Treat the Patient, Not the Image: Dr. Angevine Explains Scoliosis

Jun. 17, 2019

A photograph of a person can offer a glimpse into their life, but to really know that person you need to talk with him or her. In a similar way, medical images provide doctors with information about a person’s medical condition, but they do not tell the full story. A doctor must consider the whole person, in addition to what appears on the medical image.

This approach is especially true for patients with scoliosis, a condition characterized by a sideways bend in the spine. Because June is National Scoliosis Awareness Month, as designated by the Scoliosis Research Society, we’d like to share more information about the condition as it occurs in adult patients, along with aspects to consider when pursuing treatment.

The most common type of scoliosis among adults is degenerative scoliosis, the result of wear and tear on spinal discs and joints over time. Many patients who have scoliosis as adults never had scoliosis when they were younger, explains Dr. Peter Angevine, neurosurgeon at The Och Spine Hospital.

Often a patient with scoliosis has observable changes in their body posture, such as one shoulder being higher than the other, a difference in hip height or position, or a difference in the way arms hang beside the body when standing. Though not always symptomatic, some patients with scoliosis experience issues such as weakness in one or both legs, numbness, pain similar to electric shock, and back pain that worsens with sitting or standing.

“By the time patients come to see me, they usually have some degree of pain,” says Dr. Angevine. However, not all patients with scoliosis have pain, and not all back pain is related to scoliosis. Dr. Angevine performs a thorough medical history, neurological examination and other tests as needed to make a diagnosis. “Part of my job is to try to determine if the symptoms are related to the scoliosis,” he says.

A patient’s symptoms and outward signs begin the process of diagnosing scoliosis, and it is confirmed when an X-ray shows that the spine has a certain degree of curve in it, explains Dr. Angevine.

Once a diagnosis of scoliosis is made, patients often ask: Which activities are safe, and which should be avoided? “We don’t have the evidence that any one activity is particularly beneficial or harmful for a patient in the absence of symptoms,” Dr. Angevine says. “Generally what I counsel is common sense.”

Dr. Angevine explains that if an activity causes significant discomfort or doesn’t feel right, it is safest to avoid the activity and talk to your doctor about it. “In the absence of any neurological signs or symptoms, like numbness or weakness or any other red flag, generally what we talk about is risk/benefit,” he says. Often, when the benefit and enjoyment from that activity outweigh the risks, the patient may engage in the activity, but it’s best for scoliosis patients to discuss any activities with a doctor first.

Just as not all adults with degenerative scoliosis have the same outward signs or symptoms, not all adults with degenerative scoliosis require treatment. Dr. Angevine explains that any significant change, in terms of symptoms or posture, is a reason to consider talking with your doctor about treatment—but the starting point is conservative, noninvasive treatments, such as physical therapy.

The goal of scoliosis treatment is to provide patients with the best quality of life possible, and surgery should be considered only once other options have been exhausted. Any surgical procedure carries a degree of risk, and about the decision to consider surgery, Dr. Angevine says, “It’s both a complicated and a very simple question.” He says it really comes down to whether that person has first, exhausted all the nonsurgical options for managing their symptoms, and second, reached a point where they feel their quality of life is no longer acceptable.

For patients who choose surgery, the exact procedure depends on the cause of the spinal degeneration. Spinal fusion is a common operation for scoliosis and involves stabilizing a portion of the spine with bone graft and instrumentation, such as rods or screws. This allows the bones to grow together into a solid block of bone.

Procedures such as a spinal fusion can help minimize the symptoms and outward signs that accompany scoliosis, even those that interfere with organ function. For example, Dr. Angevine’s patient Elizabeth had such severe scoliosis that not only was she in pain but her rib cage was putting pressure on her lungs, making it difficult to breathe. (You can read Elizabeth’s full story here.)

Elizabeth required surgery to realign and stabilize her spine. Although long and complicated, the surgery was a success, allowing her to return to her daily activities without the breathing problems and severe pain she had been experiencing.

“[Spinal fusion] is the best option we have for somebody who otherwise can’t function because of pain,” says Dr. Angevine. “For patients in that situation, the vast majority tell me after surgery—with some surprise and sometimes some reluctance, because they don’t want to jinx anything—how much better their quality of life is without the leg pain, having regained the height they’d lost and being able to stand up straight and look family members in the eye.”

Ultimately though, the patient is driving the treatment decisions. Dr. Angevine emphasizes that how a person’s scoliosis appears on an X-ray does not determine treatment. “The X-rays really help us plan the surgery—but they don’t tell us what the appropriate surgery is,” he says. “That comes from the patient.”

Read more about Dr. Angevine at his bio page here.

Watch last year’s Facebook live event in which Dr. Angevine discussed adult scoliosis here.

Learn more about scoliosis on the condition page here.

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