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
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
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
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.
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