Scoliosis Surgery – Risks of Refusing Fusion Surgery for Adolescent Idiopathic Scoliosis Overstated

Severe scoliosis can present problems with cardiopulmonary function. The definition of severe scoliosis varies depending on sources. Most authors consider 60 degrees the benchmark for a scoliosis to be called severe. As far as crushing internal organs most of the current literature states that it is very rare less than 1% and only in cases over 100 degrees. There are two main factors that go into deciding whether or not to have your child undergo a major spinal fusion surgery. The first is the cosmetic appearance which most orthopedic surgeons say is the number one concern of the patients and parents prior to learning of the potential cardiopulmonary effect. The second is the fear of health problems not only in the immediate future but also down the road.

This fear is most likely based on the discussion with their orthopedic doctor regarding scoliosis and its harmful affect on the cardiopulmonary system. Most often from my experience in consultations with parents of kids that have progressing scoliosis is that their understanding of “risk” is that if they don’t have surgery they are placing their child at a significant risk of health problems and potentially death. I think it is extremely important to discuss this particular mindset before entering into something that will alter your child’s life forever.

There are several parameters that are often not discussed with parents that would indicate a higher risk versus almost no risk. The studies conclusively show that increased risk of pulmonary function loss stems from thoracic structural scoliosis with a cobb measurement greater than 60 degrees in the frontal plane and a significant loss normal kyphosis in the sagital plane of 50% or more. According to Lenke classification this would be a subcategory of about 18% of AIS patients that reach surgical threshold of 50 degrees.

Curves with apexes below T9 generally do not have any restrictive pulmonary issues because there is no rib cage deformity and much less spinal rigidity. Thoracic curves with apexes higher than T7 are also excluded. Thoracic primary structural scoliosis with normal to slightly reduced kyphosis are also questionable. So it would be highly unlikely that we could say that “all” kids with big curves will have any form of damaging pulmonary function loss.

Therefore any child not showing measurable decline in pulmonary function should not be subjected to scoliosis surgery using medical necessity rationale and should be thoroughly aware that the procedure is for cosmetic appearance only since the procedure is not correcting an existing loss of function but rather a medical assumption that they are correcting a potential problem. So I should have my kidney removed because it looks abnormal on ultrasound and MRI but all my kidney function tests are normal hmmm.

The other question that is currently being debated is whether or not scoliosis surgery actually improves pulmonary function in adolescent idiopathic scoliosis. They have agreed conclusively that short term effects significantly decreases pulmonary function but the long term studies are most definitely inconclusive.

Conclusions. Pulmonary function following thoracotomy with ASF with instrumentation demonstrated a significant decline of 3-month postoperative PFT values, but returned to preoperative baseline absolute values by the 2-year follow-up visit. The percent predicted values returned to within 95% of baseline 2 years postoperatively. Scoliosis surgeons should be aware of these findings when deciding upon the approach. Spine 2000;25:2319-2325

Notice the pulmonary function returned to preoperative levels after two years but the scoliosis surgery did not improve pulmonary function.

Conclusions – Forced vital capacity is reduced at long term follow up in adult patients with idiopathic scoliosis who undergo anterior spinal surgery. The fall in FVC is small and is unlikely to be of clinical significance in patients with reasonable lung function in whom surgery is planned for prevention of curve progression or improvement of cosmetic appearance and pain. However, surgical intervention should not be undertaken in an attempt to improve pulmonary function. (Thorax 1996;51:534-536)

If the only medical reason to perform scoliosis fusion surgery is for pulmonary function then the patient should have measurable dysfunction at the time of surgery and increased pulmonary function post surgery for the surgery to be considered necessary from a medical procedural standpoint, NO?

This isn’t a matter of trusting a doctor’s opinion but rather a message to all patients and parents to learn all the facts, study the research, and get informed before agreeing to highly invasive procedures that alter the body structurally and can never be undone.

Dr. Brian T. Dovorany