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Specialist Scoliosis Outpatient Clinic (patients seen every week on Thursday between 8:30 and 11:00, Physician in charge: Hideki Sudo)

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Greeting

The Department of Orthopedics at the Hokkaido University Hospital has a long history of more than 50 years of treating patients with scoliosis and currently treats the largest number of patients in Hokkaido. This department has created a system with the highest level of treatment in the world, starting from diagnosis and extending to orthotic and surgical therapy.

 

Idiopathic scoliosis

There are several types of scoliosis, and most cases occur in girls aged 10 years or older who are entering puberty. If the scoliosis curvature is less than 30°, the patient is periodically followed-up; however, with scoliosis of 30°–45°, we investigate whether targeted orthotic therapy is required in girls from around the time they start menstruation using various factors, such as the patient’s age, overall balance, increase in height, and degree of skeletal maturity based on X-rays. Furthermore, those with scoliosis of 45°–50° commonly undergo surgical treatment. Osteopathic clinics, which commonly provide advice, and non-customized health equipment are completely ineffective and cannot be expected to provide correction.

Orthotic therapy

There are 3 main types of orthotics (Figure 1) that are selected according to the position of the curve and the characteristics of the case and are created subject to complete customization. These are made by several prosthetists who are skilled in orthotic therapy for scoliosis, and after being made, they are periodically repaired and adjusted.

(図1)左からLow profile Milwaukee brace,under arm brace, Boston brace

(Figure 1) From left: Low-profile Milwaukee brace, under arm brace, and Boston brace

Surgical treatment

Surgery for spinal deformities is one of the most difficult operations to perform in the field of orthopedics. The Department of Orthopedics at Hokkaido University is well known throughout the world for this type of surgery, and at present, surgery is conducted every week on Tuesday. In addition, superior clinical outcomes have been published in several highly rated international English journals (Kaneda et al. Spine, 1996, 1997. Ito et al. J Neurosurg Spine, 2010. Sudo et al. J Bone Joint Surg Am, 2013. Spine, 2013, 2014). Here we will explain the surgical techniques that we usually perform.

The apex of the curve is located over the thoracic vertebrae or extends from the thoracic to the lumbar spine: posterior correction

This type of surgery is indicated when the apex of the curve is located over the thoracic vertebrae or when there is an S-shaped curve that also involves the lumbar spine. Posterior correction is the most commonly performed surgical technique. The deformity is corrected using a cable made of metal or ultra-high-molecular-weight polyethylene, made up of vertebral pedicle screws and transverse process hooks that extend from the middle of the back to the spine (Figure 2). Patients can be discharged home within 2 weeks. In our department, we not only correct scoliosis but have also developed a treatment technique called the simultaneous double-rod rotation technique, which is an independent technique that makes it possible to correct the deformity three dimensionally, resulting in interest from a number of international and domestic visitors.

 (Figure 2) Posterior correction and fusion

(Figure 2) Posterior correction and fusion

The apex of the curve is located over the lumbar vertebrae: anterior correction

Anterior correction is indicated when the apex of the curve is located over the lumbar spine. However, depending on the pattern of the lumbar spine curvature, posterior correction may be performed in some cases. When performing anterior correction, the lateral aspect of the spine is reached via the ribs, and vertebral screws are inserted after the intervertebral discs are resected (Figure 3). Compared with posterior correction, fusion is possible over a comparatively shorter range. Patients can be discharged home within 2 weeks after this surgery as well. Irrespective of whether posterior or anterior correction is applied, blood collected from the patient at the Hokkaido University Hospital Transfusion Department 1 month prior to surgery is transfused back to the patient (autologous blood transfusion), and blood that is lost during surgery is returned and reused (intraoperative salvage transfusion). Therefore, there is almost no requirement for transfusion from other patients. The technique we use to perform anterior correction at our hospital is known throughout the world, and the superior long-term clinical outcomes have also been reported in leading international orthopedic surgery journals.

 (Figure 3) Anterior correction and fusion

(Figure 3) Anterior correction and fusion

 

Other types of scoliosis

Other types of scoliosis include early-onset scoliosis (Figure 4), neuromuscular scoliosis (Figure 5), and congenital scoliosis. If progression of the curvature is evident in any of these disorders, treatment with orthotics or surgery becomes necessary.

(Figure 4)

Because onset occurred before the age of 10 years, fusion was not performed immediately. Instead, extension of the region indicated by the arrow was achieved surgically with approximately 2 procedures per year, and once growth was completed, fusion was finally performed.

(Figure 4)

(Figure 5)

Scoliosis associated with congenital myopathy
Surgery was performed in this patient because of difficulty in balancing when sitting and difficulty in walking.

(Figure 5)
 

Clinical Research

Although the cause of idiopathic scoliosis, which commonly occurs in pubescent females, has not been identified, institutes under the leadership of the Institute of Physical and Chemical Research and Keio University and including Hokkaido University, Dokkyo University School of Medicine, Seirei Sakura Citizen Hospital, Meijo Hospital, Kobe Medical Center, and Fukuoka Hospital, which are the leading domestic institutions that specialize in the treatment of spinal deformities, have been performing international multicenter joint research.This research has led to the identification of the first genes related to idiopathic scoliosis in the world (Nature Genetics. 2011, 2013). At present, studies are underway to identify genes related to the prediction of the prognosis of scoliosis, and Hokkaido University continues to participate in this collaborative research.