Dirty Harry, Scoliosis And You
by Dr. Mark R. Payne D.C.
A man has got to know his limitations." Clint Eastwood growls the famous line right after administering a lethal case of justice to some villain foolish enough to take on Inspector "Dirty" Harry Callahan. Just goes to show there are some things in life you shouldn’t ever try. Sometimes we have to learn that the hard way in practice and a good example is managing scoliotic patients. I speak with lots of doctors from a wide range of educational backgrounds and practice styles. Some don’t think scoliosis can be managed at all in the chiropractic office. Others are so overly optimistic of their abilities that they recommend extensive corrective care programs for every case only to find out down the road that there’s been little or no change. As is often the case, the truth appears to be somewhere in the middle. Let’s take a brief look at two cases which illustrate some of the factors which might affect your prognosis for a successful outcome.
Case # 1: An 8-year-old boy presented with mild neck and shoulder soreness following a motor vehicle accident. Both parents were under care for their injuries and I did a cursory examination of the child upon discovering he was involved in the accident as well. The child’s neck injuries were quite mild, but Adam’s test was positive and his posture was suggestive of scoliosis. I suggested we take films to see what was happening.
X-ray revealed a 12 degree Cobb angle with the apex at L-3. (See Fig.1) I noted what appeared to be a possible leg length deficiency which appeared to be contributing to the curvature and opted to take an A-P femur head view to more accurately measure the amount of leg length inequality. The right leg ultimately measured 5 mm shorter than the left and a 5 mm heel lift was provided. Over the next few weeks, the child was adjusted a few times and rehabbed with simple posture reversal exercises to address the worst aspects of his postural imbalance. On each visit, the parents were tutored on how to properly observe and monitor the child’s exercise at home.
Approximately 6 weeks later, a post care film was taken to see how things were progressing. The results were gratifying with the Cobb angle now reduced to zero degrees. (See Fig. 2) Parents were instructed to make sure the child continued to use the heel lift and exercise three times weekly. Twice annual follow ups were recommended until the child reached skeletal maturity.
Factors which contributed to such a successful outcome were:
• A fairly mild curvature ( Cobb angle less than 20 degrees)
• An easily remedied cause (leg length inequality)
• No vertebral wedging/deformity
• Parents who were disciplined about following home care recommendations.
• Early treatment…well before skeletal maturity.
Case # 2: 57-year-old female presents with chronic LBP and a prior diagnosis of scoliosis. X Rays revealed a 48° Cobb angle with apex at L-1. (See Fig. 3) Closer inspection revealed severe wedging of vertebrae at multiple levels plus pronounced disc degeneration. Patient was adjusted in our office on a symptomatic basis for 2-3 weeks and given home exercises to help strengthen the area and minimize asymmetrical loading of the spine. Symptomatic management was successful and she now returns as needed for relief of any exacerbations. Corrective care was not recommended, as it seemed highly unlikely to produce significant structural correction.
Factors here which would likely complicate a successful corrective outcome are:
• Large Cobb angle
• Patient well past the age of skeletal maturity
• Significant vertebral remodeling (wedging)
• Advanced disc degeneration
Incredibly, this patient had visited another chiropractor earlier who had recommended a year long program of adjustments to correct her problem. Fortunately, the patient had declined to accept the treatment plan which would have been highly unlikely to correct this advanced curvature.
Please don’t misconstrue this to mean I am opposed to corrective care programs. To the contrary; what I am opposed to is any doctor making promises he/she can’t reasonably hope to keep. If you recommend a corrective care program, you must have reasonable professional expectation of a successful outcome. The moral here is to be realistic as to what you can actually deliver before recommending programs of extensive corrective care. Scoliosis cases present with a unique set of variables which can either work in your favor or complicate things greatly. Like it or not, once the growth plates have closed, any vertebral wedging or deformity constitutes permanent change in the spinal architecture. All the adjustments in the world won’t change structural asymmetry which has literally become "set in stone." Yes, you can work wonders with some cases but, ultimately, Dirty Harry was right. We’ve all got to know our limitations.