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Can everyone hear me okay? >> Thank you very much.
and everyone I really want to thank Ellen
This is really an honor. for inviting me here.
time to be here and be part of It's also an incredibly exciting
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
This morning I'm going to talk* period of time here.
and really focus on the evaluation and treatment.
There will be certainly plenty of time for questions.
And I wrote a couple
One is to be able to identify of lchildren's scoliosisere.
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.
history of idiopathic scoliosis, Two, to understand the natural
really need to worry about, and which ones you probably
don't need to worry about.
clinical findings that suggest And then three, to know the
I think one of the things, a diagnose other than scoliosis.
is the idea that scoliosis hopefully, you'll take away
So not all scoliosis really is quite different.
*There are a couple is the same.
This really is a discussion to the orthopedic treatment
of scoliosis. There are some therapy options
that people have talked about,
But this is really sort of and I'll touch on that briefly.
of scoliosis. Really the emphasis at this
point is on the identification
less on the treatment. of scoliosis, and a little bit
of the treatment options Although I'll show you some
people are starting to do. and some of the newer things
of the talk. *So this is the outline
as this outline looks. It's not really as arduous
anatomy, the simplified version. But we'll talk briefly about the
the physical exam, A little bit about etiology,
demographics, non-surgical treatment,
surgical treatment
we're treating this. and then new ideas and new ways
maybe not a typical case, Sobut it's a 7-year-old female,*
that presented to us
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
bit, which probably is, what we like to see is the head directly
over the pelvis.
may have been one of the things Bthat bothered her the most.at
She, of course, is seven, so she's a little bit young.
That's the lateral x-ray, which shows a relatively normal
contour.
and how we treated that patient. We'll get back to that case
most of you know, is Greek *So scoliosis, as probably
curvature of the spine. andSo really any curvatureral
of the spine would be considered
don't define it until it's at least 10 degrees.
As I tell a lot of patients,
going to have a scoliosis. if you lean to one side, you're
the really simplest approach *And if you want to take
the spine from the front, it really should be straight,
unless there's some particular issue.
But if you look at the spine
view, you should have a curve. from the side or the lateral
40 degrees in thoracic spine And the curve is about
down to a lumbar curve and then it varies
So overall, the head should be that balances that out.
*Scoliosis classification over the sacrum.
In general, there's two broad types of scoliosis..
One is idiopathic,
what causes it, and I'll which just means we don't know
And then there's a whole other talk about the possible causes.
And probably the most important thing, other than identifying
scoliosis, is being able
is idiopathic and which one to has an underlying cause,ose
because if it has a cause, for
want to know about that. various reasons, we obviously
of the non-idiopathic scoliosis. *So I'll just talk about some
is the dominant form Because idiopathic scoliosis
what we treat the most often. I'll focus most of my talk
on that, but just to touch
It's important to realize, on neuromuscular scoliosis.
not all scoliosis is idiopathic, as we just talked about,
to search for etiology. *So every patient thatnt
has scoliosis,
is what's the underlying cause. tNine out of ten times,k
the underlying cause
But that one out of ten times will be something else.
*This is a patient with
the classic cafe au lait spots. neurAnd they tend to havey had
different kinds of curves.
that will tell you that this So there are some clues
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
And that can be very consistent with the congenital scoliosis.
Now congenital scoliosis
born with and the bone is really something you're
And there's really two just forms abnormally.
of this congenital scoliosis. In orthopedics,s
we like to keep it very simple. It's either a failure
of formation
So you may have a situation orwhere 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
So those are the two. Over time, congenital scoliosis
can get worse or it can stay the same.
So a child may be born
that may stay the same forever, withor it may get worse. and
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
issues or cardiac issues, and those need to be evaluated.
And classically, we evaluate
or a cardiac ultrasound. them with a renal ultrasound
common other forms. So But certainly childrenost
with cerebral palsy and other disorders
will have scoliosis as well.
nine out of ten children *The number one cause,
And the question is will why do they have that.sis.
And we don't really know. We don't even really know
why the vast majority of those
Various different theories curves are right-sided curves.
Melatonin is one have been brought forward.
had a fair amount of support. If you take the pineal gland
out of chickens,
Then you treat these chickens they wouwith melatoninliosis.
and the scoliosis would go away.
it was really much more complex. And we looked at that in humans,
would go up and down, and it was hard to determine
if that was related to it.
and now it's starting It to get into favor again.r,
*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.
what the cause is. So we don't really know
any reason to focus too much And I don't think there's
until we find the cause. at this point,
an underlying genetic etiology *But there probably is
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%
*The scoliosis exam with a third-degree relative.
These are actual pictures taken from a fairly old textbook,
as you can see. But in general,
you want to look at the patient.
to look at their hips It'and their shoulders,le
because often that will be
So you want to make sure their their primary complaint.
But you can still have shoulders and hips are balanced.
and it can not be so obvious. a sIt really is amazing.ced
I remember a next door neighbor* who was 8 years old.
She had a fairly significant
but when you would looked scoat her, you wouldn't know,g,
because she had a very balanced curve.
So hips and shoulders are very important.
And it's important for
important to exam the spine decision-mcarefully. it's also
And the easiest way to do that*
And that's where they have is the Adams Forward Bend Test.
they slowly bend forward and their feet together, and
It's termed a rib hump, ywhich is probably not a very.
complimentary term. But it's really fairly obvious,
and it's due to rotation
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
will almost always have either leg length inequality
or more likely a rib hump. a lumbar prominence,
if you exam someone with a leg length inequality.
So one of the important things
you exam them, that they don't to do is to make sure that
And really the easiest way have a leg length inequality.
them standing up to do that is just to examine
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
and much less accurate. So make sure they don't have
leg length inequality.
the Adams Forward Bend Test. *Have them do
everyone with curves You'll screen out just about
So it's unlikely to have a curve under 20 degrees with this test.
that you won't identify that's with this test. degrees
*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.
dramatic kyphosis. Here you can see a fairly
a gibbous, if it's not And it's actually termed
it's a fairly dramatic curve. a gentlIt's a gibbousnstead
and that's abnormal.
and routine. So a gentle curve is normal
isn't, and that has to be But a morevaluated.ant curve
And interesting enough, children with scoliosis,
idiopathic scoliosis, actually tend to have
decreased kyphosis, or a straighter back.
I will show examples of that
*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,
the scoliosis. obviously, is to identify
thing to do is to rule out The second most important
The best way to rule that out is with a careful
neurologic exam.
raise a red flag that this Abnormal neurologic exam should*
or at least deserves is not idiopathic scoliosis,
*School screening and needs further evaluation.
It fell very much in favor is a little bit controversial.
It's fallen very much out of favor over the last
couple of years.
because school screenings predicated on the idea that
if you find someone with
you've got a reasonable way a to treat that patiente,
that is effective,
than other forms of treatment. and is less of a burden
is you have to believe So in general, what that means
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
of patients, so it's hundreds and hundreds
I certainly think, personally, gone in and out of favor.
a very reasonable thing to do, that school screening is
bracing, but that is subject and I actually believe in
*There are different ways to some controversy.
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
on your referral rate. will depend
cut off of seven So in you've got a fairly high
to refer very few patients. oUnfortunately, you are moreng
likely to miss a few patients that have scoliosis.
And just the opposite's true
as a cut off. iSo in general, the number tor
use, if you use a scoliometer,
and seven. is somewhere between five
about a six degree cut off And I think most people use
and when not to. for when to refer patients
not a very valuable test. The Adams Forward Bending Test
is not that accurate, scoliometers
are not that useful.
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
*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,
an x-ray if you're concerned and it's very reasonable to get
How you get the x-ray ais important.s.
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.
is fairly important. So how you get the x-ray
assuming they don't have We typically get standing x-rays
If they do, then we'll get a leg length inequality.
And if they are unable to stand because they have got
other conditions or disorders,
We always include then wa lateral x-ray.x-ray.
And the reason we include a lateral x-ray is because
we worry about kyphosis,
occurs in about 10% of patients. an abnormal kyphosis, which
occur either independently Spinal listhesis, which can
occurs about 5% of the time. or associated with scoliosis,
a thoracic lordosis. And then you can get
in idiopathic scoliosis. And that's actually very common
or lordosis or a flat back, that's quite common.
And if it's very severe,
pulmonary function. *If we get to the point where
we do treatment,
and that gives us some idea then wof the flexibilityfilms,
of the curve. How much it bends back
and forth.
with the Cobb angle, For those that aren't familiar*
the degree of curve. this is what we use to determine
about this, it will give you If you think too much
but this is not the only way a little bit of a headache,
A sharp curve and a gentle curve to describe a curve.
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.
is taken from an x-ray. *TheAnd what you do isy,
you measure down
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,
to the disk you or to the end plate, andlel
just take that out laterally
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
for each and measure that angle. just have to make a right angle
tells you it's the same angle, But as basic trigonometry
aren't wide enough to draw it it's jway out here.x-rays
Is that's all the Cobb angle is.
of what the curve is, and And iif the curve is betteridea*
or it's getting worse.
they've got a 15% curve, People will come in and say
but they all know which what that number is.urve,
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,
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,
and find out it's really you may take a 30-degree curve
because now you're getting it at its greatest deformity.
*We look a lot at kyphosis.
won't be kyphotic, As we said, idiopathic scoliosis
round back or hump back. they won't have increased
And in fact, as we'll show you, They'llif you see someoneghter.
that's got increased kyphosis and a scoliosis,
that raises a red flag, that you have to think
there's something else going on.
scoliosis. *This is not idiopathic
exactly like you measure You can measure kyphosis,
curve in an identical fashion. the Cobb angle, and measure that
parallel to the end plates Draw your lines
It's a little bit hard to do and getting that angle.
As you get up in the thoracic becausspine, it's hardssue.
to actually see the vertebra. So you can measure
from the upper thoracic curve,
is greater than 40 degrees, to you start thinkinghat
they have increased kyphosis. Because that's hard to measure,
there's a test you can use
And if that's over 32 degrees, from T-5 to T-12.
If it's under 32 degrees, it's not kyphosis.
If it's over 32 degrees,
screening test that something else may be going on.
So that's a reasonable
on a spinal x-ray. screening test to do
look down at the lumbar spine, *It's also important to
or spondylolisthesis, and those two tend to go together.
*So again, this is kyphosis, this is actually
one of our partners.
a round back is not uncommon. KBut when you see thisn,
sharp curve or gibbous, then
Kyphosis in itself, though, that rais not an issue.oncern.
Mark Spitz, for example,
And they think it may be related won seven gold medals.
kyphosis, and he had to the fact that he did have
So kyphosis in itself that's not a larger lung volume.
is not particularly a problem. painful, and not getting worse,
opposite, the decreased kyphosis Interestingly enough, just the*
and can decrease lung volume can be an issue,
*We've discussed a little bit if it's severe.
a lateral curvature, about this not just being
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.
to the spine, because you always Pedicles are very important
A missing pedicle is a big issue want to see two pedicles.
especially with different ametastatic 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
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
to it's midline, it's three. and so as the pedicle rotates
So you get some idea Across midline, it's four.
associated with the curve. of how much rotation's
because if you would try Rotation is important to note,*
if you just bend to one side, to you'd get a curve,is,
but you wouldn't get
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,
is this a real curve and you're thinking
and you see a lot of rotation, or maybe they're standing funny,
*So, I'm sure everyone here then you know it's a real curve.
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
And by that, that doesn't will usually mean a tumor,ology.
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.
you can identify that. And there are ways
looked at different ways *So different people have
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
in children under 11. So across the board, it's small,
but under 11, it's about 15%
*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 abnormal It can be neck and back pain.
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.
as a midpoint, you can do upper left, upper right,
lower right, lower left.
abdominal reflexes. You If you don't have that,etric
that's a consideration
neurologic exam. they may have an abnormal
exam, which I'm sure you do Amore carefully than we do,c
is important. And if that's abnormal,
then those are things to raise
we should get an MRI. *Any left thoracic curve.,
For some reason,
is always to the right. If it's left, about a third
will have underlying
It could be something obvious. neurologic etiology.
or some other diagnosis, It could be cerebral palsy
Under 11, abnormal neurologic exam, or a left curve, or
a curve with increased kyphosis,
Assuming they don't have all deserve further evaluation.
pretty confident it's idiopathic any of that, and you're
is figuring out, is this really scgoing to get worse or not.p
*Because if it's not going to get worse, who cares?
Scoliosis will not kill you.
or a fracture, or an infection. So really the concern is,
is this going to get worse? And it depends, really,
on two things.
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 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
Well, I'll just touch on important is--
Scoliosis is much more common femin females.tio.
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
A 25 degree curve, is deciding natural history.
is really not an issue. likeIt will not effect you,left,
it should not cause lower back
But some of these curves pain or long-term issues.
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.
if the child is very young And so at presentation,
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.
A curve over 20 degrees And juand under age 10,hings.
is going to progress
So if you just use virtually 100% of the time.
a child is under age 10, as a general marker,
this one's going to get worse. a curve over 20 degrees,
I would treat it, certainly with bracing,.
but you want to treat it
*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
the point that it requires any never going to get worse to
There are a lot of other things kiyou can do, if you wantednt.
to try to narrow that down
I'm not sure they help a little bit.
*People have looked at, that much.
this child is mature or not. how can you tell whether
but we will look at x-rays I don't do the Tanner Stages,
and we can look at the Risser. of the hip
looks at the iliac apophysis The Risser score actually
And if you look down here, to see when it forms.
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,
that line. and you can't even see
I wouldn't spend a lot of time That's not very accurate, so
what's been used historically worrying afor years. but it's
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
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,
So open triradiated cartilage they ain itself is a risk.ature.
If it's open, the chance
*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.
is easier to look at. *We know that if they're
under age 10, over 20 degrees,
But if you want to use 100% chance of progressing.
you can do the same. the Risser score,
is saying is if they have Wa curve under 20 degrees,l
and the iliac apophysis is
a one or two percent chance just aboof progressing.only have
And that's nice to be able
*People focus on some of the toother issues as well,t.
including peak height velocity, which is a little more accurate.
In general, it's 12 in girls
So if you just want to age and 14 in boys.
in general, they are skeletally mature.
Over 14 in boys.
both, are also ways to indicate Mthe end of the growth spurton
and risk of progression of scoliosis.
*Although boys are less likely to get scoliosis,
the negative for males is that
even when they're older. their scoliosis can progress,
or have a young male So if you are going to brace,
to brace them until they're quite a bit older.
Not only do they mature later,
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
There isn't a lot nof natural history studies..
Nachemson, which is a researcher
you know, if you have scoliosis, in northern Europe in 1968 said,
two times. it increases your mortality
are on disability. Half the people
The problem with that study Mostis that they had largeied.
initial curves. These were not sort of
mild scoliosis, and many of them
disorders. probably had neuromuscular
and other disorders that So they had cerebral palsy
So it really wasn't wera very accurate study.ch.
*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,
as the general population. almost at the same rate
a cosmetic deformity, but it rarely causes significant
functional limitations, and that
What kind of functional is alimitations it causes,ial.
but for day-to-day activities,
functional limitations. *The other issue comes upant
with pain.
can cause actually increased-- And in general, scoliosis
that long-term scoliosis There is some concern
I think that's probably true. caThe caveat is children.
who have scoliosis
But long-term, if you have don't present with pain.
it can cause a higher incidence scoliosis, of pain.rogresses,
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,
how much worse that is. iIt depends on who you talk to.
*So the studies in Iowa
big of a deal, it doesn't shoincrease pain that much.hat
Other studies say it's a bigger issue.
And what we don't know, if we fuse the spine
or make it straight,
that incidence of pain. So we don't know if our
treatment makes it better.
neuromuscular congenital *So we've sort of ruled out
We're looking at idiopathic scoliosis, just to make it
a little more confusing,
tends to come in three flavors idiopathic scoliosis
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,
And then in between is juvenile. typically referred to as AIS.
but you can see infantile I'lis very small, about 5%,se,
juvenile is 15% and adolescent is 80%.
*This is infantile scoliosis.
as Bazaro Scoliosis, And I refer to it
It's just different becthan idiopathic scoliosis.s.
It tends to occur young,
than girls. Right-sided curves are uncommon.
And we looked at something
angle difference. cBut the bottom line isl
curves under about 35 degrees tend to actually get better.
That is something that doesn't
Curves over 30 degrees-- happen in idiopathic scoliosis.
over 20 degrees, That is rib-vertebral angles
If you want to measure it, tend to progress.
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,
right here. Here's the rib, draw a line up.
And then this is the angle
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,
The others actually tend it will tend to progress.
*The problem is the ones that don't get better, now you
have a real problem, because
and it's going to get worse and they're very, very young.
We don't have a great treatment.
the older one on the left, This is Dr. Meta,
And she really has focused on bracing and casting techniques
for this, and really feels
It was printed in our major journal, the JBJS, about two
or three years ago. And people are starting
to do these casts.
but whether or not it works, It's starting to catch on,
a little bit up for debate. *Some people feel that castingl
a child from this young of age
for the rest of their life and forcing them to wear a brace
to do. is really not a fair thing
casting is the right way to go So it's not clear whether
But we did, where I trained, or not.
We would place this cast on, had a casting program.
in the cast. and that's a picture of a child
trimmed down, but it does go up fairly high around the neck.
There's a cutout
In Dr. Meta's hands, for the abdomen.
relatively reasonable it has shcorrection. provides
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,
They're now using a titanium rib or adapter to try
to get some correction and
allowing the spine to grow be used as a temporary splint,
as the child grows. aI'll show examples of some ofnt
those in just a little bit. *Juvenile scoliosis is sort of
a mixed bag, because now
between four and ten. Their curves, if they're
younger, tend to be a little bit
If they're older, they more like infantile.
idiopathic. tend So there seems to belike
a higher genetic
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
so these are ones that have abnormal MRIs,
*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
that come in our door. the vast majority of patients
of idiopathic scoliosis. So we've ruled out other forms
And this is in general, We khow we treat it.ent.
Curves less than 20 degrees,
Curves, whether they're mature we observe, we don't treat.
If their mature, or not immature.
we observe it, because and it's less than 45 degrees,
of this progressing. there's very little chance
necessarily just saying By good-bye, but it probablyean
is worth a follow-up
So once they've gone through every one to two years.
if they're less than 45 degrees, their growth spurt,
*Curves, if they're immature and it's greater than 30 degrees
or we see it progressing
think it's reasonable to brace. That's the standard treatment.
This has been around
It's really undergoing scrutiny. for ten years or so.
double blind study There's now a randomized
the value of bracing. And unfortunately this study,
from my understanding,
that they were able to recruit, because you're asking someonee
either to have bracing
And most people don't want or not bracing.
so we'll see if they can get to be randomized to that,
*But there are clearly some information from that.
curves will progress surgeons that believe
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
depending on the various we may consider surgery,
*So here are all the different kinds of braces that we use.
The Milwaukee Braces
It's a large brace. And it actually has a collar
that goes around the neck.
and kids hate it. And the collar's designed,
actually, not to push against the neck,
but to irritate enough
in a straighter position. So an upper thoracic curve,
that's really the only brace
But now more and more people that works.
*This is a Molded TLSO, use one of these other braces.
as the Boston Brace. some people refer to it
to correct the curve, but it goes under the arms,
and it's less obvious to wear.
about braces, *Theand it's very important.s
You can't just prescribe
This is a brace that has to be prescribed,
and it has to be fitted.
that the brace Then we have to make sure
Because if you have a curve, and is actually causing correction.
making the curve straighter, you put a brace on and it's not
going to do anything. iSo 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.
is decreased by about 50%. We make sure the curve
you'll want it If you have a 40-degree curve,
And the second issue, if they don't wear it, obviously
it's not going to do anything.
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
on braces, and who have sort of given up
I think it's part of our aren't strongly promoting it.
that there's good evidence responsibility to say
And if you wear it, thait may make a difference. it.
So it's a little bit hard to know how effective they are.
But I'll show some studies
there is some good evidence that say they work.
*How do braces work? Well, this is a couple
different studies that show that
to 20 degrees, you increase ifstability of the curvee
from 50-80% of normal.
the Leaning Tower of Pisa. So again, it's a little like
but you can sort of hoist it up. You can't make it straight,
to a smaller curve to the point Aof skeletal maturity,em
then the curve
So if you keep the curve should not progress.
it probably won't progress. *The biggest study came out
in 1995 was again Nachemson,
Same person from before. and you may remember this name.
looking at 247 patients. Did a multi-center study,
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%.
because they had such a huge It's a little bit hard to say,
at least it's about the best dropout in the study, but
bracing makes a difference. and*Rowe, two years later,to say
did a meta-analysis of nearly 2,000 patients.
He found a fairly significant improvement with bracing.
It's not 100%,
than electrical stimulation, but it's certainly better
a little worse than observation. which had actually made things
would be great. If you could send someone to
therapy to correct their curve, that would be wonderful.
But there's really
to say physical therapy no good is effective.his point
But there are some
which have shown increasing trunkal strength may actually
long-term improve scoliosis.
hasn't been there. But the follow-up
of anyone today that prescribes physical therapy
for scoliosis.
that have mild kyphosis, but We will for people
This is just a little bit on physical therapy for surgery,
I'll skip over that.
where we believe *So once we get to the point
we actually try ito define the curve.,
And this is a classic King Classification, which looks
at where the curve is:
if it's a lumbar curve, if it's a combination of both.
And it's supposed to help us
*People have now gone to decidea different curve spine.
classification system named after Larry Lenke.
It was developed at a number
It actually breaks of different institutions.
46 different patterns. curve patterns up to a possible
confusing systems Sthat we have in place.
But I think it's important
a system like that. foIt classifies a curve bothse
on sagittal and coronal views.
not only which ones may progress, but from our
standpoint, more importantly, how you would actually
treat them surgically.
to treat it surgically *There has been trends
So there's a big trend to try to fuse the spine anteriorly,
and I'll show a little bit
The trend has now gone back to basically fusing people
posteriorly.
The spine is very superficial There's aposteriorly.vantage.
You don't have to go through
And in that regard, it's quite a bit a safer..
There are disadvantages to going posteriorly.
But with the new instrumentation
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.
and you dissect the musculature You go stralaterally.the midline
And then the concept
That's really what is you want to fuse the spine.
The instrumentation and stuff we put in
is absolutely secondary.
even historically, So most children fuse very well,
all the soft tissue, they would just strip off
and put them in a cast, most of those fused.
*Now we use instrumentation
the cast part and get a little better correction.
Instrumentation has varied. About ten years ago, pedicle
hooks, which you can see here,
There are little wires that go were the primary device used.
called lamina wires. under the lamina, right here,
here in Madison, *Dr. Drummond developed wires
are probably the safest device, cwhich actually goes throughh
the spinous processes and stay
*And now pedicle screws, which obviously can have a problem.
If you put it incorrectly it can
major vessels. obviously hit the spinal cord,
give you great fixation. But pedicle screws
are using pedicle screws today More and more people
*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.
at 82 degrees, This is a curve that started
I think that's about and it went down to 28.
which is fine. the correction you'll get,
with a correction of 28 degrees. I'd be very happy
thing is you want the patient But probto be balanced.mportant*
So if their curve is small and
and then they have a good their hsagittal profile, pelvis,
they're going to be very happy
I think as a surgeon, regyou want to get the curve is.
as small as possible. That's really not the most
important thing for the patient.
is balance. *We've found that fromng
a functional standpoint,
from a side view that matters, that it's really balance
that makes all the difference, or the sagittal alignment
in the lumbar region, anso we work hardwn
to restore that as best we can. *Neuromuscular scoliosis
classically has been treated a
don't fuse part of the spine. liSo, in neuropathic scoliosisu
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
*So this is a patient that had cucerebral palsy, andw.
they actually had a hip issue.
and the hip actually is seated We addressed the hip issue first
great deal of pelvic obliquity. Pelvic obliquity is actually
what puts the hip at risk.
treat the pelvic obliquity. AnOften, people will actuallyer
address the spine first to even out the pelvis, and
then treat the hip as needed. In this case,
the hip was treated first.
curve. They had a fairly significant
They had difficulty sitting We knin their wheelchair.ing.
We treated them with the
and this is standthe final correction.fusion
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
and clearly it's a long you ddiscussion you havegery,
with the patients and family. But caregivers, in every study
I've looked at are extremely
and 80-90, 90-95% of caregivers really believe that surgical
treatment for scoliosis is beneficial.
*There are a lot of
in neuromuscular scoliosis. Most of those you can work
through.
a lot of people in the hospital Anhelp us get throughave
these issues. But postoperatively,
it's a big surgery. They almost always require
blood.
It's not quite as much of an They have huge fluid changes.
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,
of a neurologic injury. A permanent neurologic injury
is about 1 in 1,000.
cord injury, but some type That doesn't mean the spinal
Infection is fairly uncommon. of nIt's about 5%,ry.
or a little bit less. Often that can be treated
without removing the hardware.
pulmonary type issues, And then there are always
*About five to ten years ago, that are a little more common.
go anteriorly, so that was there was a big push to try to
putting instrumentation min the front, and it actuallyt,
works relatively well.
to do that, is because you The reason why you might want
And even though we really don't coknow what the consequencese.
are of fusing the spine to the rest of the spine,
it just make sense, you want to fuse as little
as possible.
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 have to move the rib aside. YPull the lung out of the way.d
There's significant changes in pulmonary function for up to
one to two years afterwards.
instrumentation. And then you put in
is actually fairly easy. *Instrumentation
pediatric surgery colleagues. We But the instrumentationwith
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
to not fuse a couple of levels, cit still may be reasonablee
to go anteriorly, but I think that is only time
people are doing that.
anteriorly, is you can do Tharthroscopic techniques,ng
that is through small band-aid type incisions.
That's done less commonly now,
And doing surgery that way but it can be done.
really gives about in experienced hands
through a big incision. the same It just takes doing it
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.
we often limit their bending For the first six months,
So after scoliosis surgery, at tit's very important thatell.
they limit their activities.
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
it just doesn't make sense. We were born with a spinee
that's mobile, why would
And one of the ways we fuse is using these solid.
memory shaped alloy staples.
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
We can put these on the convex the same thing with the spine.
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
like the heart and other places anyou don't want them to be.s
So that was sort of poo-pooed,*
that stay in and until we found the staples
So unless your body temperature tgoes below about 20 degrees.
Celsius, they will stay in. And this is that 7-year-old
that had a bump on her back.
curve is now over 20 degrees. ShWe know this is going tos
progress. And one option is bracing.
And certainly, this was a patient that was offered
and tried bracing.
but didn't use a bracing I hate to say wasn't compliant,
Here's a fairly flexible curve regimen and went on--
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.
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.
40 patients and in general, Ait's very unlikely for a curvet
to progress to a point
some curves actually improved. where it needs surgery, and
curve at about 20 degrees, So if you can keep a 20-degree
that the natural history and one where you know
I think that's probably is fora victory.gress,
Other options.
is to use what we call For the very young patients
and this is something that stays out of the spine.
It goes on the rib and down to the pelvis.
And by doing that,
It's a temporary thing, so you can actually get correction.
you can do more formal surgery. the And so those are some ofer,
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?