9UNP0147SD_Jim McCarthy_WordPress

- Thank you very much. Can everyone hear me okay? I really want to thank Ellen and everyone for inviting me here. This is really an honor. It's also an incredibly exciting time to be here and be part of the new Children's Hospital. It is one thing that I really look forward to, the ability to interact with the colleagues here, and be part of the incredibly high quality of care that I've seen delivered even in my short period of time here. 

This morning I'm going to talk a little bit about scoliosis, and really focus on the evaluation and treatment. There will be certainly plenty of time for questions. And I wrote a couple of learning objectives here. 

One is to be able to identify children's scoliosis from clinical exam. And I think probably most people can do that already, but I'll show a few examples and we'll go through that. Two, to understand the natural history of idiopathic scoliosis, so you know which ones you really need to worry about, and which ones you probably don't need to worry about. And then three, to know the clinical findings that suggest a diagnose other than scoliosis. I think one of the things, hopefully, you'll take away is the idea that scoliosis really is quite different. So not all scoliosis is the same. 

There are a couple of disclaimers. This really is a discussion to the orthopedic treatment of scoliosis. There are some therapy options that people have talked about, and I'll touch on that briefly. But this is really sort of our semi-skewed perspective of scoliosis. 

Really the emphasis at this point is on the identification of scoliosis, and a little bit less on the treatment. Although I'll show you some of the treatment options and some of the newer things people are starting to do. 

So this is the outline of the talk. It's not really as arduous as this outline looks. But we'll talk briefly about the anatomy, the simplified version. A little bit about etiology, the physical exam, the radiographic exam, demographics, non-surgical treatment, surgical treatment and then new ideas and new ways we're treating this. 

So I want to start with a case, maybe not a typical case, but it's a 7-year-old female that presented to us with a bump on her back. People present a lot of different ways and this is what the x-rays showed. She has a little bit of scoliosis and you can see that her head is offset just a little bit, which probably is, what we like to see is the head directly over the pelvis. But it's not, and I think that may have been one of the things that bothered her the most. 

She, of course, is seven, so she's a little bit young. That's the lateral x-ray, which shows a relatively normal contour. We'll get back to that case and how we treated that patient. 

So scoliosis, as probably most of you know, is Greek and it really means a lateral curvature of the spine. So really any curvature of the spine would be considered scoliosis, but we typically don't define it until it's at least 10 degrees. As I tell a lot of patients, if you lean to one side, you're going to have a scoliosis. 

And if you want to take the really simplest approach to anatomy, if you look at the spine from the front, it really should be straight, unless there's some particular issue. But if you look at the spine from the side or the lateral view, you should have a curve. And the curve is about 40 degrees in thoracic spine and then it varies down to a lumbar curve that balances that out. So overall, the head should be over the sacrum. 

Scoliosis classification is fairly straightforward. In general, there's two broad types of scoliosis. One is idiopathic, which just means we don't know what causes it, and I'll talk about the possible causes. And then there's a whole other branch with a known etiology. And probably the most important thing, other than identifying scoliosis, is being able to fret out which one of those is idiopathic and which one has an underlying cause, because if it has a cause, for various reasons, we obviously want to know about that. 

So I'll just talk about some of the non-idiopathic scoliosis. Because idiopathic scoliosis is the dominant form of scoliosis, and what we treat the most often. I'll focus most of my talk on that, but just to touch on neuromuscular scoliosis. It's important to realize, as we just talked about, not all scoliosis is idiopathic, so it's always important to search for etiology. 

So every patient that has scoliosis, the first question I ask is what's the underlying cause. 

Nine out of ten times, the underlying cause is idiopathic. But that one out of ten times will be something else. 

This is a patient with neurofibromatosis, so they had the classic cafe au lait spots. And they tend to have different kinds of curves. So there are some clues that will tell you that this may not be idiopathic. If you have a long, sort of gradual curve, a C-shaped curve, a long S-shaped curve, that is consistent with the neuromuscular scoliosis. 

If you have a very short, sharp curve, that's also not consistent with idiopathic scoliosis. And that can be very consistent with the congenital scoliosis. Now congenital scoliosis is really something you're born with and the bone just forms abnormally. And there's really two broad categories of this congenital scoliosis. 

In orthopedics, we like to keep it very simple. It's either a failure of formation or failure of segmentation. So you may have a situation where you don't actually segment like this bar that's shown here. So that area's not segmented. Or you may have a failure of formation, where the vertebra has not formed completely. So those are the two. Over time, congenital scoliosis can get worse or it can stay the same. So a child may be born with a 30 degrees curve, and that may stay the same forever, or it may get worse. So with congenital scoliosis, we follow that over time. If we see it getting worse, then we consider treatment. 

Probably the most important thing to realize is about 30% have underlying urogenical problems, especially renal issues or cardiac issues, and those need to be evaluated. And classically, we evaluate them with a renal ultrasound or a cardiac ultrasound. So those are two of the most common other forms. But certainly children with cerebral palsy and other disorders will have scoliosis as well. 

The number one cause, nine out of ten children will have idiopathic scoliosis. And the question is why do they have that. And we don't really know. We don't even really know why the vast majority of those curves are right-sided curves. Various different theories have been brought forward. Melatonin is one that in the 1990s had a fair amount of support. 

If you take the pineal gland out of chickens, they would develop scoliosis. Then you treat these chickens with melatonin and the scoliosis would go away. And we looked at that in humans, it was really much more complex. Melatonin levels would go up and down, and it was hard to determine if that was related to it. It sort of fell out of favor, and now it's starting to get into favor again. 

We know that children's scoliosis have changes in the equilibrium and proprioception, and that may be related to scoliosis. And certainly some of these have platelet abnormalities. So we don't really know what the cause is. And I don't think there's any reason to focus too much at this point, until we find the cause. 

But there probably is an underlying genetic etiology or at least a predisposition. 

We know that because in general the chance of having scoliosis goes up if you have a family history of that. So it's up to 11% with a first-degree relative and 1.4% with a third-degree relative. 

The scoliosis exam is fairly straightforward. These are actual pictures taken from a fairly old textbook, as you can see. But in general, you want to look at the patient. It's important to be able to look at their hips and their shoulders, because often that will be their primary complaint. So you want to make sure their shoulders and hips are balanced. But you can still have a scoliosis that's balanced and it can not be so obvious. It really is amazing. 

I remember a next door neighbor who was 8 years old. 

She had a fairly significant scoliosis we ended up treating, but when you would looked at her, you wouldn't know, because she had a very balanced curve. So hips and shoulders are very important. And it's important for decision-making, but it's also important to exam the spine carefully. 

And the easiest way to do that is the Adams Forward Bend Test. And that's where they have their feet together, and they slowly bend forward and you really look for asymmetry. It's termed a rib hump, which is probably not a very complimentary term. But it's really fairly obvious, and it's due to rotation of the spine, not a curve of the spine. So in scoliosis, it's not just a curve, but it's truly 3-dimensional through rotation. As the ribs are rotated back, and they bend forward, it becomes obvious. 

The one caveat to that is somewhat the significant leg length inequality will almost always have either a lumbar prominence, or more likely a rib hump. 

So it can be very deceiving if you exam someone with a leg length inequality. So one of the important things to do is to make sure that you exam them, that they don't have a leg length inequality. And really the easiest way to do that is just to examine them standing up with their knees extended and look at their pelvis, because you'll be able to tell if there's a leg length inequality greater than a centimeter, simply by looking at them. Using a tape measure is much more difficult and much less accurate. So make sure they don't have leg length inequality. 

Have them do the Adams Forward Bend Test. You'll screen out just about everyone with curves under 20 degrees with this test. So it's unlikely to have a curve that's greater than 20 degrees that you won't identify with this test. 

The second thing is to always exam them from the side. Look at the lateral view, because they may have a kyphosis. 

And a lot of people have a kyphosis. Here you can see a fairly dramatic kyphosis. And it's actually termed a gibbous, if it's not a gentle curve, but instead it's a fairly dramatic curve. It's a gibbous and that's abnormal. So a gentle curve is normal and routine. But a more significant curve isn't, and that has to be evaluated. And interesting enough, children with scoliosis, idiopathic scoliosis, actually tend to have decreased kyphosis, or a straighter back. I will show examples of that and why that's important. 

If you see a scoliosis, the next step then is to do a fairly careful neurologic exam. Because, again, the most important thing to do, obviously, is to identify the scoliosis. 

The second most important thing to do is to rule out other causes. The best way to rule that out is with a careful neurologic exam. 

Abnormal neurologic exam should raise a red flag that this is not idiopathic scoliosis, or at least deserves and needs further evaluation. 

School screening is a little bit controversial. It fell very much in favor on the east coast. It's fallen very much out of favor over the last couple of years. And I think that's in part because school screenings predicated on the idea that if you find someone with a scoliosis at early age, you've got a reasonable way to treat that patient that is effective, and is less of a burden than other forms of treatment. So in general, what that means is you have to believe and feel that bracing is a reasonable option. Many people no longer feel that bracing is a reasonable option. I'll talk about that a little bit under treatment. 

It's also not particularly cost-effective to screen hundreds and hundreds of patients, so it's gone in and out of favor. I certainly think, personally, that school screening is a very reasonable thing to do, and I actually believe in bracing, but that is subject to some controversy. 

There are different ways to do a school screening, but if you use a scoliometer, which is that little device that shows you how much of a trunk asymmetry there is, what number, what degree you use will depend on your referral rate. So in you've got a fairly high cut off of seven or eight degrees, you're going to refer very few patients. Unfortunately, you are more likely to miss a few patients that have scoliosis. And just the opposite's true if you use a fairly low number as a cut off. So in general, the number to use, if you use a scoliometer, is somewhere between five and seven. And I think most people use about a six degree cut off for when to refer patients and when not to. Some people have said this is not a very valuable test. The Adams Forward Bending Test is not that accurate, scoliometers are not that useful. 

But the truth is it actually is fairly accurate. It's got a sensitivity of about 85%, specificity of over 90%, and that's from a study that wanted to disprove its usefulness. So I think it's a fairly useful exam. 

If we see patients, we have the luxury of having x-rays. So we really, not that we don't examine the patient, but we now have a lot more information, and it's very reasonable to get an x-ray if you're concerned about scoliosis. How you get the x-ray is important. If you get an x-ray with a patient standing with a leg length inequality, they may have a scoliosis they wouldn't normally have. So how you get the x-ray is fairly important. We typically get standing x-rays assuming they don't have a leg length inequality. If they do, then we'll get a sitting x-ray. 

And if they are unable to stand because they have got other conditions or disorders, then we can do supine x-ray. We always include a lateral x-ray. And the reason we include a lateral x-ray is because we worry about kyphosis, an abnormal kyphosis, which occurs in about 10% of patients. Spinal listhesis, which can occur either independently or associated with scoliosis, occurs about 5% of the time. And then you can get a thoracic lordosis. And that's actually very common in idiopathic scoliosis. So hypokyphosis or lordosis or a flat back, that's quite common. And if it's very severe, it can actually affect pulmonary function. 

If we get to the point where we do treatment, then we look at bending films, and that gives us some idea of the flexibility of the curve. How much it bends back and forth. 

For those that aren't familiar with the Cobb angle, this is what we use to determine the degree of curve. If you think too much about this, it will give you a little bit of a headache, but this is not the only way to describe a curve. A sharp curve and a gentle curve may get the same number and be very different curves. But this is how it's been described, and I think it's probably still the best way. There are other things that we use, but this is probably a reasonable marker. 

The Cobb angle, simply, is taken from an x-ray. And what you do is you measure down until you get the vertebra that's the most tilted. And once you find the vertebra that's the most tilted, in this case, it's the sixth thoracic vertebra, you draw a line that's parallel to the disk or to the end plate, and just take that out laterally or medially, and that's this line right here. Let's see if I can do this. That's this line right there. 

Then you do the same thing here. And where these two meet, that angle is the Cobb angle. Now sometimes where they meet is so far off the x-ray, you just have to make a right angle for each and measure that angle. But as basic trigonometry tells you it's the same angle, it's just that our x-rays aren't wide enough to draw it way out here. Is that's all the Cobb angle is. 

And it gives you a general idea of what the curve is, and if the curve is better or it's getting worse. People will come in and say they've got a 15% curve, which is really a degree curve, but they all know what that number is. Patients all know what that number is. 

How you get the x-ray is kind of interesting, because we get a straight AP x-ray. But we said that curves aren't really bent, they are actually rotated. 

So if you really wanted to get an accurate x-ray, you'd have to get an x-ray with the beam coming in at an angle, and that's called the Stagnera view, and occasionally we'll do that. And it's very interesting. If get that x-ray, you may take a 30-degree curve and find out it's really a 60-degree curve, because now you're getting it at its greatest deformity. 

We look a lot at kyphosis. As we said, idiopathic scoliosis won't be kyphotic, they won't have increased round back or hump back. They'll actually be straighter. And in fact, as we'll show you, if you see someone that's got increased kyphosis and a scoliosis, that raises a red flag, that you have to think there's something else going on. 

This is not idiopathic scoliosis. You can measure kyphosis, exactly like you measure the Cobb angle, and measure that curve in an identical fashion. Draw your lines parallel to the end plates and getting that angle. 

It's a little bit hard to do because of the soft tissue. As you get up in the thoracic spine, it's hard to actually see the vertebra. So you can measure from the upper thoracic curve, to the T-12, and if that is greater than 40 degrees, you start thinking they have increased kyphosis. Because that's hard to measure, there's a test you can use from T-5 to T-12. And if that's over 32 degrees, it's been shown-- If it's under 32 degrees, it's not kyphosis. If it's over 32 degrees, then it's a pretty good screening test that something else may be going on. So that's a reasonable screening test to do on a spinal x-ray. 

It's also important to look down at the lumbar spine, to see if there's any slippage or spondylolisthesis, and those two tend to go together. 

So again, this is kyphosis, this is actually one of our partners. Kyphosis is very common, a round back is not uncommon. 

But when you see this sharp curve or gibbous, then that raises a greater concern. Kyphosis in itself, though, is not an issue. Mark Spitz, for example, won seven gold medals. And they think it may be related to the fact that he did have kyphosis, and he had a larger lung volume. So kyphosis in itself that's not painful, and not getting worse, is not particularly a problem. 

Interestingly enough, just the opposite, the decreased kyphosis can be an issue, and can decrease lung volume if it's severe. 

We've discussed a little bit about this not just being a lateral curvature, but also a rotation. And there are some ways you can estimate how much rotation just by looking at the x-ray. One way is to look at the pedicles. So if you look at the x-rays, you can see the pedicles on end. 

Pedicles are very important to the spine, because you always want to see two pedicles. A missing pedicle is a big issue and can be consistent, especially with different metastatic diseases. So always try to identify the pedicles. 

On scoliosis, you may not see it, because it's rotated. It may, as the spine rotates, the pedicles may actually rotate and you may not see them. And if you look at the pedicles, you can get some idea of how much rotation they are. So here's where the pedicles should lie. And as it starts to rotate, the pedicles look like they're coming off the spine, and you can grade it, one, this pedicle's right on the curve and so as the pedicle rotates to it's midline, it's three. Across midline, it's four. So you get some idea of how much rotation's associated with the curve. 

Rotation is important to note, because if you would try to recreate a scoliosis, if you just bend to one side, you'd get a curve, but you wouldn't get any rotation in it. Or, if they have a leg length inequality, typically you'll get a curve, but you won't get a rotation. So if you see a curve, and you're thinking is this a real curve or maybe they're standing funny, and you see a lot of rotation, then you know it's a real curve. 

So, I'm sure everyone here is very good at identifying scoliosis. We've looked at how it's measured on x-ray. Some of these patients really deserve to get an MRI. And the reason is a certain percentage, it's really a small percentage of children, who have scoliosis will have interspinal pathology. And by that, that doesn't usually mean a tumor, it usually means a hydromyelia, or there could be a little fibrous band across the spine or to the cord. A small percentage, somewhere between one and four percent will have interspinal pathology. And there are ways you can identify that. 

So different people have looked at different ways of identifying that. I think any patient under age 11 who has scoliosis, is probably worth getting an MRI. If you look at a number of different studies, it shows a much higher incidence of interspinal abnormalities in children under 11. So across the board, it's small, but under 11, it's about 15% I'm sorry, about 50%. 

The other issue is that people have different changes on physical exam, and what kind of changes? It can be a persistent headache. It can be neck and back pain. It can be abnormal neurologic exam. And the one exam that we've looked at is abdominal reflexes. So if you lightly touch the abdomen, you'll see the abdominal muscles contract. 

And that should be symmetrical on four quadrants. If you use umbilicus as a midpoint, you can do upper left, upper right, lower right, lower left. You should have fairly symmetric abdominal reflexes. If you don't have that, that's a consideration they may have an abnormal neurologic exam. And your standard neurologic exam, which I'm sure you do more carefully than we do, is important. And if that's abnormal, then those are things to raise a red flag and say look, we should get an MRI. 

Any left thoracic curve. For some reason, idiopathic scoliosis is always to the right. If it's left, about a third will have underlying neurologic etiology. It could be something obvious. 

It could be cerebral palsy or some other diagnosis, so those are the reasons. Under 11, abnormal neurologic exam, or a left curve, or a curve with increased kyphosis, all deserve further evaluation. Assuming they don't have any of that, and you're pretty confident it's idiopathic scoliosis, then the next step is figuring out, is this really going to get worse or not. 

Because if it's not going to get worse, who cares? Scoliosis will not kill you. It's not a tumor, or a fracture, or an infection. So really the concern is, is this going to get worse? And it depends, really, on two things. It depends on the size of the angle. So if you've got a big curve, chances are more likely it will get worse. 

It's a little bit like the Leaning Tower of Pisa. The more it leans, the more likely it's going to fall. So if it's under ten degrees, the chance of it getting worse in general are small. Over 40, it's greater. 

But there's other factors that come into play, and probably the second most important is-- Well, I'll just touch on female/male ratio. Scoliosis is much more common in females. Small curves are almost equally as common. But the bigger curve you get, the more likely and the more asymmetric that balance is, so as you get to be big curves, it's much more common to be females than male. 

So part of the issue is deciding natural history. A 25 degree curve, like we see up here on the left, is really not an issue. 

It will not effect you, it should not cause lower back pain or long-term issues. But some of these curves go on like this one, and get to be severe, and some of them don't. And that's really the focus of most of the research now. Figuring out which one of these curves will stay 25 degrees, which ones go to 102, because that's what we're going to need to know when to intervene. I don't know which ones will necessarily go and which ones don't. 

But we do have some information. And so at presentation, if the child is very young and they have a big curve, as you might guess, those are much more likely to get worse. If they're older, they've gone through the growth spurt and they have a small curve, it's very unlikely to get worse. And just some general things. A curve over 20 degrees and under age 10, is going to progress virtually 100% of the time. 

So if you just use as a general marker, a child is under age 10, a curve over 20 degrees, this one's going to get worse. You'll want to treat it. I would treat it, certainly with bracing, but you want to treat it even at a fairly small curve. 

If they're over 15, and the curve is under 20 degrees, it's only a 4% chance of getting worse. And even then, it's probably never going to get worse to the point that it requires any kind of significant treatment. There are a lot of other things you can do, if you wanted to try to narrow that down a little bit. I'm not sure they help that much. 

People have looked at, how can you tell whether this child is mature or not. I don't do the Tanner Stages, but we will look at x-rays of the hip and we can look at the Risser. The Risser score actually looks at the iliac apophysis to see when it forms. 

And if you look down here, there's apophysis. And it's forming. It has not fully consolidated, so there's this black line. It kind of starts in front and works all the way back, to there and you can divide that into quadrants. Risser one and two is over here. As it goes back, it's four. And then as you get to be an adult, it completely fuses, and you can't even see that line. That's not very accurate, so I wouldn't spend a lot of time worrying about that, but it's what's been used historically for years. If their Risser is zero or one, they're immature, if they're anything more, they're mature. The bottom line is by the time you really see this, they're already mature, so it's not all that helpful. 

The triradiated cartilage is at the hip, and I apologize, it's just off this x-ray. But it's where the different bones of the hip come together, and when that fuses, once that's fused, they are also skeletally mature. So open triradiated cartilage in itself is a risk. If it's open, the chance of progression is about 40%. 

This is the classic risk factor, so it's looking at that risk assigned. Again, people who are less mature, so we're not looking at age, but less mature, Risser is 0-1 curves that are over 20 degrees, 68% chance of progressing. So I think the age is easier to look at. 

We know that if they're under age 10, over 20 degrees, 100% chance of progressing. But if you want to use the Risser score, you can do the same. What this really is helpful is saying is if they have a curve under 20 degrees, and the iliac apophysis is just about fused, they only have a one or two percent chance of progressing. 

And that's nice to be able to tell the parents that. 

People focus on some of the other issues as well, including peak height velocity, which is a little more accurate. In general, it's 12 in girls and 14 in boys. So if you just want to age over the age 12 in girls in general, they are skeletally mature. Over 14 in boys. Menarche, and axillary hair on both, are also ways to indicate the end of the growth spurt and risk of progression of scoliosis. 

Although boys are less likely to get scoliosis, the negative for males is that their scoliosis can progress, even when they're older. So if you are going to brace, or have a young male that's braced, then you want to brace them until they're quite a bit older. Not only do they mature later, but you need to brace them close to 18 years of age. 

Before you really want to think about treating any disease, you have to have some idea of what the natural history of the disease is, because why treat something that's not going to cause a problem. 

There isn't a lot of natural history studies. Nachemson, which is a researcher in northern Europe in 1968 said, you know, if you have scoliosis, it increases your mortality two times. Half the people are on disability. Most people don't get married. The problem with that study is that they had large initial curves. These were not sort of mild scoliosis, and many of them probably had neuromuscular disorders. So they had cerebral palsy and other disorders that were all mixed in the batch. So it really wasn't a very accurate study. 

I think people have found since then that scoliosis does not necessarily have to be a major impediment to life, that you can work and be independent, you can get married, almost at the same rate as the general population. 

So scoliosis, it may cause a cosmetic deformity, but it rarely causes significant functional limitations, and that is a little bit controversial. 

What kind of functional limitations it causes, but for day-to-day activities, it rarely causes significant functional limitations. 

The other issue comes up with pain. And in general, scoliosis can cause actually increased-- There is some concern that long-term scoliosis can cause increased pain. I think that's probably true. The caveat is children who have scoliosis don't present with pain. But long-term, if you have scoliosis, and it progresses, it can cause a higher incidence of pain. And the pain may be a little bit more severe. But if you take into fact that about 80% of adults will have back pain that's significant enough they seek medical attention, it's very difficult to sort out how much worse that is. It depends on who you talk to. 

So the studies in Iowa show that it's really not that big of a deal, it doesn't increase pain that much. 

Other studies say it's a bigger issue. And what we don't know, if we fuse the spine or make it straight, do we decrease that incidence of pain. So we don't know if our treatment makes it better. 

So we've sort of ruled out neuromuscular congenital scoliosis. We're looking at idiopathic scoliosis, just to make it a little more confusing, idiopathic scoliosis tends to come in three flavors and is set by age. And this is really arbitrary. Anything under age 3, is called infantile and over age 10 is adolescent, which is by far the most common. Adolescent idiopathic scoliosis, typically referred to as AIS. And then in between is juvenile. I'll talk briefly about these, but you can see infantile is very small, about 5%, juvenile is 15% and adolescent is 80%. 

This is infantile scoliosis. And I refer to it as Bazaro Scoliosis, because everything's backwards. It's just different than idiopathic scoliosis. It tends to occur young, it's more common in boys than girls. Right-sided curves are uncommon. And we looked at something called the rib-vertebral angle difference. But the bottom line is curves under about 35 degrees tend to actually get better. That is something that doesn't happen in idiopathic scoliosis. Curves over 30 degrees-- That is rib-vertebral angles over 20 degrees, tend to progress. If you want to measure it, it's a little bit hard to measure. 

What you do is you find the curve, the apex of the curve, so that's where the curve is the worst, and you measure the rib angle with the vertebra, with the horizontal right here. Here's the rib, draw a line up. And then this is the angle it takes with the vertical. You do it on the other side and you take the difference between the two angles. And if the difference is more than 20 degrees, it will tend to progress. The others actually tend to get better. 

The problem is the ones that don't get better, now you have a real problem, because you have this little spine and it's going to get worse and they're very, very young. We don't have a great treatment. This is Dr. Meta, the older one on the left, who developed the angle. 

And she really has focused on bracing and casting techniques for this, and really feels this is important. It was printed in our major journal, the JBJS, about two or three years ago. And people are starting to do these casts. It's starting to catch on, but whether or not it works, and how well it works is still a little bit up for debate. 

Some people feel that casting a child from this young of age and forcing them to wear a brace for the rest of their life is really not a fair thing to do. So it's not clear whether casting is the right way to go or not. But we did, where I trained, had a casting program. We would place this cast on, and that's a picture of a child in the cast. The cast is obviously trimmed down, but it does go up fairly high around the neck. There's a cutout for the abdomen. 

In Dr. Meta's hands, it has shown that it provides relatively reasonable correction. She, by the way, has a really significant scoliosis and obviously is doing just fine. Newer treatments and probably what most people here in North America are doing are various different types of what they call growing rods, which is a misnomer. They're now using a titanium rib or adapter to try to get some correction and be used as a temporary splint, allowing the spine to grow and do more definitive treatment as the child grows. I'll show examples of some of those in just a little bit. 

Juvenile scoliosis is sort of a mixed bag, because now you're dealing with kids between four and ten. Their curves, if they're younger, tend to be a little bit more like infantile. If they're older, they tend to be a little more like idiopathic. So there seems to be a higher genetic predisposition influence. 

It's children between age four and ten, by definition, at diagnosis. And about generally, one-third don't progress, one-third can be braced and do well with bracing. Actually, you can get correction in the brace. About a third go on to surgery. A fair number of these have abnormal MRIs, so these are ones that you want to get an MRI on. 

And this is a patient that had juvenile scoliosis, was braced, was very diligent about the bracing, and you can see the curve actually improved. That is something you won't see with idiopathic scoliosis, you can't make the curve better with idiopathic. But with juvenile, there is a potential to do that. 

Most of the treatment now will focus on the idiopathic scoliosis in adolescence. Adolescent idiopathic scoliosis. 

So this is our algorithm for the vast majority of patients that come in our door. So we've ruled out other forms of idiopathic scoliosis. We know it's adolescent. And this is in general, how we treat it. Curves less than 20 degrees, we observe, we don't treat. Curves, whether they're mature or not immature. If their mature, and it's less than 45 degrees, we observe it, because there's very little chance of this progressing. By observation, is doesn't mean necessarily just saying good-bye, but it probably is worth a follow-up every one to two years. So once they've gone through their growth spurt, if they're less than 45 degrees, then we don't do anything. 

Curves, if they're immature and it's greater than 30 degrees or we see it progressing beyond about 25 degrees, we think it's reasonable to brace. 

That's the standard treatment. This has been around for ten years or so. It's really undergoing scrutiny. There's now a randomized double blind study where they're looking at the value of bracing. And unfortunately this study, from my understanding, has only had a very few people that they were able to recruit, because you're asking someone either to have bracing or not bracing. And most people don't want to be randomized to that, so we'll see if they can get information from that. 

But there are clearly some surgeons that believe curves will progress or won't progress whether you brace them, and bracing does nothing. Yet there is some pretty good evidence that bracing works. So, I still certainly believe that bracing is important. And if it's done right, it can make the difference. 

And then finally, if you have a patient with a curve over 50 degrees, especially if they're skeletally immature, those are ones we may consider surgery, depending on the various different circumstances. 

So here are all the different kinds of braces that we use. The Milwaukee Braces are the gold standard. It's a large brace. And it actually has a collar that goes around the neck. It's somewhat unsightly, and kids hate it. And the collar's designed, actually, not to push against the neck, but to irritate enough so that the child stands in a straighter position. So an upper thoracic curve, that's really the only brace that works. But now more and more people use one of these other braces. 

This is a Molded TLSO, some people refer to it as the Boston Brace. 

And it's actually designed to correct the curve, but it goes under the arms, and it's less obvious to wear. 

There are a couple of things about braces, and it's very important. You can't just prescribe this brace. This is a brace that has to be prescribed, and it has to be fitted. Then we have to make sure that the brace is actually causing correction. Because if you have a curve, and you put a brace on and it's not making the curve straighter, it's really not going to do anything. So the concept was to get the brace. We see them back after they've had the brace for about a month and it's fitting, we know it's fitting well. We make sure the curve is decreased by about 50%. If you have a 40-degree curve, you'll want it less than 20 degrees. 

And the second issue, if they don't wear it, obviously it's not going to do anything. 

So what we found is that people, on average, will wear the brace about two-thirds what they say they wear it, just as a general rule. And often people don't wear the brace quite as much as you think. On the other hand, you wonder how much of that is people who have sort of given up on braces, and aren't strongly promoting it. I think it's part of our responsibility to say that there's good evidence that this works, if you wear it. And if you wear it, it may make a difference. So it's a little bit hard to know how effective they are. But I'll show some studies that actually show there is some good evidence that say they work. 

How do braces work? Well, this is a couple different studies that show that if you decrease the curve to 20 degrees, you increase stability of the curve from 50-80% of normal. 

So again, it's a little like the Leaning Tower of Pisa. You can't make it straight, but you can sort of hoist it up. And if you can keep them to a smaller curve to the point of skeletal maturity, then the curve should not progress. So if you keep the curve under 50 degrees, it probably won't progress. 

The biggest study came out in 1995 was again Nachemson, and you may remember this name. Same person from before. Did a multi-center study, looking at 247 patients. Now there's a big dropout, so there's hundreds of patients that didn't have follow up, but of the patients that had, they looked at electrical stimulation, observation, and they had a failure rate of about 67%. But those that had bracing, had a failure rate of 26%. It's a little bit hard to say, because they had such a huge dropout in the study, but at least it's about the best and largest study we have to say bracing makes a difference. 

Rowe, two years later, did a meta-analysis of nearly 2,000 patients. He found a fairly significant improvement with bracing. It's not 100%, but it's certainly better than electrical stimulation, which had actually made things a little worse than observation. 

Physical therapy would be great. If you could send someone to therapy to correct their curve, that would be wonderful. But there's really no good evidence at this point to say physical therapy is effective. But there are some interesting studies out there which have shown increasing trunkal strength may actually long-term improve scoliosis. But the follow-up hasn't been there. So, in general, I don't know of anyone today that prescribes physical therapy for scoliosis. We will for people that have mild kyphosis, but we won't do it for scoliosis. 

This is just a little bit on physical therapy for surgery, I'll skip over that. 

So once we get to the point where we believe it's a surgical curve, we actually try to define the curve. And this is a classic King Classification, which looks at where the curve is: if it's a thoracic curve, if it's a lumbar curve, if it's a combination of both. And it's supposed to help us decide when to fuse the spine. 

People have now gone to a different curve classification system named after Larry Lenke. It was developed at a number of different institutions. It actually breaks curve patterns up to a possible 46 different patterns. So it's one of the more confusing systems that we have in place. But I think it's important for research to be able to use a system like that. It classifies a curve both on sagittal and coronal views. 

It helps give an idea of, not only which ones may progress, but from our standpoint, more importantly, how you would actually treat them surgically. 

There has been trends to treat it surgically a lot of different ways. So there's a big trend to try to fuse the spine anteriorly, and I'll show a little bit about that. The trend has now gone back to basically fusing people posteriorly. There's an obvious advantage. The spine is very superficial posteriorly. You don't have to go through the abdomen or the pelvis. And in that regard, it's quite a bit a safer. There are disadvantages to going posteriorly. But with the new instrumentation that we're using today which include pedicle screws, it seems like we can get fairly significant correction by going posteriorly. 

And this is just a straight posterior incision. It's very straightforward. You go straight down the midline and you dissect the musculature laterally. And then the concept is you want to fuse the spine. That's really what you want to do. The instrumentation and stuff we put in is absolutely secondary. So most children fuse very well, even historically, they would just strip off all the soft tissue, put bone down and put them in a cast, most of those fused. 

Now we use instrumentation mainly just to get rid of the cast part and get a little better correction. Instrumentation has varied. About ten years ago, pedicle hooks, which you can see here, were the primary device used. 

There are little wires that go under the lamina, right here, called lamina wires. 

Dr. Drummond developed wires here in Madison, called Wisconsin Wires, which are probably the safest device, which actually goes through the spinous processes and stay completely out of the spine. 

And now pedicle screws, which obviously can have a problem. If you put it incorrectly it can obviously hit the spinal cord, major vessels. But pedicle screws give you great fixation. More and more people are using pedicle screws today to get fixation. 

This is just an example of what you get. In general, if you have a curve that's 80 degrees, you'll get about 50-70% correction. This is a curve that started at 82 degrees, and it went down to 28. 

I think that's about the correction you'll get, which is fine. I'd be very happy with a correction of 28 degrees. 

But probably the more important thing is you want the patient to be balanced. So if their curve is small and their head is over their pelvis, and then they have a good sagittal profile, they're going to be very happy regardless of what the curve is. I think as a surgeon, you want to get the curve as small as possible. That's really not the most important thing for the patient. The most important thing is balance. 

We've found that from a functional standpoint, that it's really balance from a side view that matters, or the sagittal alignment that makes all the difference, and especially down in the lumbar region, so we work hard to restore that as best we can. 

Neuromuscular scoliosis classically has been treated a little differently, because you don't fuse part of the spine. So, in neuropathic scoliosis you just treat the curve, for the most part. 

In neuromuscular, you treat the whole spine, because if you don't, they tend to get curves above and below. 

So this is a patient that had cerebral palsy, and they actually had a hip issue. We addressed the hip issue first and the hip actually is seated nicely, but they have a great deal of pelvic obliquity. Pelvic obliquity is actually what puts the hip at risk. And treating the hip will never treat the pelvic obliquity. Often, people will actually address the spine first to even out the pelvis, and then treat the hip as needed. In this case, the hip was treated first. They had a fairly significant curve. We knew this was progressing. They had difficulty sitting in their wheelchair. 

We treated them with the standard posterior spinal fusion and this is the final correction. So you can get really pretty good correction. And again, even if it's not perfect, it really does seem to make a difference in their lives. And some people argue that you don't need to do surgery, and clearly it's a long discussion you have with the patients and family. But caregivers, in every study I've looked at are extremely happy with the results, and 80-90, 90-95% of caregivers really believe that surgical treatment for scoliosis is beneficial. 

There are a lot of complications, especially in neuromuscular scoliosis. Most of those you can work through. And fortunately, we have a lot of people in the hospital help us get through these issues. But postoperatively, it's a big surgery. They almost always require blood. 

They have huge fluid changes. It's not quite as much of an issue in idiopathic scoliosis, so complication rate, the big one we worry about obviously, is neurologic complication rate is about 1 in 1,000. That's the question you get, what's the chance of a neurologic injury. A permanent neurologic injury is about 1 in 1,000. That doesn't mean the spinal cord injury, but some type of neurologic injury. Infection is fairly uncommon. It's about 5%, or a little bit less. Often that can be treated without removing the hardware. And then there are always pulmonary type issues, that are a little more common. 

About five to ten years ago, there was a big push to try to go anteriorly, so that was making an incision in the front, putting instrumentation in the front, and it actually works relatively well. 

The reason why you might want to do that, is because you could fuse less of your spine. And even though we really don't know what the consequences are of fusing the spine to the rest of the spine, it just make sense, you want to fuse as little as possible. There's a big push to go anteriorly. I won't go into great detail, but as you can see, it's a big incision. I'll show you some pictures. You can see that's the rib, and you have to move the rib aside. Pull the lung out of the way. There's significant changes in pulmonary function for up to one to two years afterwards. And then you put in instrumentation. 

Instrumentation is actually fairly easy. 

We typically perform this with pediatric surgery colleagues. But the instrumentation and the surgery part actually is fairly straightforward, because the spine is right there. And this is the type of correction that you can get. Here's another example. 

When anterior versus posterior instrumentation was compared, basically what was found that in certain curves, you can actually save a couple of levels, but the actual correction is not any different. So if you have that particular curve, where you may be able to not fuse a couple of levels, it still may be reasonable to go anteriorly, but I think that is only time people are doing that. The other advantage to going anteriorly, is you can do arthroscopic techniques, that is through small band-aid type incisions. That's done less commonly now, but it can be done. And doing surgery that way in experienced hands really gives about the same correction as doing it through a big incision. It just takes about four times as long. 

This is post-op activities. Our post-op regimen has changed quite a bit, depending on the quality of fixation and the patient. But in general, for up to a year, we want people lifting less than 50 pounds. For the first six months, we often limit their bending at the hips and lifting as well. So after scoliosis surgery, it's very important that they limit their activities. And most backpacks now seem to weigh about 100 pounds, so that limits their backpacks. 

There are new treatments coming out and one of the big pushes is how can we correct this curve without fusing it, because it just doesn't make sense. We were born with a spine that's mobile, why would we fuse it and make it solid. And one of the ways is using these memory shaped alloy staples. In a long bone, if you put a staple or some kind of tether on one side of the growth plate, the leg will grow asymmetrically. 

The thought is maybe we can do the same thing with the spine. We can put these on the convex curve, and put them into a small little incision, and the spine might start to grow straight. And so that's the concept. 

Unfortunately what happened in the '50s, this was done, and all the staples would fall out and they would go into things like the heart and other places you don't want them to be. 

So that was sort of poo-pooed, until we found the staples that stay in and they're a shape memory alloy. So unless your body temperature goes below about 20 degrees Celsius, they will stay in. And this is that 7-year-old that had a bump on her back. She's seven years old, this curve is now over 20 degrees. We know this is going to progress. And one option is bracing. 

And certainly, this was a patient that was offered and tried bracing. I hate to say wasn't compliant, but didn't use a bracing regimen and went on-- Here's a fairly flexible curve though. Went on to have these staples placed on the convex of both curves. And over time-- this is how they're placed, so they're actually placed through small incisions. It's not technically that difficult to put these in. 

So that basically showed that over time, the curve basically did not progress over time, which saves a larger surgery down the road. And we looked at our first about 40 patients and in general, it's very unlikely for a curve to progress to a point where it needs surgery, and some curves actually improved. So if you can keep a 20-degree curve at about 20 degrees, and one where you know that the natural history is for it to progress, I think that's probably a victory. Other options. For the very young patients is to use what we call a titanium rib or adapter and this is something that stays out of the spine. 

It goes on the rib and down to the pelvis. And by doing that, you can actually get correction. It's a temporary thing, so the idea is when they're older, you can do more formal surgery. And so those are some of the different treatment options that are being used, newer treatment options that are being used today. And that was really it, just some of these pictures. Thank you very much. Any questions at all? history of idiopathic scoliosis,