Courtney H.— Fresno, CA
Scoliosis surgery isn't just for kids. Thanks to advances in spinal technology that enable comparable curve correction in skeletally mature patients, former collegiate water sports standout Courtney is looking forward to the future—and training for her first triathlon!
Each year, roughly 100,000 new scoliosis patients are identified in the United States,1 the majority of which are age 9 to 15. Traditionally, the preferred treatment protocol for young patients with a high degree of spinal curvature—or a curve expected to progress rapidly—has been to perform corrective surgery during the pre- or early-adolescent years, when the bones of the spine are more flexible.
In recent years, advancements in spinal technology have enabled surgeons to achieve comparable curve correction in post-adolescent, skeletally mature patients. Today, patients who didn't have surgery during their formative years—or whose curves didn't warrant surgical correction until they'd reached adulthood—have the opportunity to achieve outcomes comparable to those of their younger counterparts.
When Courtney, a former competitive swimmer and water polo player for California State University-Long Beach, was first diagnosed with a spinal curve through a school screening program in the eighth grade, the degree of curvature was so slight that neither she nor her family took much note of it. "We just put it on the back burner and never really looked into it," she recalls. "It had no effect on my life, so at that point it was not a big deal."
A few years later, when Courtney was in high school, her mother spotted the first outward signs of what was to come. "One day Mom noticed one of my shoulders was higher than the other," she says. "We were on our way to the doctor pretty quickly after that."
An elite-level player on her school's varsity swimming and water polo teams, Courtney had her heart set on continuing to play competitively in college—and on winning an athletic scholarship. After examining her spine, Courtney's physician determined her curve to be about 40°, a significant progression from her initial diagnosis a few years earlier. Because she hadn't felt any pain and was still at the top of her game, performance-wise, Courtney was blindsided by the new diagnosis and concerned about how treatment of it could affect her future plans. "The doctor said my curve was still in the 'gray zone' in terms of the need for surgery," she notes. "So if I wanted to postpone surgery and continue playing, I could. But, he would continue to track my curve very closely and if it got any worse, I'd definitely have to go through with it."
After graduation, Courtney headed to Cal State, having achieved her dream of winning a scholarship to play collegiate water sports. However, over the next few years Courtney's scoliosis started making her life much more difficult. "When I was playing, I could tell I was getting tired a lot easier and more quickly," she says. "The pain was also starting to get to me; I could only stand for so long until it got so bad I had to sit down. After practice, I'd really hurt. I was working out a lot but it didn't take me long to realize it wasn't muscle pain, it was my back."
As she neared graduation, Courtney was in near-constant pain and the asymmetry of her spine much more visible. "People started asking me what was wrong with my back, and pointing out that I had a hump when I bent over," she says. "My clothes fit differently; the hems would be crooked and it was really obvious something was wrong. So, I just started wearing baggy clothes. I'm all about comfort, but still, it bothered me."
Courtney also quit swimming and water polo, in part because of her spinal condition and its effect on her performance. Realizing the time had come to finally consider surgery, Courtney returned to her doctor who, after confirming her spinal curve had indeed become much more severe, referred her to orthopaedic surgeon Dr. Robert Pashman, with the Cedars-Sinai Institute for Spinal Disorders in Los Angeles, California. "That first appointment was great," Courtney recalls. "Dr. Pashman explained exactly what the surgery would involve and laid out all the pros and cons, which I really appreciated. And when I told him one of my main concerns was whether I could continue to be as active as I had been, he was very reassuring, which also helped me feel more confident about what was ahead."
By the time Courtney met with Dr. Pashman, her curve had progressed to 58°. "This is considered a solid indication for surgery. There's no 'gray area' about it," notes Pashman, who is internationally recognized in the treatment of scoliosis, spinal deformities and complex spinal revision surgery, and whose Los Angeles-based practice consists of about 75% to 80% post-adolescent/adult scoliosis patients. "If her curve had been this severe when she was 16, there's no doubt she would have been advised to have surgery right away."
Treatment of scoliosis depends on the severity of the curve, along with other factors such as the patient's age and physical condition. Nonsurgical treatment options, such as observation and bracing, typically are the first line of defense. Bracing, however, had not been advised for Courtney as it only works to stop curve progression in a growing child and is not recommended for patients who are already skeletally mature or almost mature, as she was at the time.
Surgery—specifically, spinal fusion—is recommended for severe curves and for curves that have not responded to nonsurgical treatment. Ultimately, the goal of the surgery is to halt the progression of the curve and reduce spinal deformity, to the extent possible, restoring proper spinal stability and alignment. The surgery involves implanting instrumentation along the treated area to create an "internal cast" to support the vertebral structures and redirect stress properly along the spine during the healing process. During the surgery bone graft material is placed between the affected vertebrae to encourage them to fuse, or join together in the newly aligned position.
Dr. Pashman's strategy for treating Courtney's spine involved the fusion of several levels in her thoracolumbar spine (mid- to upper back). Because of advances in fixation technology in the past decade or so, he believed he would be able to obtain a good outcome in the reduction of her curve. "We have some very effective solutions available to us today for treating scoliosis patients considered older than the norm, and whose spines are no longer as flexible," Pashman says.
Since the mid-20th century, rods have been a mainstay in scoliosis correction technology and until the 1980s, hooks the primary means of fixation to the vertebrae. In recent years, surgeons have been able to use pedicle screws in skeletally mature patients. These are very small bone screws designed to be implanted into the two bony protrusions—the pedicles — that project from the back, or posterior, of each vertebra, and connect to other spinal structures such as the lamina and vertebral arch. Pedicle screws can be used to affix rods and plates to the spine, and to stabilize the spine to promote fusion. "This technology enables us to apply a greater degree of force through the instrumentation in skeletally mature patients," Pashman explains. "It also allows us to address the curve in all three dimensions and derotate the spine in those cases that require it. And I'm finding that patients do really well."
Dr. Pashman also used surgical imaging technology to confirm the accurate placement of the pedicle screws in Courtney's spine. "This is a relatively new technology that enables us to see, in real time, the spine in three dimensions," he says. "Information from an intraoperative scanner is relayed to a computer, and it tells us exactly where to place the screws."
After surgery, Courtney's spinal curve was 10°—a significant reduction from the 58 ° it was before. "I'm also two inches taller!" Courtney exclaims. "I don't know too many 21-year-olds who get a two-inch growth spurt, but it's been really nice to adjust to."
Please keep in mind that all treatment and outcome results are specific to the individual patient. Results may vary. Complications, such as infection, blood loss, or nerve damage are some of the potential adverse risks of spinal surgery. Please consult your physician for a complete list of indications, warnings, precautions, adverse events, clinical results, and other important medical information.
At six months after her procedure, Courtney says essentially all of her scoliosis-related symptoms have eased up; however she admits she was in a good deal of pain right after surgery. "It was tough at first, but now I'm so thankful I went through it," she says. "And I'm definitely not in the same kind of pain I was before surgery."
And while Courtney's days on the college pool circuit might be behind her, her competitive spirit is still very much alive and well. Her new goal: triathlons. "I'm still not quite where I was before, but it's getting better and better every day and I can't wait to get back into training full-time" she says. "I feel very blessed and am really looking forward to the future. I'm very grateful to Dr. Pashman and his staff, and that he had the technology available to make this happen. It has been a wonderful growth experience, physically and mentally, and an awesome challenge that I'm proud to be in the process of overcoming. It's just a great feeling."
It is important that you discuss the potential risks, complications, and benefits of spinal surgery with your doctor prior to receiving treatment, and that you rely on your physician's judgment. Only your doctor can determine whether you are a suitable candidate for this treatment.
After reading this please keep in mind that all treatment and outcome results are specific to the individual patient. Results may vary. Complications, such as infection, blood loss, or nerve damage are some of the potential adverse risks of spinal surgery. Please consult your physician for a complete list of indications, warnings, precautions, adverse events, clinical results, and other important medical information.