Tuesday, June 19, 2007


First published in The Jakarta Post, June 20, 2007


Alpha Amirrachman, Contributor, Jakarta

Until she reached 30 years of age, Dewi* was not aware that she had scoliosis, or a stunted spine. At a glance she looked physically normal.

However, when she bends down, upon careful observation her spine appears asymmetrical.

Dewi was shy about speaking of her condition.

"I once watched a person with scoliosis like me trying on a dress in a dress shop, and the shop attendant looked at her with weird-looking eyes," she said of what she described as humiliation.

She did not speak to anyone until she began to worry that this condition might eventually affect her physical appearance. When Dewi browsed the Internet, she found out that scoliosis is actually preventable at an earlier stage.

Another case concerns 12-year-old Nadia, who was diagnosed with scoliosis that had a 50-degree curvature.

Still another child with scoliosis said that it was extremely painful every time she sat down, which disrupted her school life.

Early intervention significantly helps people developing scoliosis, but shyness, low awareness and ignorance often allow for curve progression. The scoliosis thus worsens to the point that it can disturb normal life, which can range from breathing difficulties to premature death.

This is not to mention the social consequences resulting from their condition.

In the United States, a standard exam called Adam's Forward Bend Test is conducted by pediatricians and at initial school screenings. Parent volunteers or school nurses can run the test effortlessly by simply asking students to place their feet together and bend 90 degrees at the waist.

From this position, any abnormal spinal curvatures or asymmetry of the trunk can be easily observed and identified.

The test also exists in Indonesia, but implementation is another matter.

"Every community health center, or puskesmas, in our country has complete technical guidance for this school screening. However, people are still overwhelmed with other disturbing cases that seem to be pervasive, such as infant mortality and others, so almost no attention has been given to administering this simple test," said orthopedic spine surgeon Dr. Luthfi Gatam of Fatmawati General Hospital.

One research conducted by a postgraduate program at Yogyakarta's Gadjah Mada University shows that a physical educator can play a supervisory role in the early prevention of scoliosis.

Technically, scoliosis is more a descriptive term than a disease.

Curves are found in all spines of the human body; some curvature in the neck and upper and lower trunk is normal for assisting the upper body to maintain balance and its configuration over the pelvis.

Nevertheless, when the spinal column consists of abnormal lateral curves and affects the balance and alignment over the pelvis, this condition is referred to as scoliosis.

In the general population, scoliosis affects more women than men.

"The ratio is nine to one for (cases in) women to men. And it remains a mystery why it affects mostly women," said Luthfi.

Causes of general scoliosis include congenital spine deformities, genetic conditions, neuromuscular problems, limb length inequality, cerebral palsy, spina bifida (a birth defect affecting the neural tube), muscular dystrophy, spinal muscular atrophy and tumors.

But roughly 80 percent of scoliosis have no known cause, or idiopathic.

Idiopathic scoliosis is often found in healthy people "regardless of people's social strata, and many are found in people with 'yellow' skin like us rather than 'black'", said Luthfi.

Idiopathic scoliosis is categorized by age: infantile (children aged 3 and under), juvenile (3-9 years old), adolescent (10-18), and adult (post-skeletal development over 19).

"However, at post-skeletal development, usually there won't be any curve progression, except for in those who already have a 50-degree curvature," said Luthfi.

Around the world, adolescent idiopathic scoliosis (AIS), which develops in young adults generally at the onset of puberty, represents approximately 80 percent of idiopathic scoliosis cases.

No comprehensive statistics are available in Indonesia, but research by noted orthopedic surgeon Prof. Subroto Sapardan reveals that from 1977 to 2006, 2,010 scoliosis cases were treated at Fatmawati General Hospital.

"Most of the patients were female adolescents, and 600 of them were so bad that they had to undergo surgery," said Luthfi.

He explained that surgery is not always necessary to correct scoliosis, depending on the condition of the patients.

"If a Cobb angle is below 20 degrees, we only observe them. From 20 to 40 degrees we give them a brace, but if it is more than 40 degrees, open surgery will be highly considered," he said.

The Cobb angle is the measurement of the degree of curvature in the spine.

However, the causes of idiopathic scoliosis remain unknown.

"Different theories concerning its etiology have been proposed and studied extensively. Genetic factors, hormonal factors, growth abnormalities, biomechanical and neuromuscular disorders of bone, muscle and fibrous tissue, have all been proposed as possible causes of scoliosis," Luthfi said.

Those with a family history of spinal deformity are also at greater risk for developing scoliosis.

For example, one patient whose spine requires a brace said her mother also had scoliosis, although with a spinal curvature of 1 to 10 degrees, this was not really disturbing. Meanwhile, her younger sister's spine was likewise obviously lop-sided, she said.

But spine surgery to correct scoliosis can be scary for patients of any age, especially when faced with a five- to seven-day recovery period, post-operative pain and the anxiety caused by knowing that they will be left with a long scar.

In the U.S., Dr. George Picetti, a highly specialized adult and pediatric spine surgeon at the Sutter Medical Center's neuroscience medical group and institute in Sacramento, California, has developed a minimally invasive approach to scoliosis treatment.

The technique he developed is known as thoracoscopic instrumentation, which utilizes video technology to correct certain types of spinal curves: extremely tiny incisions are made through which the surgeon corrects the scoliosis by using an endoscope. This has minimized incision scarring and decreased the amount of dent to tissue and blood loss during surgery.

"But it is a time-consuming operation and is very expensive. Normally, (the operation) takes around eight hours," said Luthfi of the minimally invasive spine surgery.

He himself had conducted the procedure only twice throughout his career, both at the Bintaro International Hospital in Tangerang, Greater Jakarta.

However, according to Luthfi, Fatmawati General Hospital, which is known as an "orthopedic hospital", has all the necessary equipment for open surgery, from the simplest to the most complicated surgical procedures.

Orthopedic surgeon Subroto invented in 1998 the "UI System" for segmental instrumentation in scoliosis surgery, so named after the University of Indonesia (UI). In this system, a rod and a reconstruction plate are inserted to either side of the spine and screwed together.

The UI System, which was patented on Sept. 2, 2004 (Patent Reg. No. 0.011.170), provides three-dimensional correction, stable instrumentation with no external support and can result in a balanced spine.

Perhaps more importantly for a developing country like Indonesia where poverty is prevalent, the procedure is relatively inexpensive.

According to Subroto, the UI System has helped people with scoliosis across the country effectively and affordably.

"It only costs Rp 4 million. Two hundred and eighty patients with severe scoliosis have used this (system) at our hospitals ... and hundreds more at other hospitals, as this system has been launched internationally," Luthfi added.

He said more and more hospitals in Indonesia are now offering spine surgery for people with scoliosis.

Another aspect that should not be overlooked in treating scoliosis is the emotional impact of the condition on patients.

"We have to convince the patients that they can finally lead a normal life," Luthfi stressed.

Psychologists should thus be retained to counsel patients through their post-surgery mental and emotional conditions to help restore their self-confidence. This can be carried out simultaneously with yoga or swimming as rehabilitative treatments.

Luthfi pointed out that public education to increase awareness of scoliosis was also important, because some people with the condition would not recover completely -- and societies needed to learn to accept and embrace them wholeheartedly.

* All patient names in this article are aliases.


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