The S shaped Spine

Should Adolescents with Scoliosis Get Surgery?

Dr Putra Vatakal, Orthopaedic Surgeon, Kuala Lumpur, Selangor, Quill Orthopaedic Specialist Centre, scoliosis, back pain, spine

“Ah Girl, can stand straight or not? Your shoulders are so senget. 

You always wear your baju so tight- tight one lah, that’s why! “ said Mum. 

Aiya, Mummy. Can you please stop picking on me?” said the young teen. 

Mum wasn’t really picking on her

Her clothes weren’t all that tight

But yes, she was a bit crooked.

As usual Mum was right…

Scoliosis—defined medically as an abnormal three-dimensional curvature of the spine, and by parents, aunties and uncles as “my daughter/niece/son/nephew’s back is crooked“— happens in about 3% of the general population.

3% seems like a small percentage, but by doing a bit of math, it can be extrapolated that there could be about 250, 000 people with scoliosis walking around the Klang Valley, mainly young people and children.

That is nearly the entire population of Miri, Taiping, or Muar. That is quite a lot of people. 

Scoliosis can be classified as congenital (caused by abnormalities of the spine from birth); neuromuscular (which is due to an abnormal pull of the muscles that straighten the spine); and most commonly, when no definite cause is identified – idiopathic scoliosis, which is most commonly seen in adolescent girls.

A few months later in the doctor’s office, Ah Girl’s parents squint concernedly at a glowing x-ray box as the doctor points out where her spine is curved. 

“Mummy, let’s go back. Back not straight, so what?” whines Ah Girl.

“Ah Girl, quiet! Later you won’t be pretty. Doctor said your bones are so crooked!” says Mum. 

“Hmpph… Ya, lah! Doctor talk so much, not like his face is so handsome also!” says Ah Girl.

“Ah Girl!!” Mum growls. 

The doctor stands speechless. 

While improving physical appearance is definitely a consideration in treating scoliosis, the grim reality is that a curved spine usually gets worse over time — particularly when the child is still growing. A badly curved spine can deform the chest and abdominal cavities — leaving little room for the patient’s lungs and organs to work properly. In extreme cases, it can be crippling, and even life- threatening. 

Until the late 1990s, correction of scoliosis frequently meant a dangerous operation, with the spine having to be accessed from the back and front— leaking blood all over the place. Metal rods (designed by Dr. Paul Harrington in the 1950s) or hooks had to be passed near the major nerves— a slight slip could spell paralysis. As their child was wheeled to the operating room, most parents would smile nervously down at him, silently praying “God, please don’t let him be paralyzed”.

While the surgical techniques above were considered revolutionary in their time, they not only sound scary, but suffered from issues like failure to correct the deformity properly, recurrence of the curve in the spine, and sometimes the metal implants simply broke or pulled out from the bone they were fixed to.

Naturally, the high-risk nature of this kind of surgery has led many medical professionals—Orthopedic surgeons included— to avoid recommending surgery for their patients.

Physiotherapy, stretching, chiropractic adjustments and back braces are among the more commonly prescribed alternatives. While back braces are helpful in preventing worsening deformity, their role is limited to milder spine curves— generally when the angle (Called a Cobb’s angle) is less than 45 degrees.

One year later, Ah Girl and her mother travel to Kuala Lumpur to seek treatment. Ah Girl’s schoolmates have been teasing her for the large lump on her back and because she can’t keep her neck straight in class. 

“Doctor, you see… she never listens! Didn’t wear her brace to school. Now so crooked,” Mum laments. 

The Professor hands Ah Girl some tissues to dab away her tears. He makes her stand straight and bend over measuring the angle of her back. They talk. 

An hour later, Ah Girl has undergone some x-rays and sits in the padded office chair next to her anxious mother.

“Cannot if don’t want to operate ah, Doctor? My friend’s wife is a doctor also— she said if do operation is so risky. Can die, can be paralyzed, must ‘matikan’ the joints in her spine then she cannot move…” says Mum. Hot tears well in her eyes.

“Last time she was so active in taekwondo and badminton, now she can’t stand properly, difficult to breathe when she has to run for sports. Aiyo, my Girl!”

Her tears stream down her face, and drip onto her flower-print blouse as she clutches at Ah Girl’s shoulder. The Professor delves into his desk drawer, producing a blue booklet. He scribbles a phone number on a notepad.

“Don’t worry, Ah Girl. You are not the only one who has gone through this. Your mummy will let you talk to some of my patients who have already underwent the operation. You will see. It will be okay.” He smiles at the mother and daughter.

As they walk out of the room, Professor Kwan turns and hands me a paper he has written on a young patient, a martial artist just like Ah Girl who underwent spinal fusion surgery for scoliosis and later went on to win a silver medal at the world championship little more than a year after her operation. I read in amazement.

The safety and side effects of scoliosis surgery are of much interest to patients and parents alike. In response, the doctors at the Spine Research Unit (SRU) at University of Malaya (UM) in Kuala Lumpur have striven to quell this anxiety by proving that with improvements in surgical techniques, anaesthesia and operative monitoring, the rate of risks and complications have fallen below 1%. 

The last few years have seen advancements in pedicle screws– a surgical tool that is inserted into the individual segments of the spine to correct their position and fix the spine in the correct position. Patients sometimes worry that inserting a device into the spine, close to the spinal cord and major nerve structures, is dangerous. While no form of medical treatment is without its risks, the doctors at SRU published a report in 2017 that showed that out of more than 2000 such screws inserted during operations they performed, only 0.1% (two screws) came close enough to the nerves to cause minor irritations that resulted in some discomfort. These minor complications recovered at the end, and the patients were definitely not paralyzed.

When scoliosis is severe, corrective surgery can take up to three to four hours. Noticing that parents of patients tend to worry greatly while their child is in the operating room for hours, Professor Kwan Mun Keong, together with Professor Chris Chan and their team in UM have devised a unique system where the surgical team sends text messages to the parents via mobile phone at different stages during surgery— to assure them that their child’s operation is carrying on smoothly. This helps reduce their anxiety. Of course, the text messages are sent by one of the supporting staff and not by the blood smeared surgeons! (They will be concentrating on the operation).

The SRU team have also been researching methods to shorten the time needed for such operations and to reduce bleeding during surgery. As a result of their work, the European Spine Journal now recommends that not one, but two senior surgeons perform scoliosis correction operations— a practice that has been shown to reduce operating time from four hours plus to about two and a half hours; and reduce blood loss by about 30%. 

Parents will be glad to know that after the scoliosis operation, their child will usually be able to sit up and walk the day after surgery. In most cases, they are allowed to go home on the third day after surgery. Gone are the days when patients need to stay in the hospital for weeks and weeks.

However, the decision to undergo scoliosis correction surgery, like any major operations, is one that must be made by the patient and his or her parents only after fully understanding the procedure and risks involved. While the risk of having a major complication is extremely low (0.1%), this does depend on the patient’s overall health and how bad his or her scoliosis is. Medical treatments should never be taken lightly, and discussion with an experienced orthopaedic spine surgeon is absolutely necessary before deciding if surgery is the right way to go. 

How do you know you have got the right surgeon? While it is always a good idea to do some research online (don’t you think nearly everybody does this for nearly everything nowadays?), one good way is to ask your surgeon to let you speak to some of his previous patients– this helps you understand what they have been through, and for better or for worse, how having corrective surgery has changed their lives. 

The stifling air drowns out murmuring voices in the background. All eyes are on the two taekwondo fighters as the referee lifts his hand in the air and lowers it swiftly between the opponents. Silence erupts into cheers as they bounce lightly on the soft floor.

As her adversary throws a punch, the smaller of the two fighters sees her opportunity and seizes it. She stands up straight and tall… then spins, lashing out with her left foot– flooring the bigger girl with a cry. 

In the moment of silence before the crowd explodes in applause, she lifts her eyes across the room to the smiling face of an older woman in a flowery blouse. Then comes the thundering roar of the spectators… 

Yet, piercing through the shouts and applause, comes the familiar voice of the flowery lady, “Ah Girl! Ah Girl!”

The future of scoliosis in Malaysia has changed. Don’t take my word for it.

Ask Ah Girl.

This article was originally written on 18 June 2018 for the Bulletin of the Malaysian Integrated Community Health Medical Association (MICHMA) to reflect on my previous attachment to the Spine Research Unit of University Malaya Medical Centre, an eminent centre of scoliosis treatment in Malaysia.

Notes: Names and some details have been changed to protect patient privacy. The model in the picture does not actually have scoliosis