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Scoliosis may be classified as functional or structural. Functional scoliosis is defined as a structurally normal spine that appears curved due to one or more underlying conditions (e.g., difference in leg length, inflammatory condition). Structural scoliosis involves a fixed lateral curve with rotation, and is associated with many conditions including neuropathic diseases such as cerebral palsy, poliomyelitis, and muscular dystrophy; congenital causes such as failure of formation or segmentation, and myelomeningocele; traumatic causes such as fracture or dislocation (non-paralytic) and post-radiation; soft tissue contractures such as post-empyema and burns; osteochondrodystrophies such as achondroplasia and spondyloepiphyseal dysplasia; tumor; and rheumatoid disease. However, the most common type of structural scoliosis is idiopathic scoliosis. Although idiopathic scoliosis is thought to have a genetic predisposition, its exact cause is still unknown.

Idiopathic scoliosis is divided into three categories: infantile (ages 0-3), juvenile (ages 3-10), and adolescent (ages > 10 but before maturity). Idiopathic scoliosis is defined as a 10 degree or greater lateral structural curvature of the spine that presents during the late juvenile or adolescent period in otherwise normal children.

Treatment of Scoliosis

Scoliosis treatment varies individually and is based on the patient’s age, growth schedule, degree and pattern of curve and type of scoliosis. The following treatment guidelines may be considered:

• Observation: The patient is followed by the physician without treatment and a re-examination is done every 4 to 6 months while the patient is still growing skeletally. The curve is usually less than 25 degrees.
• Bracing: Bracing is recommended when the patient;
  1. is still growing and has an idiopathic curve that is more than 25-30 degrees
  2. has at least two years of growth remaining, has an idiopathic curve that is between 20 and 29 degree, and, if a female, has not had her first menstrual period; or
  3. is still growing and has an idiopathic curve between 20 and 29 degrees that is getting progressively worse.
• Surgery: Spinal fusion surgery is recommended for growing children and adolescents with progressive curvatures of more than 45 degrees, despite bracing. This technique is relatively successful at obtaining substantial curve correction and stabilization from a spinal fusion whereby the vertebrae are welded together for long term stability.

Depending of the severity of the curvature, most patients with idiopathic scoliosis can be treated conservatively. For relatively few patients for whom surgery is indicated to stabilize the spine and/or reduce the lateral curvature, a diskectomy and fusion is the established technique. Recently, new, less invasive techniques have been proposed to eliminate the fusion of the vertebral segments and allow for greater spinal mobility.

Endoscopic Surgery

Endoscopic surgery for the treatment of scoliosis is a new evolving surgical technique which uses scopes to perform minimally invasive surgery on the spine. The potential benefits of this type of surgery includes less post-operative pain, improved rehabilitation, recovery and cosmetic results; however, there are no randomized, controlled clinical trials comparing the technique to standard surgical procedures. Patient selection criteria and the long term impact on outcomes remain unknown. The Horizon® Eclipse® Spinal System (Medtronic, Inc., Beverly, MA) is an endoscopic instrumentation system specifically developed for minimally-invasive, endoscopic surgery. Although promising, the role of endoscopic surgery for scoliosis requires further study.

Vertebral Stapling

The vertebral stapling technique is designed for patients who have not reached skeletal maturity, and involves endoscopic placement of titanium alloy staples along the spinal curvature in an attempt to retard progression of the scoliosis as the patient matures. Early published results show that the technique is feasible and relatively safe; however, the data is insufficient to permit conclusions as to whether the technique improves health outcomes.

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Braun JT, Hoffman M, Akyuz E, et al. Mechanical modulation of vertebral growth in the fusionless treatment of progressive scoliosis in an experimental model. Spine. 2006; 31(12): 1314-1320.

Charles YP, Daures JP, de Rosa V, Dimaglio A. Progression risk of idiopathic juvenile scoliosis during pubertal growth. Spine. 2006; 31(17): 1933-1942.

Gillingham B, Fan R, Akbarnia B. Early onset idiopathic scoliosis. J Am Acad Orthop Surg. 2006; 14(2):101-112.

Little DG, Song KM, Katz D, Herring JA. Relationship of peak height velocity to other maturity indicators in idiopathic scoliosis in girls. J Bone Joint Surg Am. 2000; 82(5): 685-693.

Medtronic Sofamor Danek. CD Horizon® Eclipse® Spinal System. Accessed January 10, 2007. Available at: http://www.sofamordanek.com/patient-minimal-eclipse.html

National Institutes of Health. National Institute of Arthritis and Musculoskeletal and Skin Disease. Questions and answers about scoliosis in children and adolescents. Accessed January 10, 2007. Available at: http://www.niams.nih.gov/hi/topics/scoliosis/scochild.htm

Song KM, Little DG. Peak height velocity as a maturity indicator for males with idiopathic scoliosis. J Pediatr Orthop. 2000; 20(3): 286-288.

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