may experience pain which is truly “organic” in other words, they experience a muscular type of pain which occurs because the muscles on the convexity of the curve are working overtime trying to control the curve. When muscles are overworked, they hurt.
Q: What about adult patients with scoliosis who complain of pain; is their pain due to scoliosis, or to something else?
A: This is one of the toughest questions doctors face when confronted with the scoliotic adult who complains of pain; how to distinguish between conventional low back pain and pain due to scoliosis. First, it should be noted that all adults-whether they have scoliosis or not-can have low back pain. It’s just part of being a human being who stands upright and is growing older. As we age, all of us eventually experience disc degeneration-i.e., the fibrous, spongy discs between our vertebrae wear out. Moreover, various joints of the body tend to wear out with age-a condition known as degenerative or “wear and tear” arthritis (also know as osteoarthritis). When these conditions occur, bone rubs against bone, which causes pain-but the pain may be due to disc degeneration or wear and tear arthritis, problems that everyone faces with age.
Q: If an adult with scoliosis is experiencing pain that is not due to disc degeneration or arthritis, what might be causing the discomfort?
A: The answer to your question has to do with mechanics. You need to understand that the discs in your back are being loaded with weight by gravity every day. If the vertebrae of the spine are perfectly straight, then the loading will occur symmetrically. However, if the spine is curved, the loading will be asymmetric and highly concentrated in the concavity of the curve. When discs and joints are loaded asymmetrically, they wear out asymmetrically, and at a much faster rate than they would normally. In these cases, we would say that the patient has scoliotic pain: the back pain, usually found in the thoracolumbar (mid-back) or lumbar area (lower back), is due to the spinal curvature which is causing asymmetric loading of discs and joints. Scoliotic pain usually does not occur in persons in their twenties or thirties but rather in those in their forties and beyond.
Q: Is there any connection between the magnitude of a curvature and the amount of pain one might feel?
A: Let me answer the question this way, I’ve seen adult patients at our clinic who have 30 degree curves and they’re miserable; yet just down the hall I’ll visit a patient who is 67 years old with a 95 degree curve and she’ll say it doesn’t hurt at all. Generally speaking, thoracic (upper back) curves don’t hurt even if they’re 90-100 degrees; in this case, breathing capacity may be diminished, but the lungs wouldn’t hurt. Lumbar Curves over 45 degrees tend to hurt over time, yet I’ve seen 95 degree lumbar curves that didn’t hurt at all.
Q: In terms of diagnosing a patient, how do doctors determine whether a patient has conventional low back pain or scoliotic pain?
A: We would begin with a physical examination and then look at routine x-rays. We might also use special diagnostic techniques such as a myelogram (an x-ray of the spinal cord); high-tech scanning devices such as Magnetic Resonance Imaging (MRI), which uses a computer to produce three-dimensional images; and/or discography which is the injection of a dye into the disc which can assess both the patient’s pain response to the injection as well as the radio graphic pictures of the discs.
Q: If the doctor determines that the patient has disc degeneration or arthritis, what can be done to treat the pain?
A: The first step for the doctor is to block scoliosis from the mind-i.e., treat the patient as though she came in with a straight spine and low back pain. The next step is patient education; learn all you can about body mechanics so that you know how to lift, sit and sleep properly; find out from your doctor which type of exercise will help you (some patients with arthritis of a spinal joint or joints, for example, may benefit more from isometric toning than from aerobic motion exercise). Third, learn not to panic when you have a little back pain. I’m a great believer in doing simple things when you can: perhaps a non-steroidal anti-inflammatory drug (NSAID) such as aspirin or ibuprofen will help. Quite often, wearing a corset, using a heating pad, lying on the floor with your feet propped on a chair, or resting in a fetal position for 10 minutes, can give you relief. As for the use of chiropractic treatment of pain, if it works for a patient, it’s fine. I’m not particularly enthusiastic about biofeedback or acupuncture for treatment of pain.
Q: What about treatment for true scoliotic pain?
A: Once the doctor has determined without a doubt that the pain is caused by the scoliotic curve, surgical techniques can be designed to solve the problem. It is crucial that the diagnosis be accurate. If the pain is strictly in the curvature, then by treating the curve surgically you treat the pain and patients do very well. On the other hand, if the doctor thinks the pain is due to the curve but in reality it’s due to disc degeneration outside the curve, you can treat the curve from now until doom’s day and the pain won’t go away.
Q: We’ve heard that there are some situations which may give rise to pain after surgery. Examples include flat back syndrome and a broken rod. Would you comment on these?
A: Flat back syndrome is a condition that occurred more frequently ten years ago, when doctors weren’t cognizant of the fact that you just can’t use a Harrington distraction rod on the lumbar spine and get good results. Today, we know that a long fused segment in the lumbar area places a great deal of stress on the remaining joints and wears them out. The condition can be corrected surgically with reconstruction techniques, but we prefer to prevent it from occurring in the first place. We still do low fusions, but we do not use Harrington distraction rods in the lumbar area. When a rod breaks, it usually happens because the patient has a pseudarthosis part of the fusion doesn’t heal properly. In this situation (which can be corrected surgically with good results), it’s the pseudarthosis of the fusion that causes pain, not the broken rod.
Q: What can you tell us about patients who have scoliosis and osteoporosis, the condition that is accompanied by brittle and/or porous bones and is associated with loss of calcium from bones?
A: Osteoporosis in and of itself does not hurt, but if you get a compression fracture because of it, it will hurt a lot. Such fractures can occur in individuals who have scoliosis; when they do, they appear either at the concave or convex side of the curvature. It’s important to note, however, that osteoporosis does not cause scoliosis; it causes kyphosis, the skeletal abnormality we associate with a rounded or humped back.
Q: Is there anything that can be done to prevent osteoporosis?
A: Here are a few guidelines: (1) From the age of 18, all women (particularly postmenopausal women) should be taking 1500 milligrams of calcium per day plus the amount of vitamin D that you’d find in a multi-vitamin. (2) In the first five years after menopause, all women should be taking the hormones estrogen and progesterone-unless they have a history of breast cancer or uterine cancer. After five years, women can stop the hormone treatment and return to taking the vitamin D and calcium combination. (3) Exercise in moderation to keep in shape.