How’s your back? Spine, thank you!

If there’s a so-called Big C, there’s also such a thing as the dreadful "S" word
among back sufferers. Spine problems, that is. A very sensitive area, the spine protects the spinal cord, which is connected to the nerves leading to the brain. And any injury to the spine, which affects the spinal cord, could paralyze at the very least, or worse, lead to death.

Dr. Rafael Cruz Bundoc, one of the country’s leading (and very idealistic) orthopedic and spine surgeons, has taken it upon himself to look for new ways of meeting this growing menace among Filipinos head-on. And mind you, spine problems aren’t exclusive to athletes or the upper-class people alone; the ailment, in its many forms, cuts across the social spectrum. For instance, his average number of charity patients in a year numbers to 45 spine patients complaining of such ailments as slipped disc in the lumbar and cervical areas. He performs spine operations at least once a week on the average.

But perhaps, one of the more common complaints he has received is scoliosis, or the unnatural curvature of the spine, which can occur in the lower, middle or upper part of the spine. While there hasn’t been enough clues to determine the exact cause of scoliosis, doctors often point the finger to tuberculosis of the spine, where viruses attack and eat away at the spine, much like the usual tuberculosis where viruses zero in on the lungs. It’s interesting to note that Filipinos often refer to this ailment as a "rich man’s disease," owing to its being identified with showbiz personalities suffering from scoliosis.

"It’s a misnomer actually. In the charity ward, tell a patient that he has scoliosis and you’ll see this smile on his face as he realizes that, hey, he now belongs to the elite group of scoliotic patients the likes of Zsazsa Padilla and Lorna Tolentino," says Dr. Bundoc, a 1997 TOYM awardee, in jest.

Certainly, scoliosis is nothing to be happy about. If the curvature of the spine is quite severe and is affecting the quality of life of the patient — meaning it’s preventing the patient from living normally — measures have to be taken to ensure the well-being of the patient. The causes of scoliosis could be idiopathic (read: mysterious), traumatic (a blow or injury to the spine), postural (beware the sloucher), or even psychological. Patients, says Dr. Bundoc, would often complain of back deformity, shoulder and/or pelvic tilt or imbalance. Some others have complained of asymmetry of the breast, particularly among female patients. Since scoliosis is not usually painful, this disorder is more often than not discovered late in the game. Dr. Bundoc says he’s had cases where scoliosis was discovered when a dad hugged his son and noticed the boy’s back wasn’t proportional, or when a teenager wore a bikini and realizedthat one shoulder was higher than the other. According to Dr. Bundoc, the ratio of scoliotic patients is one male for every six females. According to studies, one out of 1,000 to 5,000 people will have scoliosis of different degrees, or angles of curvature.

"Until now, after so many centuries of development in western medicine, the exact cause of scoliosis is still not known. The ballgame here is prevention, that’s the only treatment so far," says Dr. Bundoc, who is currently based at the UP-PGH Spine Center.

The traditional way of screening potential scoliotic patients and measuring the curve of the spine is called the Adam’s test. Here, a patient is asked to put his hands together as in prayer and then bend forward. The doctor will then look at the shoulder of the patient and try to see if there’s a visible curvature or deformity. In other words, if a shoulder bone, or some other bones at the back for that matter, protrudes unnaturally or if there’s a hump on the back, then the person is a candidate for scoliosis. Succeeding thoraco-lumbar X-rays are then conducted to measure the degree of curvature. Dr. Bundoc says that a 1 to 20-degree angle is considered mild; 21 to 40-degree is moderate; and 40 and above is severe.

"The younger the patient, the more careful we are in observing the progression of the disorder since the measurements could radically change for the worst. For instance, if you find an 18 to 20-year-old patient with a 1 to 20-degree, you’re almost sure it won’t progress anymore since the skeletal composition of an 18-year-old is already mature and has stopped growing. But if it’s a growing 14-year-old with a 1 to 20-degree angle, we have them put a brace and placed under close observation. If the angle is 31-40 degrees, we watch them really closely and even suggest surgery. A 40-degree angle by international research standards is accepted as the halfway mark for conservatism and going towards surgery for patients below 18 years old."

Surgical methods for treating scoliosis have been in existence for the last four decades or so. From Dr. Fritz Lange’s "two-tin plated steel bars sutures" to Dr. Paul Harrington’s "pedicle and laminar hooks and rod" to Raymond Roy-Camille’s screw insertions "into the pedicles of the lumbar spine" and Yves Cotrel and Jean Dubuosset’s system of "especially-designed hooks that could be anchored to different posterior structures of the spine," the quest for the perfect scoliosis treatment has improved by screws and hooks. (Don’t let the highly technical terms scare you. In plain English, the curved spine is straightened by means of metal rods, hooks and screws to restore it to its original length.)

After the development of the segmental pedicle screw fixation by Dr. Se-Il Suk of South Korea, Dr. Bundoc and the UP-PGH spine team headed by Dr. Adrian Catbagan (with the support of UP-PGH Department of Orthopedics current chairman Dr. Cirilo Tacata), initiated the method of applying screws in different positions.

See, modern methods entail the use of rods attached to the spine which are held in place by screws 4.5 mm in diameter, which are attached to pedicles (something like little spaces or holes in the vertebra where the screws will be embedded). In Dr. Bundoc and company’s case, they are offering a more stable (because of "its architectural stability afforded by the segmental rib cage attached to it," says Dr. Bundoc) segment of the spine — the thoracic spine — where they could attach the screws. And since this method uses a so-called pediculo-costal corridor, which in essence prevents other bones from being damaged since the Filipino spine is definitely smaller in diameter at 4mm, then this latest method is what’s needed in this country to treat scoliotic patients.

Dr. Bundoc and company’s pioneering work as far as scoliosis treatment in the Philippines is concerned is welcome news. Spine surgery is one of the most delicate – not to mention expensive – procedures in the field of medicine. Dr. Bundoc credits the people behind UP-PGH’s Spine and Orthopedic Learning Center, including Dr. Antonio Montalban, Dr. Ellewellyn Pasion and Dr. Napoleon Apolinario, who took an active part in supporting the research on the revolutionary method. In the coming months, Dr. Bundoc is presenting his paper on the segmental pedicle screw fixation. Despite the lack of resources, these doctors aren’t giving up (and are not migrating abroad to become nurses either) the fight to find the best way to treat scoliosis – and other spine problems for that matter.