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Near the end of Sarah's fifth-grade year, her mother noticed that her back looked uneven. "I had just made her a top and it looked crooked," Jane Bonham said. "At first I thought it was my sewing. But I had helped the school nurse screen older students for scoliosis earlier that year and was familiar with the signs. I told Sarah, 'Let's have the school nurse look at your back.'"
At the nurse's recommendation, Bonham took her 11-year old daughter to her pediatrician, who referred her to Gary Brock, MD, chief of pediatric orthopedics at Children's Memorial Hermann Hospital. Brock measured a curve of 23 degrees in Sarah's back and asked to see her again in three months. It was May 2002, and the waiting game had begun.
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For unknown reasons, about 10 percent of adolescents develop some curvature in the thoracic or lumbar vertebrae, with deviations from the normal frontal axis of the body in all three planes. Curves that spontaneously halt their progression at 10 degrees or less are considered normal. When they progress with no underlying cause, they're diagnosed as adolescent idiopathic scoliosis (AIS).
AIS typically appears during puberty, usually between the ages of 10 and 15 when growth rate is fastest and children are at their highest risk for curve progression. With a 0.3 percent to 15.3 percent statistical occurrence rate in the general population, AIS is the most common form of spinal deformity seen by doctors.
Telltale signs of scoliosis include uneven shoulders, an elevated hip, a protruding shoulder blade or a hump in the back when a child bends forward. But often scoliosis exhibits no visible signs, making diagnosis difficult without X-rays.
While AIS is seen with equal frequency in boys and girls at low curve magnitudes, girls are at significantly higher risk for curve progression. "We see seven to 10 girls who require treatment for every one boy," Brock said. "While most cases have little or no medical or cosmetic significance, about 2 percent to 3 percent progress enough to require brace wear to stop the progression or surgery to correct it."
By September, Sarah's curve had progressed to 25 degrees and she was fitted for a brace, the recommended treatment for thoracic curves greater than 25 degrees and less than 45 degrees and lumbar curves greater than 25 degrees and less than 40 degrees. By November, when she began wearing the brace, her curve was at 37 degrees.
Like most patients who qualify for bracing, Sarah was fitted with a thoraco-lumbar-sacral orthosis (TLSO), constructed of advanced plastics and custom molded to exactly match her curve pattern. The brace extended from below the breast to the beginning of the pelvic area in front and just below the shoulder blades to the middle of the buttocks in the back.
It applied three-point pressure to the curve to prevent its progression, holding the lumbar area in a flexed position by pushing the abdomen in and flattening the posterior lumbar contour. The low-profile TLSO can be worn under clothing, and it can be removed easily to allow children with scoliosis to engage in sports.
"We recommend brace wear from 20 to 23 hours a day, with some modification made for various types of athletics," Brock said. "It's important for children to continue to be children, and participating in sports and dance helps in their physical, social and emotional development."
An avid athlete, Sarah wore the brace for the next two years while continuing her participation in competitive swimming and volleyball. "By June 2004, her curve had progressed to 50 degrees, so we scheduled surgery," Brock said.
Using an anterior approach, the surgeon fused Sarah's spine from the ninth thoracic to the third lumbar vertebra and removed parts of the seventh and ninth ribs on the right side to allow for greater exposure to the spine and increased flex for the correction.
Today, Sarah has a single five-inch scar on her right side – and the libero position on the Pasadena Memorial High School freshman volleyball A team.
"I've always played sports," the 15-year-old athlete said, "and while it was hard wearing the brace, it never really slowed me down. When my curve kept progressing, I knew I was going to need the surgery so I started preparing myself. It helped a lot that my family and friends were looking out for me.
"Nowadays, I still play hard but I also look out for myself more than I used to. I can do everything except jump on a trampoline, and I can live with that."
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