cc >> 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?