WEBVTT 00:00.100 --> 00:02.266 align:left position:40% line:83% size:50% cc >> Thank you very much. 00:02.266 --> 00:04.400 align:left position:10% line:83% size:80% Can everyone hear me okay? I really want to thank Ellen 00:04.400 --> 00:06.466 align:left position:30% line:83% size:60% and everyone for inviting me here. 00:06.466 --> 00:08.333 align:left position:20% line:83% size:70% This is really an honor. It's also an incredibly exciting 00:08.333 --> 00:11.133 align:left position:10% line:83% size:80% time to be here and be part of the new Children's Hospital. 00:11.133 --> 00:16.366 align:left position:10% line:83% size:80% It is one thing that I really look forward to, the ability 00:16.366 --> 00:21.133 align:left position:10% line:83% size:80% to interact with the colleagues here, and be part of the 00:21.133 --> 00:24.833 align:left position:10% line:83% size:80% incredibly high quality of care that I've seen delivered 00:24.833 --> 00:27.733 align:left position:30% line:83% size:60% even in my short period of time here. 00:27.733 --> 00:30.066 align:left position:10% line:83% size:80% x*This morning I'm going to talk a little bit about scoliosis, 00:30.066 --> 00:32.566 align:left position:20% line:83% size:70% and really focus on the evaluation and treatment. 00:32.566 --> 00:35.633 align:left position:20% line:83% size:70% There will be certainly plenty of time for questions. 00:35.633 --> 00:40.000 align:left position:20% line:83% size:70% And I wrote a couple of learning objectives here. 00:40.000 --> 00:41.933 align:left position:10% line:83% size:80% One is to be able to identify children's scoliosis 00:41.933 --> 00:43.800 align:left position:20% line:83% size:70% from clinical exam. And I think probably most 00:43.800 --> 00:46.233 align:left position:10% line:83% size:80% people can do that already, but I'll show a few examples 00:46.233 --> 00:49.900 align:left position:10% line:83% size:80% and we'll go through that. Two, to understand the natural 00:49.900 --> 00:53.533 align:left position:10% line:83% size:80% history of idiopathic scoliosis, so you know which ones you 00:53.533 --> 00:55.500 align:left position:10% line:83% size:80% really need to worry about, and which ones you probably 00:55.500 --> 00:58.033 align:left position:10% line:83% size:80% don't need to worry about. And then three, to know the 00:58.033 --> 01:01.366 align:left position:10% line:83% size:80% clinical findings that suggest a diagnose other than scoliosis. 01:01.366 --> 01:03.333 align:left position:10% line:83% size:80% I think one of the things, hopefully, you'll take away 01:03.333 --> 01:06.700 align:left position:10% line:83% size:80% is the idea that scoliosis really is quite different. 01:06.700 --> 01:10.766 align:left position:20% line:83% size:70% So not all scoliosis is the same. 01:10.766 --> 01:14.733 align:left position:20% line:83% size:70% x*There are a couple of disclaimers. 01:14.733 --> 01:17.200 align:left position:10% line:83% size:80% This really is a discussion to the orthopedic treatment 01:17.200 --> 01:20.133 align:left position:30% line:83% size:60% of scoliosis. There are some therapy options 01:20.133 --> 01:23.566 align:left position:10% line:83% size:80% that people have talked about, and I'll touch on that briefly. 01:23.566 --> 01:26.133 align:left position:10% line:83% size:80% But this is really sort of our semi-skewed perspective 01:26.133 --> 01:29.233 align:left position:30% line:83% size:60% of scoliosis. Really the emphasis at this 01:29.233 --> 01:32.233 align:left position:10% line:83% size:80% point is on the identification of scoliosis, and a little bit 01:32.233 --> 01:34.766 align:left position:20% line:83% size:70% less on the treatment. Although I'll show you some 01:34.766 --> 01:36.733 align:left position:20% line:83% size:70% of the treatment options and some of the newer things 01:36.733 --> 01:40.866 align:left position:10% line:83% size:80% people are starting to do. x*So this is the outline 01:40.866 --> 01:42.833 align:left position:30% line:83% size:60% of the talk. It's not really as arduous 01:42.833 --> 01:44.833 align:left position:20% line:83% size:70% as this outline looks. But we'll talk briefly about the 01:44.833 --> 01:48.000 align:left position:10% line:83% size:80% anatomy, the simplified version. A little bit about etiology, 01:48.000 --> 01:52.000 align:left position:20% line:83% size:70% the physical exam, the radiographic exam, 01:52.000 --> 01:54.166 align:left position:30% line:83% size:60% demographics, non-surgical treatment, 01:54.166 --> 01:56.400 align:left position:20% line:83% size:70% surgical treatment and then new ideas and new ways 01:56.400 --> 02:02.566 align:left position:20% line:83% size:70% we're treating this. x*So I want to start with a case, 02:02.566 --> 02:07.066 align:left position:10% line:83% size:80% maybe not a typical case, but it's a 7-year-old female 02:07.066 --> 02:10.533 align:left position:20% line:83% size:70% that presented to us with a bump on her back. 02:10.533 --> 02:12.533 align:left position:20% line:83% size:70% People present a lot of different ways and this is 02:12.533 --> 02:16.066 align:left position:20% line:83% size:70% what the x-rays showed. She has a little bit of 02:16.066 --> 02:18.333 align:left position:10% line:83% size:80% scoliosis and you can see that her head is offset just a little 02:18.333 --> 02:22.200 align:left position:10% line:83% size:80% bit, which probably is, what we like to see is the head directly 02:22.200 --> 02:25.266 align:left position:30% line:83% size:60% over the pelvis. But it's not, and I think that 02:25.266 --> 02:29.266 align:left position:10% line:83% size:80% may have been one of the things that bothered her the most. 02:29.266 --> 02:32.700 align:left position:10% line:83% size:80% She, of course, is seven, so she's a little bit young. 02:32.700 --> 02:35.866 align:left position:10% line:83% size:80% That's the lateral x-ray, which shows a relatively normal 02:35.866 --> 02:40.300 align:left position:40% line:83% size:50% contour. We'll get back to that case 02:40.300 --> 02:45.166 align:left position:10% line:83% size:80% and how we treated that patient. x*So scoliosis, as probably 02:45.166 --> 02:47.800 align:left position:10% line:83% size:80% most of you know, is Greek and it really means a lateral 02:47.800 --> 02:50.733 align:left position:20% line:83% size:70% curvature of the spine. So really any curvature 02:50.733 --> 02:52.766 align:left position:10% line:83% size:80% of the spine would be considered scoliosis, but we typically 02:52.766 --> 02:55.933 align:left position:30% line:83% size:60% don't define it until it's at least 10 degrees. 02:55.933 --> 02:57.900 align:left position:10% line:83% size:80% As I tell a lot of patients, if you lean to one side, you're 02:57.900 --> 03:04.000 align:left position:10% line:83% size:80% going to have a scoliosis. x*And if you want to take 03:04.000 --> 03:06.733 align:left position:10% line:83% size:80% the really simplest approach to anatomy, if you look at 03:06.733 --> 03:10.733 align:left position:10% line:83% size:80% the spine from the front, it really should be straight, 03:10.733 --> 03:12.866 align:left position:20% line:83% size:70% unless there's some particular issue. 03:12.866 --> 03:15.500 align:left position:10% line:83% size:80% But if you look at the spine from the side or the lateral 03:15.500 --> 03:19.433 align:left position:10% line:83% size:80% view, you should have a curve. And the curve is about 03:19.433 --> 03:22.966 align:left position:10% line:83% size:80% 40 degrees in thoracic spine and then it varies 03:22.966 --> 03:26.166 align:left position:20% line:83% size:70% down to a lumbar curve that balances that out. 03:26.166 --> 03:33.900 align:left position:10% line:83% size:80% So overall, the head should be over the sacrum. 03:33.900 --> 03:36.700 align:left position:10% line:83% size:80% x*Scoliosis classification is fairly straightforward. 03:36.700 --> 03:38.933 align:left position:20% line:83% size:70% In general, there's two broad types of scoliosis. 03:38.933 --> 03:41.466 align:left position:20% line:83% size:70% One is idiopathic, which just means we don't know 03:41.466 --> 03:45.066 align:left position:20% line:83% size:70% what causes it, and I'll talk about the possible causes. 03:45.066 --> 03:47.533 align:left position:10% line:83% size:80% And then there's a whole other branch with a known etiology. 03:47.533 --> 03:50.200 align:left position:10% line:83% size:80% And probably the most important thing, other than identifying 03:50.200 --> 03:53.033 align:left position:20% line:83% size:70% scoliosis, is being able to fret out which one of those 03:53.033 --> 03:56.133 align:left position:10% line:83% size:80% is idiopathic and which one has an underlying cause, 03:56.133 --> 03:58.933 align:left position:10% line:83% size:80% because if it has a cause, for various reasons, we obviously 03:58.933 --> 04:03.366 align:left position:20% line:83% size:70% want to know about that. x*So I'll just talk about some 04:03.366 --> 04:06.700 align:left position:10% line:83% size:80% of the non-idiopathic scoliosis. Because idiopathic scoliosis 04:06.700 --> 04:08.800 align:left position:20% line:83% size:70% is the dominant form of scoliosis, and 04:08.800 --> 04:11.800 align:left position:10% line:83% size:80% what we treat the most often. I'll focus most of my talk 04:11.800 --> 04:15.133 align:left position:10% line:83% size:80% on that, but just to touch on neuromuscular scoliosis. 04:15.133 --> 04:17.066 align:left position:10% line:83% size:80% It's important to realize, as we just talked about, 04:17.066 --> 04:19.333 align:left position:10% line:83% size:80% not all scoliosis is idiopathic, so it's always important 04:19.333 --> 04:21.400 align:left position:20% line:83% size:70% to search for etiology. x*So every patient that 04:21.400 --> 04:23.666 align:left position:30% line:83% size:60% has scoliosis, the first question I ask 04:23.666 --> 04:27.000 align:left position:10% line:83% size:80% is what's the underlying cause. Nine out of ten times, 04:27.000 --> 04:30.000 align:left position:20% line:83% size:70% the underlying cause is idiopathic. 04:30.000 --> 04:32.400 align:left position:10% line:83% size:80% But that one out of ten times will be something else. 04:32.400 --> 04:34.666 align:left position:20% line:83% size:70% x*This is a patient with neurofibromatosis, so they had 04:34.666 --> 04:37.000 align:left position:10% line:83% size:80% the classic cafe au lait spots. And they tend to have 04:37.000 --> 04:39.533 align:left position:10% line:83% size:80% different kinds of curves. So there are some clues 04:39.533 --> 04:41.866 align:left position:10% line:83% size:80% that will tell you that this may not be idiopathic. 04:41.866 --> 04:44.166 align:left position:20% line:83% size:70% If you have a long, sort of gradual curve, 04:44.166 --> 04:46.633 align:left position:20% line:83% size:70% a C-shaped curve, a long S-shaped curve, 04:46.633 --> 04:53.666 align:left position:20% line:83% size:70% that is consistent with the neuromuscular scoliosis. 04:53.666 --> 04:56.833 align:left position:10% line:83% size:80% x*If you have a very short, sharp curve, that's also 04:56.833 --> 05:00.700 align:left position:10% line:83% size:80% not consistent with idiopathic scoliosis. 05:00.700 --> 05:04.300 align:left position:10% line:83% size:80% And that can be very consistent with the congenital scoliosis. 05:04.300 --> 05:06.766 align:left position:20% line:83% size:70% Now congenital scoliosis is really something you're 05:06.766 --> 05:10.033 align:left position:20% line:83% size:70% born with and the bone just forms abnormally. 05:10.033 --> 05:12.300 align:left position:20% line:83% size:70% And there's really two broad categories 05:12.300 --> 05:15.266 align:left position:10% line:83% size:80% of this congenital scoliosis. In orthopedics, 05:15.266 --> 05:17.866 align:left position:10% line:83% size:80% we like to keep it very simple. It's either a failure 05:17.866 --> 05:20.200 align:left position:30% line:83% size:60% of formation or failure of segmentation. 05:20.200 --> 05:23.033 align:left position:10% line:83% size:80% So you may have a situation where you don't actually 05:23.033 --> 05:29.800 align:left position:20% line:83% size:70% segment like this bar that's shown here. 05:29.800 --> 05:32.566 align:left position:10% line:83% size:80% So that area's not segmented. Or you may have a failure 05:32.566 --> 05:36.733 align:left position:10% line:83% size:80% of formation, where the vertebra has not formed completely. 05:36.733 --> 05:41.633 align:left position:20% line:83% size:70% So those are the two. Over time, congenital scoliosis 05:41.633 --> 05:44.466 align:left position:30% line:83% size:60% can get worse or it can stay the same. 05:44.466 --> 05:47.266 align:left position:20% line:83% size:70% So a child may be born with a 30 degrees curve, and 05:47.266 --> 05:49.833 align:left position:10% line:83% size:80% that may stay the same forever, or it may get worse. 05:49.833 --> 05:53.500 align:left position:10% line:83% size:80% So with congenital scoliosis, we follow that over time. 05:53.500 --> 05:56.866 align:left position:10% line:83% size:80% If we see it getting worse, then we consider treatment. 05:56.866 --> 05:59.233 align:left position:10% line:83% size:80% x*Probably the most important thing to realize is about 30% 05:59.233 --> 06:02.800 align:left position:10% line:83% size:80% have underlying urogenical problems, especially renal 06:02.800 --> 06:06.233 align:left position:10% line:83% size:80% issues or cardiac issues, and those need to be evaluated. 06:06.233 --> 06:08.766 align:left position:10% line:83% size:80% And classically, we evaluate them with a renal ultrasound 06:08.766 --> 06:16.433 align:left position:20% line:83% size:70% or a cardiac ultrasound. So those are two of the most 06:16.433 --> 06:18.633 align:left position:20% line:83% size:70% common other forms. But certainly children 06:18.633 --> 06:21.366 align:left position:20% line:83% size:70% with cerebral palsy and other disorders 06:21.366 --> 06:24.700 align:left position:10% line:83% size:80% will have scoliosis as well. x*The number one cause, 06:24.700 --> 06:27.200 align:left position:20% line:83% size:70% nine out of ten children will have idiopathic scoliosis. 06:27.200 --> 06:29.366 align:left position:20% line:83% size:70% And the question is why do they have that. 06:29.366 --> 06:31.866 align:left position:10% line:83% size:80% And we don't really know. We don't even really know 06:31.866 --> 06:35.666 align:left position:10% line:83% size:80% why the vast majority of those curves are right-sided curves. 06:35.666 --> 06:38.866 align:left position:10% line:83% size:80% Various different theories have been brought forward. 06:38.866 --> 06:41.900 align:left position:30% line:83% size:60% Melatonin is one that in the 1990s 06:41.900 --> 06:45.966 align:left position:10% line:83% size:80% had a fair amount of support. If you take the pineal gland 06:45.966 --> 06:48.600 align:left position:30% line:83% size:60% out of chickens, they would develop scoliosis. 06:48.600 --> 06:51.233 align:left position:10% line:83% size:80% Then you treat these chickens with melatonin 06:51.233 --> 06:54.033 align:left position:10% line:83% size:80% and the scoliosis would go away. And we looked at that in humans, 06:54.033 --> 06:57.933 align:left position:10% line:83% size:80% it was really much more complex. Melatonin levels 06:57.933 --> 07:00.066 align:left position:20% line:83% size:70% would go up and down, and it was hard to determine 07:00.066 --> 07:02.366 align:left position:10% line:83% size:80% if that was related to it. It sort of fell out of favor, 07:02.366 --> 07:04.766 align:left position:20% line:83% size:70% and now it's starting to get into favor again. 07:04.766 --> 07:07.000 align:left position:20% line:83% size:70% x*We know that children's scoliosis have changes in the 07:07.000 --> 07:09.666 align:left position:10% line:83% size:80% equilibrium and proprioception, and that may be related 07:09.666 --> 07:12.233 align:left position:30% line:83% size:60% to scoliosis. And certainly some of these 07:12.233 --> 07:14.966 align:left position:10% line:83% size:80% have platelet abnormalities. So we don't really know 07:14.966 --> 07:17.366 align:left position:20% line:83% size:70% what the cause is. And I don't think there's 07:17.366 --> 07:19.666 align:left position:10% line:83% size:80% any reason to focus too much at this point, 07:19.666 --> 07:23.666 align:left position:20% line:83% size:70% until we find the cause. x*But there probably is 07:23.666 --> 07:27.400 align:left position:10% line:83% size:80% an underlying genetic etiology or at least a predisposition. 07:27.400 --> 07:30.266 align:left position:10% line:83% size:80% We know that because in general the chance of having scoliosis 07:30.266 --> 07:32.866 align:left position:20% line:83% size:70% goes up if you have a family history of that. 07:32.866 --> 07:35.533 align:left position:20% line:83% size:70% So it's up to 11% with a first-degree relative 07:35.533 --> 07:42.000 align:left position:40% line:83% size:50% and 1.4% with a third-degree relative. 07:42.000 --> 07:44.433 align:left position:20% line:83% size:70% x*The scoliosis exam is fairly straightforward. 07:44.433 --> 07:47.166 align:left position:10% line:83% size:80% These are actual pictures taken from a fairly old textbook, 07:47.166 --> 07:49.533 align:left position:30% line:83% size:60% as you can see. But in general, 07:49.533 --> 07:53.733 align:left position:10% line:83% size:80% you want to look at the patient. It's important to be able 07:53.733 --> 07:58.866 align:left position:20% line:83% size:70% to look at their hips and their shoulders, 07:58.866 --> 08:02.800 align:left position:10% line:83% size:80% because often that will be their primary complaint. 08:02.800 --> 08:05.166 align:left position:10% line:83% size:80% So you want to make sure their shoulders and hips are balanced. 08:05.166 --> 08:07.400 align:left position:20% line:83% size:70% But you can still have a scoliosis that's balanced 08:07.400 --> 08:10.433 align:left position:10% line:83% size:80% and it can not be so obvious. It really is amazing. 08:10.433 --> 08:13.033 align:left position:10% line:83% size:80% x*I remember a next door neighbor who was 8 years old. 08:13.033 --> 08:15.466 align:left position:10% line:83% size:80% She had a fairly significant scoliosis we ended up treating, 08:15.466 --> 08:17.733 align:left position:10% line:83% size:80% but when you would looked at her, you wouldn't know, 08:17.733 --> 08:19.866 align:left position:30% line:83% size:60% because she had a very balanced curve. 08:19.866 --> 08:22.233 align:left position:20% line:83% size:70% So hips and shoulders are very important. 08:22.233 --> 08:24.766 align:left position:20% line:83% size:70% And it's important for decision-making, but it's also 08:24.766 --> 08:27.400 align:left position:10% line:83% size:80% important to exam the spine carefully. 08:27.400 --> 08:29.800 align:left position:10% line:83% size:80% x*And the easiest way to do that is the Adams Forward Bend Test. 08:29.800 --> 08:32.133 align:left position:10% line:83% size:80% And that's where they have their feet together, and 08:32.133 --> 08:34.866 align:left position:10% line:83% size:80% they slowly bend forward and you really look for asymmetry. 08:34.866 --> 08:37.933 align:left position:20% line:83% size:70% It's termed a rib hump, which is probably not a very 08:37.933 --> 08:40.800 align:left position:20% line:83% size:70% complimentary term. But it's really fairly obvious, 08:40.800 --> 08:43.366 align:left position:20% line:83% size:70% and it's due to rotation of the spine, 08:43.366 --> 08:45.966 align:left position:10% line:83% size:80% not a curve of the spine. So in scoliosis, it's not just 08:45.966 --> 08:48.500 align:left position:20% line:83% size:70% a curve, but it's truly 3-dimensional through rotation. 08:48.500 --> 08:51.666 align:left position:10% line:83% size:80% As the ribs are rotated back, and they bend forward, 08:51.666 --> 08:54.200 align:left position:20% line:83% size:70% it becomes obvious. x*The one caveat to that is 08:54.200 --> 08:56.466 align:left position:20% line:83% size:70% somewhat the significant leg length inequality 08:56.466 --> 08:59.300 align:left position:10% line:83% size:80% will almost always have either a lumbar prominence, 08:59.300 --> 09:03.066 align:left position:10% line:83% size:80% or more likely a rib hump. So it can be very deceiving 09:03.066 --> 09:05.733 align:left position:20% line:83% size:70% if you exam someone with a leg length inequality. 09:05.733 --> 09:08.233 align:left position:10% line:83% size:80% So one of the important things to do is to make sure that 09:08.233 --> 09:10.500 align:left position:10% line:83% size:80% you exam them, that they don't have a leg length inequality. 09:10.500 --> 09:12.900 align:left position:10% line:83% size:80% And really the easiest way to do that is just to examine 09:12.900 --> 09:15.333 align:left position:30% line:83% size:60% them standing up with their knees extended 09:15.333 --> 09:17.866 align:left position:10% line:83% size:80% and look at their pelvis, because you'll be able to tell 09:17.866 --> 09:20.133 align:left position:20% line:83% size:70% if there's a leg length inequality greater than 09:20.133 --> 09:22.400 align:left position:30% line:83% size:60% a centimeter, simply by looking at them. 09:22.400 --> 09:24.633 align:left position:20% line:83% size:70% Using a tape measure is much more difficult 09:24.633 --> 09:26.933 align:left position:20% line:83% size:70% and much less accurate. So make sure they don't have 09:26.933 --> 09:29.166 align:left position:20% line:83% size:70% leg length inequality. x*Have them do 09:29.166 --> 09:31.500 align:left position:10% line:83% size:80% the Adams Forward Bend Test. You'll screen out just about 09:31.500 --> 09:33.700 align:left position:20% line:83% size:70% everyone with curves under 20 degrees with this test. 09:33.700 --> 09:36.066 align:left position:10% line:83% size:80% So it's unlikely to have a curve that's greater than 20 degrees 09:36.066 --> 09:39.433 align:left position:20% line:83% size:70% that you won't identify with this test. 09:39.433 --> 09:42.900 align:left position:10% line:83% size:80% x*The second thing is to always exam them from the side. 09:42.900 --> 09:45.566 align:left position:10% line:83% size:80% Look at the lateral view, because they may have 09:45.566 --> 09:47.600 align:left position:30% line:83% size:60% a kyphosis. And a lot of people 09:47.600 --> 09:50.166 align:left position:30% line:83% size:60% have a kyphosis. Here you can see a fairly 09:50.166 --> 09:54.166 align:left position:20% line:83% size:70% dramatic kyphosis. And it's actually termed 09:54.166 --> 09:56.566 align:left position:20% line:83% size:70% a gibbous, if it's not a gentle curve, but instead 09:56.566 --> 09:59.533 align:left position:10% line:83% size:80% it's a fairly dramatic curve. It's a gibbous 09:59.533 --> 10:02.066 align:left position:20% line:83% size:70% and that's abnormal. So a gentle curve is normal 10:02.066 --> 10:04.500 align:left position:30% line:83% size:60% and routine. But a more significant curve 10:04.500 --> 10:07.066 align:left position:10% line:83% size:80% isn't, and that has to be evaluated. 10:07.066 --> 10:09.633 align:left position:20% line:83% size:70% And interesting enough, children with scoliosis, 10:09.633 --> 10:12.366 align:left position:20% line:83% size:70% idiopathic scoliosis, actually tend to have 10:12.366 --> 10:15.066 align:left position:20% line:83% size:70% decreased kyphosis, or a straighter back. 10:15.066 --> 10:18.866 align:left position:10% line:83% size:80% I will show examples of that and why that's important. 10:18.866 --> 10:25.033 align:left position:20% line:83% size:70% x*If you see a scoliosis, the next step then is to do a 10:25.033 --> 10:28.800 align:left position:10% line:83% size:80% fairly careful neurologic exam. Because, again, the most 10:28.800 --> 10:31.700 align:left position:20% line:83% size:70% important thing to do, obviously, is to identify 10:31.700 --> 10:34.033 align:left position:30% line:83% size:60% the scoliosis. The second most important 10:34.033 --> 10:36.333 align:left position:10% line:83% size:80% thing to do is to rule out other causes. 10:36.333 --> 10:38.666 align:left position:10% line:83% size:80% The best way to rule that out is with a careful 10:38.666 --> 10:40.866 align:left position:30% line:83% size:60% neurologic exam. x*Abnormal neurologic exam should 10:40.866 --> 10:43.300 align:left position:10% line:83% size:80% raise a red flag that this is not idiopathic scoliosis, 10:43.300 --> 10:50.133 align:left position:20% line:83% size:70% or at least deserves and needs further evaluation. 10:50.133 --> 10:53.066 align:left position:20% line:83% size:70% x*School screening is a little bit controversial. 10:53.066 --> 10:55.033 align:left position:10% line:83% size:80% It fell very much in favor on the east coast. 10:55.033 --> 10:56.900 align:left position:20% line:83% size:70% It's fallen very much out of favor over the last 10:56.900 --> 10:59.800 align:left position:30% line:83% size:60% couple of years. And I think that's in part 10:59.800 --> 11:02.700 align:left position:10% line:83% size:80% because school screenings predicated on the idea that 11:02.700 --> 11:05.433 align:left position:20% line:83% size:70% if you find someone with a scoliosis at early age, 11:05.433 --> 11:08.766 align:left position:10% line:83% size:80% you've got a reasonable way to treat that patient 11:08.766 --> 11:14.733 align:left position:20% line:83% size:70% that is effective, and is less of a burden 11:14.733 --> 11:17.433 align:left position:10% line:83% size:80% than other forms of treatment. So in general, what that means 11:17.433 --> 11:19.900 align:left position:20% line:83% size:70% is you have to believe and feel that bracing 11:19.900 --> 11:22.533 align:left position:20% line:83% size:70% is a reasonable option. Many people no longer feel that 11:22.533 --> 11:26.966 align:left position:10% line:83% size:80% bracing is a reasonable option. I'll talk about that 11:26.966 --> 11:30.333 align:left position:10% line:83% size:80% a little bit under treatment. It's also not particularly 11:30.333 --> 11:32.600 align:left position:20% line:83% size:70% cost-effective to screen hundreds and hundreds 11:32.600 --> 11:36.366 align:left position:20% line:83% size:70% of patients, so it's gone in and out of favor. 11:36.366 --> 11:39.066 align:left position:10% line:83% size:80% I certainly think, personally, that school screening is 11:39.066 --> 11:41.300 align:left position:10% line:83% size:80% a very reasonable thing to do, and I actually believe in 11:41.300 --> 11:47.633 align:left position:10% line:83% size:80% bracing, but that is subject to some controversy. 11:47.633 --> 11:51.066 align:left position:10% line:83% size:80% x*There are different ways to do a school screening, 11:51.066 --> 11:53.466 align:left position:10% line:83% size:80% but if you use a scoliometer, which is that little device 11:53.466 --> 11:57.333 align:left position:20% line:83% size:70% that shows you how much of a trunk asymmetry there is, 11:57.333 --> 12:01.733 align:left position:10% line:83% size:80% what number, what degree you use will depend 12:01.733 --> 12:04.200 align:left position:20% line:83% size:70% on your referral rate. So in you've got a fairly high 12:04.200 --> 12:06.666 align:left position:30% line:83% size:60% cut off of seven or eight degrees, you're going 12:06.666 --> 12:09.800 align:left position:10% line:83% size:80% to refer very few patients. Unfortunately, you are more 12:09.800 --> 12:12.266 align:left position:10% line:83% size:80% likely to miss a few patients that have scoliosis. 12:12.266 --> 12:15.400 align:left position:10% line:83% size:80% And just the opposite's true if you use a fairly low number 12:15.400 --> 12:17.633 align:left position:30% line:83% size:60% as a cut off. So in general, the number to 12:17.633 --> 12:20.533 align:left position:10% line:83% size:80% use, if you use a scoliometer, is somewhere between five 12:20.533 --> 12:22.733 align:left position:30% line:83% size:60% and seven. And I think most people use 12:22.733 --> 12:26.033 align:left position:10% line:83% size:80% about a six degree cut off for when to refer patients 12:26.033 --> 12:31.166 align:left position:30% line:83% size:60% and when not to. Some people have said this is 12:31.166 --> 12:33.533 align:left position:10% line:83% size:80% not a very valuable test. The Adams Forward Bending Test 12:33.533 --> 12:35.633 align:left position:20% line:83% size:70% is not that accurate, scoliometers 12:35.633 --> 12:38.000 align:left position:20% line:83% size:70% are not that useful. But the truth is 12:38.000 --> 12:40.766 align:left position:10% line:83% size:80% it actually is fairly accurate. It's got a sensitivity of about 12:40.766 --> 12:44.966 align:left position:10% line:83% size:80% 85%, specificity of over 90%, and that's from a study 12:44.966 --> 12:47.633 align:left position:20% line:83% size:70% that wanted to disprove its usefulness. 12:47.633 --> 12:51.500 align:left position:30% line:83% size:60% So I think it's a fairly useful exam. 12:51.500 --> 12:53.733 align:left position:10% line:83% size:80% x*If we see patients, we have the luxury of having x-rays. 12:53.733 --> 12:55.800 align:left position:10% line:83% size:80% So we really, not that we don't examine the patient, but we now 12:55.800 --> 12:59.800 align:left position:10% line:83% size:80% have a lot more information, and it's very reasonable to get 12:59.800 --> 13:02.466 align:left position:10% line:83% size:80% an x-ray if you're concerned about scoliosis. 13:02.466 --> 13:04.533 align:left position:20% line:83% size:70% How you get the x-ray is important. 13:04.533 --> 13:06.633 align:left position:20% line:83% size:70% If you get an x-ray with a patient standing 13:06.633 --> 13:09.300 align:left position:10% line:83% size:80% with a leg length inequality, they may have a scoliosis 13:09.300 --> 13:12.566 align:left position:10% line:83% size:80% they wouldn't normally have. So how you get the x-ray 13:12.566 --> 13:15.000 align:left position:20% line:83% size:70% is fairly important. We typically get standing x-rays 13:15.000 --> 13:17.266 align:left position:20% line:83% size:70% assuming they don't have a leg length inequality. 13:17.266 --> 13:19.800 align:left position:10% line:83% size:80% If they do, then we'll get a sitting x-ray. 13:19.800 --> 13:23.000 align:left position:10% line:83% size:80% And if they are unable to stand because they have got 13:23.000 --> 13:25.966 align:left position:10% line:83% size:80% other conditions or disorders, then we can do supine x-ray. 13:25.966 --> 13:28.266 align:left position:20% line:83% size:70% We always include a lateral x-ray. 13:28.266 --> 13:30.333 align:left position:10% line:83% size:80% And the reason we include a lateral x-ray is because 13:30.333 --> 13:34.933 align:left position:20% line:83% size:70% we worry about kyphosis, an abnormal kyphosis, which 13:34.933 --> 13:38.300 align:left position:10% line:83% size:80% occurs in about 10% of patients. Spinal listhesis, which can 13:38.300 --> 13:41.066 align:left position:10% line:83% size:80% occur either independently or associated with scoliosis, 13:41.066 --> 13:44.466 align:left position:10% line:83% size:80% occurs about 5% of the time. And then you can get 13:44.466 --> 13:48.166 align:left position:20% line:83% size:70% a thoracic lordosis. And that's actually very common 13:48.166 --> 13:51.500 align:left position:20% line:83% size:70% in idiopathic scoliosis. So hypokyphosis 13:51.500 --> 13:54.966 align:left position:10% line:83% size:80% or lordosis or a flat back, that's quite common. 13:54.966 --> 13:56.966 align:left position:20% line:83% size:70% And if it's very severe, it can actually affect 13:56.966 --> 14:01.666 align:left position:20% line:83% size:70% pulmonary function. x*If we get to the point where 14:01.666 --> 14:04.100 align:left position:30% line:83% size:60% we do treatment, then we look at bending films, 14:04.100 --> 14:06.566 align:left position:10% line:83% size:80% and that gives us some idea of the flexibility 14:06.566 --> 14:12.033 align:left position:30% line:83% size:60% of the curve. How much it bends back 14:12.033 --> 14:14.833 align:left position:30% line:83% size:60% and forth. x*For those that aren't familiar 14:14.833 --> 14:17.233 align:left position:20% line:83% size:70% with the Cobb angle, this is what we use to determine 14:17.233 --> 14:19.366 align:left position:20% line:83% size:70% the degree of curve. If you think too much 14:19.366 --> 14:21.766 align:left position:10% line:83% size:80% about this, it will give you a little bit of a headache, 14:21.766 --> 14:24.066 align:left position:10% line:83% size:80% but this is not the only way to describe a curve. 14:24.066 --> 14:26.333 align:left position:10% line:83% size:80% A sharp curve and a gentle curve may get the same number 14:26.333 --> 14:28.633 align:left position:10% line:83% size:80% and be very different curves. But this is how it's been 14:28.633 --> 14:30.966 align:left position:10% line:83% size:80% described, and I think it's probably still the best way. 14:30.966 --> 14:33.233 align:left position:10% line:83% size:80% There are other things that we use, but this is probably 14:33.233 --> 14:35.433 align:left position:20% line:83% size:70% a reasonable marker. x*The Cobb angle, simply, 14:35.433 --> 14:37.600 align:left position:20% line:83% size:70% is taken from an x-ray. And what you do is 14:37.600 --> 14:39.800 align:left position:30% line:83% size:60% you measure down until you get the vertebra 14:39.800 --> 14:42.266 align:left position:20% line:83% size:70% that's the most tilted. And once you find the vertebra 14:42.266 --> 14:44.666 align:left position:20% line:83% size:70% that's the most tilted, in this case, it's the sixth 14:44.666 --> 14:47.433 align:left position:20% line:83% size:70% thoracic vertebra, you draw a line that's parallel 14:47.433 --> 14:52.066 align:left position:30% line:83% size:60% to the disk or to the end plate, and 14:52.066 --> 14:56.266 align:left position:10% line:83% size:80% just take that out laterally or medially, and that's 14:56.266 --> 15:00.733 align:left position:20% line:83% size:70% this line right here. Let's see if I can do this. 15:00.733 --> 15:03.000 align:left position:10% line:83% size:80% That's this line right there. Then you do the same thing 15:03.000 --> 15:05.266 align:left position:40% line:83% size:50% here. And where these two meet, 15:05.266 --> 15:07.633 align:left position:10% line:83% size:80% that angle is the Cobb angle. Now sometimes where they meet 15:07.633 --> 15:10.033 align:left position:10% line:83% size:80% is so far off the x-ray, you just have to make a right angle 15:10.033 --> 15:12.900 align:left position:10% line:83% size:80% for each and measure that angle. But as basic trigonometry 15:12.900 --> 15:16.033 align:left position:10% line:83% size:80% tells you it's the same angle, it's just that our x-rays 15:16.033 --> 15:18.300 align:left position:10% line:83% size:80% aren't wide enough to draw it way out here. 15:18.300 --> 15:20.900 align:left position:10% line:83% size:80% Is that's all the Cobb angle is. x*And it gives you a general idea 15:20.900 --> 15:23.733 align:left position:10% line:83% size:80% of what the curve is, and if the curve is better 15:23.733 --> 15:26.133 align:left position:20% line:83% size:70% or it's getting worse. People will come in and say 15:26.133 --> 15:29.300 align:left position:20% line:83% size:70% they've got a 15% curve, which is really a degree curve, 15:29.300 --> 15:31.500 align:left position:20% line:83% size:70% but they all know what that number is. 15:31.500 --> 15:33.700 align:left position:20% line:83% size:70% Patients all know what that number is. 15:33.700 --> 15:35.600 align:left position:20% line:83% size:70% x*How you get the x-ray is kind of interesting, because 15:35.600 --> 15:37.633 align:left position:10% line:83% size:80% we get a straight AP x-ray. But we said that 15:37.633 --> 15:40.166 align:left position:10% line:83% size:80% curves aren't really bent, they are actually rotated. 15:40.166 --> 15:42.666 align:left position:20% line:83% size:70% So if you really wanted to get an accurate x-ray, 15:42.666 --> 15:45.133 align:left position:10% line:83% size:80% you'd have to get an x-ray with the beam coming in at an angle, 15:45.133 --> 15:47.266 align:left position:20% line:83% size:70% and that's called the Stagnera view, 15:47.266 --> 15:49.666 align:left position:10% line:83% size:80% and occasionally we'll do that. And it's very interesting. 15:49.666 --> 15:51.900 align:left position:20% line:83% size:70% If get that x-ray, you may take a 30-degree curve 15:51.900 --> 15:54.066 align:left position:20% line:83% size:70% and find out it's really a 60-degree curve, 15:54.066 --> 16:01.333 align:left position:10% line:83% size:80% because now you're getting it at its greatest deformity. 16:01.333 --> 16:04.166 align:left position:10% line:83% size:80% x*We look a lot at kyphosis. As we said, idiopathic scoliosis 16:04.166 --> 16:07.000 align:left position:20% line:83% size:70% won't be kyphotic, they won't have increased 16:07.000 --> 16:09.566 align:left position:20% line:83% size:70% round back or hump back. They'll actually be straighter. 16:09.566 --> 16:12.366 align:left position:10% line:83% size:80% And in fact, as we'll show you, if you see someone 16:12.366 --> 16:15.333 align:left position:10% line:83% size:80% that's got increased kyphosis and a scoliosis, 16:15.333 --> 16:18.166 align:left position:20% line:83% size:70% that raises a red flag, that you have to think 16:18.166 --> 16:20.300 align:left position:10% line:83% size:80% there's something else going on. x*This is not idiopathic 16:20.300 --> 16:23.366 align:left position:30% line:83% size:60% scoliosis. You can measure kyphosis, 16:23.366 --> 16:26.000 align:left position:20% line:83% size:70% exactly like you measure the Cobb angle, and measure that 16:26.000 --> 16:29.033 align:left position:10% line:83% size:80% curve in an identical fashion. Draw your lines 16:29.033 --> 16:31.533 align:left position:10% line:83% size:80% parallel to the end plates and getting that angle. 16:31.533 --> 16:34.500 align:left position:10% line:83% size:80% It's a little bit hard to do because of the soft tissue. 16:34.500 --> 16:37.000 align:left position:10% line:83% size:80% As you get up in the thoracic spine, it's hard 16:37.000 --> 16:40.866 align:left position:10% line:83% size:80% to actually see the vertebra. So you can measure 16:40.866 --> 16:44.866 align:left position:10% line:83% size:80% from the upper thoracic curve, to the T-12, and if that 16:44.866 --> 16:47.300 align:left position:10% line:83% size:80% is greater than 40 degrees, you start thinking 16:47.300 --> 16:50.833 align:left position:10% line:83% size:80% they have increased kyphosis. Because that's hard to measure, 16:50.833 --> 16:54.433 align:left position:10% line:83% size:80% there's a test you can use from T-5 to T-12. 16:54.433 --> 16:57.200 align:left position:10% line:83% size:80% And if that's over 32 degrees, it's been shown-- 16:57.200 --> 16:59.533 align:left position:10% line:83% size:80% If it's under 32 degrees, it's not kyphosis. 16:59.533 --> 17:02.033 align:left position:20% line:83% size:70% If it's over 32 degrees, then it's a pretty good 17:02.033 --> 17:04.366 align:left position:20% line:83% size:70% screening test that something else may be going on. 17:04.366 --> 17:07.500 align:left position:20% line:83% size:70% So that's a reasonable screening test to do 17:07.500 --> 17:11.000 align:left position:20% line:83% size:70% on a spinal x-ray. x*It's also important to 17:11.000 --> 17:13.400 align:left position:10% line:83% size:80% look down at the lumbar spine, to see if there's any slippage 17:13.400 --> 17:20.266 align:left position:10% line:83% size:80% or spondylolisthesis, and those two tend to go together. 17:20.266 --> 17:22.433 align:left position:10% line:83% size:80% x*So again, this is kyphosis, this is actually 17:22.433 --> 17:24.733 align:left position:20% line:83% size:70% one of our partners. Kyphosis is very common, 17:24.733 --> 17:27.133 align:left position:10% line:83% size:80% a round back is not uncommon. But when you see this 17:27.133 --> 17:31.666 align:left position:10% line:83% size:80% sharp curve or gibbous, then that raises a greater concern. 17:31.666 --> 17:34.500 align:left position:10% line:83% size:80% Kyphosis in itself, though, is not an issue. 17:34.500 --> 17:37.133 align:left position:20% line:83% size:70% Mark Spitz, for example, won seven gold medals. 17:37.133 --> 17:39.200 align:left position:10% line:83% size:80% And they think it may be related to the fact that he did have 17:39.200 --> 17:41.400 align:left position:20% line:83% size:70% kyphosis, and he had a larger lung volume. 17:41.400 --> 17:44.000 align:left position:10% line:83% size:80% So kyphosis in itself that's not painful, and not getting worse, 17:44.000 --> 17:46.766 align:left position:10% line:83% size:80% is not particularly a problem. x*Interestingly enough, just the 17:46.766 --> 17:49.300 align:left position:10% line:83% size:80% opposite, the decreased kyphosis can be an issue, 17:49.300 --> 17:51.966 align:left position:10% line:83% size:80% and can decrease lung volume if it's severe. 17:51.966 --> 17:55.766 align:left position:10% line:83% size:80% x*We've discussed a little bit about this not just being 17:55.766 --> 17:58.600 align:left position:20% line:83% size:70% a lateral curvature, but also a rotation. 17:58.600 --> 18:00.633 align:left position:10% line:83% size:80% And there are some ways you can estimate how much rotation 18:00.633 --> 18:03.400 align:left position:10% line:83% size:80% just by looking at the x-ray. One way is to look at 18:03.400 --> 18:05.933 align:left position:30% line:83% size:60% the pedicles. So if you look at the x-rays, 18:05.933 --> 18:08.933 align:left position:10% line:83% size:80% you can see the pedicles on end. Pedicles are very important 18:08.933 --> 18:11.400 align:left position:10% line:83% size:80% to the spine, because you always want to see two pedicles. 18:11.400 --> 18:15.633 align:left position:10% line:83% size:80% A missing pedicle is a big issue and can be consistent, 18:15.633 --> 18:20.133 align:left position:10% line:83% size:80% especially with different metastatic diseases. 18:20.133 --> 18:22.266 align:left position:30% line:83% size:60% So always try to identify the pedicles. 18:22.266 --> 18:24.533 align:left position:10% line:83% size:80% x*On scoliosis, you may not see it, because it's rotated. 18:24.533 --> 18:27.300 align:left position:10% line:83% size:80% It may, as the spine rotates, the pedicles may actually rotate 18:27.300 --> 18:30.833 align:left position:10% line:83% size:80% and you may not see them. And if you look at the pedicles, 18:30.833 --> 18:33.300 align:left position:20% line:83% size:70% you can get some idea of how much rotation they are. 18:33.300 --> 18:36.200 align:left position:10% line:83% size:80% So here's where the pedicles should lie. 18:36.200 --> 18:38.666 align:left position:10% line:83% size:80% And as it starts to rotate, the pedicles look like 18:38.666 --> 18:41.200 align:left position:10% line:83% size:80% they're coming off the spine, and you can grade it, one, this 18:41.200 --> 18:45.200 align:left position:10% line:83% size:80% pedicle's right on the curve and so as the pedicle rotates 18:45.200 --> 18:48.900 align:left position:10% line:83% size:80% to it's midline, it's three. Across midline, it's four. 18:48.900 --> 18:50.900 align:left position:20% line:83% size:70% So you get some idea of how much rotation's 18:50.900 --> 18:54.033 align:left position:10% line:83% size:80% associated with the curve. x*Rotation is important to note, 18:54.033 --> 18:56.500 align:left position:20% line:83% size:70% because if you would try to recreate a scoliosis, 18:56.500 --> 18:59.000 align:left position:10% line:83% size:80% if you just bend to one side, you'd get a curve, 18:59.000 --> 19:01.033 align:left position:20% line:83% size:70% but you wouldn't get any rotation in it. 19:01.033 --> 19:03.266 align:left position:10% line:83% size:80% Or, if they have a leg length inequality, typically 19:03.266 --> 19:05.666 align:left position:20% line:83% size:70% you'll get a curve, but you won't get a rotation. 19:05.666 --> 19:07.766 align:left position:20% line:83% size:70% So if you see a curve, and you're thinking 19:07.766 --> 19:09.966 align:left position:20% line:83% size:70% is this a real curve or maybe they're standing funny, 19:09.966 --> 19:16.366 align:left position:10% line:83% size:80% and you see a lot of rotation, then you know it's a real curve. 19:16.366 --> 19:19.566 align:left position:10% line:83% size:80% x*So, I'm sure everyone here is very good 19:19.566 --> 19:22.066 align:left position:10% line:83% size:80% at identifying scoliosis. We've looked at how 19:22.066 --> 19:24.533 align:left position:20% line:83% size:70% it's measured on x-ray. Some of these patients 19:24.533 --> 19:27.466 align:left position:10% line:83% size:80% really deserve to get an MRI. And the reason is a certain 19:27.466 --> 19:30.833 align:left position:20% line:83% size:70% percentage, it's really a small percentage of children, 19:30.833 --> 19:34.266 align:left position:20% line:83% size:70% who have scoliosis will have interspinal pathology. 19:34.266 --> 19:36.566 align:left position:10% line:83% size:80% And by that, that doesn't usually mean a tumor, 19:36.566 --> 19:40.566 align:left position:10% line:83% size:80% it usually means a hydromyelia, or there could be 19:40.566 --> 19:45.633 align:left position:20% line:83% size:70% a little fibrous band across the spine or to the cord. 19:45.633 --> 19:49.000 align:left position:10% line:83% size:80% A small percentage, somewhere between one and four percent 19:49.000 --> 19:51.866 align:left position:10% line:83% size:80% will have interspinal pathology. And there are ways 19:51.866 --> 19:54.633 align:left position:20% line:83% size:70% you can identify that. x*So different people have 19:54.633 --> 19:57.233 align:left position:20% line:83% size:70% looked at different ways of identifying that. 19:57.233 --> 19:59.766 align:left position:20% line:83% size:70% I think any patient under age 11 who has scoliosis, 19:59.766 --> 20:04.466 align:left position:20% line:83% size:70% is probably worth getting an MRI. 20:04.466 --> 20:07.666 align:left position:20% line:83% size:70% If you look at a number of different studies, 20:07.666 --> 20:12.200 align:left position:10% line:83% size:80% it shows a much higher incidence of interspinal abnormalities 20:12.200 --> 20:15.066 align:left position:20% line:83% size:70% in children under 11. So across the board, it's small, 20:15.066 --> 20:23.433 align:left position:10% line:83% size:80% but under 11, it's about 15% I'm sorry, about 50%. 20:23.433 --> 20:26.300 align:left position:20% line:83% size:70% x*The other issue is that people have different changes 20:26.300 --> 20:28.800 align:left position:20% line:83% size:70% on physical exam, and what kind of changes? 20:28.800 --> 20:31.766 align:left position:10% line:83% size:80% It can be a persistent headache. It can be neck and back pain. 20:31.766 --> 20:34.533 align:left position:20% line:83% size:70% It can be abnormal neurologic exam. 20:34.533 --> 20:37.600 align:left position:10% line:83% size:80% And the one exam that we've looked at is abdominal reflexes. 20:37.600 --> 20:40.533 align:left position:20% line:83% size:70% So if you lightly touch the abdomen, you'll see 20:40.533 --> 20:42.566 align:left position:10% line:83% size:80% the abdominal muscles contract. And that should be symmetrical 20:42.566 --> 20:44.566 align:left position:20% line:83% size:70% on four quadrants. If you use umbilicus 20:44.566 --> 20:47.633 align:left position:10% line:83% size:80% as a midpoint, you can do upper left, upper right, 20:47.633 --> 20:50.666 align:left position:20% line:83% size:70% lower right, lower left. You should have fairly symmetric 20:50.666 --> 20:53.600 align:left position:20% line:83% size:70% abdominal reflexes. If you don't have that, 20:53.600 --> 20:55.633 align:left position:20% line:83% size:70% that's a consideration they may have an abnormal 20:55.633 --> 20:58.700 align:left position:30% line:83% size:60% neurologic exam. And your standard neurologic 20:58.700 --> 21:01.166 align:left position:10% line:83% size:80% exam, which I'm sure you do more carefully than we do, 21:01.166 --> 21:03.900 align:left position:30% line:83% size:60% is important. And if that's abnormal, 21:03.900 --> 21:06.366 align:left position:10% line:83% size:80% then those are things to raise a red flag and say look, 21:06.366 --> 21:11.733 align:left position:20% line:83% size:70% we should get an MRI. x*Any left thoracic curve. 21:11.733 --> 21:13.700 align:left position:30% line:83% size:60% For some reason, idiopathic scoliosis 21:13.700 --> 21:17.200 align:left position:20% line:83% size:70% is always to the right. If it's left, about a third 21:17.200 --> 21:19.900 align:left position:20% line:83% size:70% will have underlying neurologic etiology. 21:19.900 --> 21:22.933 align:left position:10% line:83% size:80% It could be something obvious. It could be cerebral palsy 21:22.933 --> 21:26.233 align:left position:20% line:83% size:70% or some other diagnosis, so those are the reasons. 21:26.233 --> 21:28.933 align:left position:10% line:83% size:80% Under 11, abnormal neurologic exam, or a left curve, or 21:28.933 --> 21:33.233 align:left position:10% line:83% size:80% a curve with increased kyphosis, all deserve further evaluation. 21:33.233 --> 21:35.833 align:left position:20% line:83% size:70% Assuming they don't have any of that, and you're 21:35.833 --> 21:38.566 align:left position:10% line:83% size:80% pretty confident it's idiopathic scoliosis, then the next step 21:38.566 --> 21:40.966 align:left position:10% line:83% size:80% is figuring out, is this really going to get worse or not. 21:40.966 --> 21:43.266 align:left position:20% line:83% size:70% x*Because if it's not going to get worse, who cares? 21:43.266 --> 21:45.800 align:left position:10% line:83% size:80% Scoliosis will not kill you. It's not a tumor, 21:45.800 --> 21:48.466 align:left position:10% line:83% size:80% or a fracture, or an infection. So really the concern is, 21:48.466 --> 21:51.333 align:left position:10% line:83% size:80% is this going to get worse? And it depends, really, 21:51.333 --> 21:53.366 align:left position:30% line:83% size:60% on two things. It depends 21:53.366 --> 21:55.666 align:left position:10% line:83% size:80% on the size of the angle. So if you've got a big curve, 21:55.666 --> 21:58.066 align:left position:20% line:83% size:70% chances are more likely it will get worse. 21:58.066 --> 22:00.300 align:left position:20% line:83% size:70% It's a little bit like the Leaning Tower of Pisa. 22:00.300 --> 22:03.633 align:left position:10% line:83% size:80% The more it leans, the more likely it's going to fall. 22:03.633 --> 22:05.866 align:left position:10% line:83% size:80% So if it's under ten degrees, the chance of it getting worse 22:05.866 --> 22:08.066 align:left position:20% line:83% size:70% in general are small. Over 40, it's greater. 22:08.066 --> 22:10.533 align:left position:10% line:83% size:80% x*But there's other factors that come into play, 22:10.533 --> 22:13.666 align:left position:10% line:83% size:80% and probably the second most important is-- 22:13.666 --> 22:16.233 align:left position:20% line:83% size:70% Well, I'll just touch on female/male ratio. 22:16.233 --> 22:18.566 align:left position:10% line:83% size:80% Scoliosis is much more common in females. 22:18.566 --> 22:21.633 align:left position:20% line:83% size:70% Small curves are almost equally as common. 22:21.633 --> 22:24.200 align:left position:10% line:83% size:80% But the bigger curve you get, the more likely and the more 22:24.200 --> 22:27.400 align:left position:10% line:83% size:80% asymmetric that balance is, so as you get to be big curves, 22:27.400 --> 22:32.533 align:left position:20% line:83% size:70% it's much more common to be females than male. 22:32.533 --> 22:34.466 align:left position:20% line:83% size:70% x*So part of the issue is deciding natural history. 22:34.466 --> 22:37.800 align:left position:20% line:83% size:70% A 25 degree curve, like we see up here on the left, 22:37.800 --> 22:39.933 align:left position:20% line:83% size:70% is really not an issue. It will not effect you, 22:39.933 --> 22:43.066 align:left position:10% line:83% size:80% it should not cause lower back pain or long-term issues. 22:43.066 --> 22:45.000 align:left position:20% line:83% size:70% But some of these curves go on like this one, 22:45.000 --> 22:47.566 align:left position:20% line:83% size:70% and get to be severe, and some of them don't. 22:47.566 --> 22:49.600 align:left position:10% line:83% size:80% And that's really the focus of most of the research now. 22:49.600 --> 22:52.533 align:left position:10% line:83% size:80% Figuring out which one of these curves will stay 25 degrees, 22:52.533 --> 22:55.300 align:left position:20% line:83% size:70% which ones go to 102, because that's what we're going 22:55.300 --> 22:58.733 align:left position:30% line:83% size:60% to need to know when to intervene. 22:58.733 --> 23:02.166 align:left position:20% line:83% size:70% I don't know which ones will necessarily go 23:02.166 --> 23:05.033 align:left position:20% line:83% size:70% and which ones don't. x*But we do have some 23:05.033 --> 23:07.333 align:left position:30% line:83% size:60% information. And so at presentation, 23:07.333 --> 23:10.266 align:left position:10% line:83% size:80% if the child is very young and they have a big curve, 23:10.266 --> 23:12.300 align:left position:20% line:83% size:70% as you might guess, those are much more likely 23:12.300 --> 23:14.866 align:left position:30% line:83% size:60% to get worse. If they're older, they've 23:14.866 --> 23:17.266 align:left position:10% line:83% size:80% gone through the growth spurt and they have a small curve, 23:17.266 --> 23:20.566 align:left position:10% line:83% size:80% it's very unlikely to get worse. And just some general things. 23:20.566 --> 23:23.533 align:left position:20% line:83% size:70% A curve over 20 degrees and under age 10, 23:23.533 --> 23:26.266 align:left position:20% line:83% size:70% is going to progress virtually 100% of the time. 23:26.266 --> 23:28.500 align:left position:20% line:83% size:70% So if you just use as a general marker, 23:28.500 --> 23:30.766 align:left position:20% line:83% size:70% a child is under age 10, a curve over 20 degrees, 23:30.766 --> 23:33.900 align:left position:10% line:83% size:80% this one's going to get worse. You'll want to treat it. 23:33.900 --> 23:36.066 align:left position:20% line:83% size:70% I would treat it, certainly with bracing, 23:36.066 --> 23:38.533 align:left position:20% line:83% size:70% but you want to treat it even at a fairly small curve. 23:38.533 --> 23:41.633 align:left position:20% line:83% size:70% x*If they're over 15, and the curve is under 20 degrees, 23:41.633 --> 23:44.033 align:left position:20% line:83% size:70% it's only a 4% chance of getting worse. 23:44.033 --> 23:46.366 align:left position:10% line:83% size:80% And even then, it's probably never going to get worse to 23:46.366 --> 23:51.866 align:left position:10% line:83% size:80% the point that it requires any kind of significant treatment. 23:51.866 --> 23:53.966 align:left position:10% line:83% size:80% There are a lot of other things you can do, if you wanted 23:53.966 --> 23:56.266 align:left position:10% line:83% size:80% to try to narrow that down a little bit. 23:56.266 --> 23:58.200 align:left position:20% line:83% size:70% I'm not sure they help that much. 23:58.200 --> 24:00.533 align:left position:20% line:83% size:70% x*People have looked at, how can you tell whether 24:00.533 --> 24:04.033 align:left position:10% line:83% size:80% this child is mature or not. I don't do the Tanner Stages, 24:04.033 --> 24:06.166 align:left position:10% line:83% size:80% but we will look at x-rays of the hip 24:06.166 --> 24:09.500 align:left position:10% line:83% size:80% and we can look at the Risser. The Risser score actually 24:09.500 --> 24:13.300 align:left position:10% line:83% size:80% looks at the iliac apophysis to see when it forms. 24:13.300 --> 24:18.400 align:left position:10% line:83% size:80% And if you look down here, there's apophysis. 24:18.400 --> 24:21.566 align:left position:20% line:83% size:70% And it's forming. It has not fully consolidated, 24:21.566 --> 24:24.266 align:left position:10% line:83% size:80% so there's this black line. It kind of starts in front 24:24.266 --> 24:27.066 align:left position:10% line:83% size:80% and works all the way back, to there and you can divide that 24:27.066 --> 24:29.333 align:left position:30% line:83% size:60% into quadrants. Risser one and two is over here. 24:29.333 --> 24:32.366 align:left position:10% line:83% size:80% As it goes back, it's four. And then as you get to be 24:32.366 --> 24:34.633 align:left position:10% line:83% size:80% an adult, it completely fuses, and you can't even see 24:34.633 --> 24:38.000 align:left position:30% line:83% size:60% that line. That's not very accurate, so 24:38.000 --> 24:40.033 align:left position:10% line:83% size:80% I wouldn't spend a lot of time worrying about that, but it's 24:40.033 --> 24:42.433 align:left position:10% line:83% size:80% what's been used historically for years. 24:42.433 --> 24:44.866 align:left position:10% line:83% size:80% If their Risser is zero or one, they're immature, 24:44.866 --> 24:47.233 align:left position:10% line:83% size:80% if they're anything more, they're mature. 24:47.233 --> 24:49.433 align:left position:10% line:83% size:80% The bottom line is by the time you really see this, 24:49.433 --> 24:51.833 align:left position:20% line:83% size:70% they're already mature, so it's not all that helpful. 24:51.833 --> 24:54.166 align:left position:10% line:83% size:80% x*The triradiated cartilage is at the hip, and I apologize, 24:54.166 --> 24:56.833 align:left position:10% line:83% size:80% it's just off this x-ray. But it's where the different 24:56.833 --> 24:59.166 align:left position:10% line:83% size:80% bones of the hip come together, and when that fuses, 24:59.166 --> 25:02.166 align:left position:20% line:83% size:70% once that's fused, they are also skeletally mature. 25:02.166 --> 25:05.266 align:left position:10% line:83% size:80% So open triradiated cartilage in itself is a risk. 25:05.266 --> 25:08.700 align:left position:20% line:83% size:70% If it's open, the chance of progression is about 40%. 25:08.700 --> 25:14.566 align:left position:20% line:83% size:70% x*This is the classic risk factor, so it's looking at 25:14.566 --> 25:17.833 align:left position:20% line:83% size:70% that risk assigned. Again, people who are 25:17.833 --> 25:21.066 align:left position:10% line:83% size:80% less mature, so we're not looking at age, but less mature, 25:21.066 --> 25:24.966 align:left position:30% line:83% size:60% Risser is 0-1 curves that are over 20 degrees, 25:24.966 --> 25:28.966 align:left position:10% line:83% size:80% 68% chance of progressing. So I think the age 25:28.966 --> 25:31.033 align:left position:20% line:83% size:70% is easier to look at. x*We know that if they're 25:31.033 --> 25:34.300 align:left position:10% line:83% size:80% under age 10, over 20 degrees, 100% chance of progressing. 25:34.300 --> 25:36.166 align:left position:20% line:83% size:70% But if you want to use the Risser score, 25:36.166 --> 25:39.466 align:left position:20% line:83% size:70% you can do the same. What this really is helpful 25:39.466 --> 25:42.166 align:left position:10% line:83% size:80% is saying is if they have a curve under 20 degrees, 25:42.166 --> 25:44.433 align:left position:10% line:83% size:80% and the iliac apophysis is just about fused, they only have 25:44.433 --> 25:46.400 align:left position:10% line:83% size:80% a one or two percent chance of progressing. 25:46.400 --> 25:51.800 align:left position:10% line:83% size:80% And that's nice to be able to tell the parents that. 25:51.800 --> 25:53.866 align:left position:10% line:83% size:80% x*People focus on some of the other issues as well, 25:53.866 --> 25:57.600 align:left position:10% line:83% size:80% including peak height velocity, which is a little more accurate. 25:57.600 --> 26:00.733 align:left position:10% line:83% size:80% In general, it's 12 in girls and 14 in boys. 26:00.733 --> 26:03.200 align:left position:10% line:83% size:80% So if you just want to age over the age 12 in girls 26:03.200 --> 26:05.466 align:left position:30% line:83% size:60% in general, they are skeletally mature. 26:05.466 --> 26:08.633 align:left position:30% line:83% size:60% Over 14 in boys. Menarche, and axillary hair on 26:08.633 --> 26:12.933 align:left position:10% line:83% size:80% both, are also ways to indicate the end of the growth spurt 26:12.933 --> 26:18.166 align:left position:20% line:83% size:70% and risk of progression of scoliosis. 26:18.166 --> 26:21.500 align:left position:10% line:83% size:80% x*Although boys are less likely to get scoliosis, 26:21.500 --> 26:25.500 align:left position:10% line:83% size:80% the negative for males is that their scoliosis can progress, 26:25.500 --> 26:28.700 align:left position:20% line:83% size:70% even when they're older. So if you are going to brace, 26:28.700 --> 26:31.766 align:left position:20% line:83% size:70% or have a young male that's braced, then you want 26:31.766 --> 26:34.466 align:left position:30% line:83% size:60% to brace them until they're quite a bit older. 26:34.466 --> 26:36.966 align:left position:10% line:83% size:80% Not only do they mature later, but you need to brace them 26:36.966 --> 26:44.233 align:left position:10% line:83% size:80% close to 18 years of age. x*Before you really want to think 26:44.233 --> 26:46.766 align:left position:10% line:83% size:80% about treating any disease, you have to have some idea 26:46.766 --> 26:49.166 align:left position:10% line:83% size:80% of what the natural history of the disease is, because 26:49.166 --> 26:52.200 align:left position:10% line:83% size:80% why treat something that's not going to cause a problem. 26:52.200 --> 26:55.966 align:left position:20% line:83% size:70% There isn't a lot of natural history studies. 26:55.966 --> 27:00.166 align:left position:10% line:83% size:80% Nachemson, which is a researcher in northern Europe in 1968 said, 27:00.166 --> 27:02.666 align:left position:10% line:83% size:80% you know, if you have scoliosis, it increases your mortality 27:02.666 --> 27:05.466 align:left position:30% line:83% size:60% two times. Half the people 27:05.466 --> 27:08.166 align:left position:20% line:83% size:70% are on disability. Most people don't get married. 27:08.166 --> 27:10.500 align:left position:10% line:83% size:80% The problem with that study is that they had large 27:10.500 --> 27:12.666 align:left position:30% line:83% size:60% initial curves. These were not sort of 27:12.666 --> 27:15.300 align:left position:10% line:83% size:80% mild scoliosis, and many of them probably had neuromuscular 27:15.300 --> 27:17.566 align:left position:30% line:83% size:60% disorders. So they had cerebral palsy 27:17.566 --> 27:19.866 align:left position:20% line:83% size:70% and other disorders that were all mixed in the batch. 27:19.866 --> 27:21.800 align:left position:20% line:83% size:70% So it really wasn't a very accurate study. 27:21.800 --> 27:24.566 align:left position:10% line:83% size:80% x*I think people have found since then that scoliosis 27:24.566 --> 27:28.800 align:left position:10% line:83% size:80% does not necessarily have to be a major impediment to life, 27:28.800 --> 27:31.200 align:left position:20% line:83% size:70% that you can work and be independent, 27:31.200 --> 27:33.300 align:left position:20% line:83% size:70% you can get married, almost at the same rate 27:33.300 --> 27:36.000 align:left position:10% line:83% size:80% as the general population. x*So scoliosis, it may cause 27:36.000 --> 27:38.833 align:left position:20% line:83% size:70% a cosmetic deformity, but it rarely causes significant 27:38.833 --> 27:43.466 align:left position:10% line:83% size:80% functional limitations, and that is a little bit controversial. 27:43.466 --> 27:46.200 align:left position:20% line:83% size:70% What kind of functional limitations it causes, 27:46.200 --> 27:48.400 align:left position:10% line:83% size:80% but for day-to-day activities, it rarely causes significant 27:48.400 --> 27:51.500 align:left position:20% line:83% size:70% functional limitations. x*The other issue comes up 27:51.500 --> 27:55.333 align:left position:30% line:83% size:60% with pain. And in general, scoliosis 27:55.333 --> 27:58.333 align:left position:10% line:83% size:80% can cause actually increased-- There is some concern 27:58.333 --> 28:01.866 align:left position:20% line:83% size:70% that long-term scoliosis can cause increased pain. 28:01.866 --> 28:06.200 align:left position:10% line:83% size:80% I think that's probably true. The caveat is children 28:06.200 --> 28:08.266 align:left position:20% line:83% size:70% who have scoliosis don't present with pain. 28:08.266 --> 28:10.533 align:left position:10% line:83% size:80% But long-term, if you have scoliosis, and it progresses, 28:10.533 --> 28:12.933 align:left position:10% line:83% size:80% it can cause a higher incidence of pain. 28:12.933 --> 28:15.066 align:left position:20% line:83% size:70% And the pain may be a little bit more severe. 28:15.066 --> 28:17.433 align:left position:10% line:83% size:80% But if you take into fact that about 80% of adults 28:17.433 --> 28:20.800 align:left position:20% line:83% size:70% will have back pain that's significant enough 28:20.800 --> 28:23.466 align:left position:10% line:83% size:80% they seek medical attention, it's very difficult to sort out 28:23.466 --> 28:26.400 align:left position:20% line:83% size:70% how much worse that is. It depends on who you talk to. 28:26.400 --> 28:29.033 align:left position:20% line:83% size:70% x*So the studies in Iowa show that it's really not that 28:29.033 --> 28:31.300 align:left position:10% line:83% size:80% big of a deal, it doesn't increase pain that much. 28:31.300 --> 28:33.466 align:left position:10% line:83% size:80% Other studies say it's a bigger issue. 28:33.466 --> 28:35.433 align:left position:20% line:83% size:70% And what we don't know, if we fuse the spine 28:35.433 --> 28:37.433 align:left position:20% line:83% size:70% or make it straight, do we decrease 28:37.433 --> 28:39.866 align:left position:20% line:83% size:70% that incidence of pain. So we don't know if our 28:39.866 --> 28:44.700 align:left position:10% line:83% size:80% treatment makes it better. x*So we've sort of ruled out 28:44.700 --> 28:46.600 align:left position:20% line:83% size:70% neuromuscular congenital scoliosis. 28:46.600 --> 28:48.833 align:left position:10% line:83% size:80% We're looking at idiopathic scoliosis, just to make it 28:48.833 --> 28:50.600 align:left position:20% line:83% size:70% a little more confusing, idiopathic scoliosis 28:50.600 --> 28:53.800 align:left position:10% line:83% size:80% tends to come in three flavors and is set by age. 28:53.800 --> 28:57.066 align:left position:10% line:83% size:80% And this is really arbitrary. Anything under age 3, 28:57.066 --> 29:00.166 align:left position:20% line:83% size:70% is called infantile and over age 10 is adolescent, 29:00.166 --> 29:02.266 align:left position:30% line:83% size:60% which is by far the most common. 29:02.266 --> 29:05.833 align:left position:10% line:83% size:80% Adolescent idiopathic scoliosis, typically referred to as AIS. 29:05.833 --> 29:08.966 align:left position:10% line:83% size:80% And then in between is juvenile. I'll talk briefly about these, 29:08.966 --> 29:11.866 align:left position:10% line:83% size:80% but you can see infantile is very small, about 5%, 29:11.866 --> 29:16.933 align:left position:30% line:83% size:60% juvenile is 15% and adolescent is 80%. 29:16.933 --> 29:21.300 align:left position:10% line:83% size:80% x*This is infantile scoliosis. And I refer to it 29:21.300 --> 29:24.000 align:left position:20% line:83% size:70% as Bazaro Scoliosis, because everything's backwards. 29:24.000 --> 29:26.900 align:left position:20% line:83% size:70% It's just different than idiopathic scoliosis. 29:26.900 --> 29:29.200 align:left position:20% line:83% size:70% It tends to occur young, it's more common in boys 29:29.200 --> 29:33.600 align:left position:30% line:83% size:60% than girls. Right-sided curves are uncommon. 29:33.600 --> 29:35.533 align:left position:10% line:83% size:80% And we looked at something called the rib-vertebral 29:35.533 --> 29:38.400 align:left position:20% line:83% size:70% angle difference. But the bottom line is 29:38.400 --> 29:42.166 align:left position:10% line:83% size:80% curves under about 35 degrees tend to actually get better. 29:42.166 --> 29:45.033 align:left position:10% line:83% size:80% That is something that doesn't happen in idiopathic scoliosis. 29:45.033 --> 29:48.633 align:left position:20% line:83% size:70% Curves over 30 degrees-- That is rib-vertebral angles 29:48.633 --> 29:51.333 align:left position:30% line:83% size:60% over 20 degrees, tend to progress. 29:51.333 --> 29:53.533 align:left position:10% line:83% size:80% If you want to measure it, it's a little bit hard 29:53.533 --> 29:56.166 align:left position:30% line:83% size:60% to measure. What you do is you find the 29:56.166 --> 29:58.766 align:left position:10% line:83% size:80% curve, the apex of the curve, so that's where the curve 29:58.766 --> 30:01.733 align:left position:30% line:83% size:60% is the worst, and you measure the rib angle 30:01.733 --> 30:03.966 align:left position:20% line:83% size:70% with the vertebra, with the horizontal 30:03.966 --> 30:06.133 align:left position:30% line:83% size:60% right here. Here's the rib, draw a line up. 30:06.133 --> 30:09.300 align:left position:10% line:83% size:80% And then this is the angle it takes with the vertical. 30:09.300 --> 30:12.100 align:left position:10% line:83% size:80% You do it on the other side and you take the difference 30:12.100 --> 30:14.433 align:left position:20% line:83% size:70% between the two angles. And if the difference 30:14.433 --> 30:17.266 align:left position:20% line:83% size:70% is more than 20 degrees, it will tend to progress. 30:17.266 --> 30:20.500 align:left position:20% line:83% size:70% The others actually tend to get better. 30:20.500 --> 30:22.933 align:left position:20% line:83% size:70% x*The problem is the ones that don't get better, now you 30:22.933 --> 30:25.366 align:left position:10% line:83% size:80% have a real problem, because you have this little spine 30:25.366 --> 30:28.066 align:left position:10% line:83% size:80% and it's going to get worse and they're very, very young. 30:28.066 --> 30:30.833 align:left position:10% line:83% size:80% We don't have a great treatment. This is Dr. Meta, 30:30.833 --> 30:34.066 align:left position:10% line:83% size:80% the older one on the left, who developed the angle. 30:34.066 --> 30:37.666 align:left position:10% line:83% size:80% And she really has focused on bracing and casting techniques 30:37.666 --> 30:40.233 align:left position:10% line:83% size:80% for this, and really feels this is important. 30:40.233 --> 30:44.500 align:left position:10% line:83% size:80% It was printed in our major journal, the JBJS, about two 30:44.500 --> 30:47.133 align:left position:20% line:83% size:70% or three years ago. And people are starting 30:47.133 --> 30:49.400 align:left position:20% line:83% size:70% to do these casts. It's starting to catch on, 30:49.400 --> 30:51.500 align:left position:10% line:83% size:80% but whether or not it works, and how well it works is still 30:51.500 --> 30:55.133 align:left position:10% line:83% size:80% a little bit up for debate. x*Some people feel that casting 30:55.133 --> 30:58.133 align:left position:10% line:83% size:80% a child from this young of age and forcing them to wear a brace 30:58.133 --> 31:00.333 align:left position:10% line:83% size:80% for the rest of their life is really not a fair thing 31:00.333 --> 31:02.866 align:left position:40% line:83% size:50% to do. So it's not clear whether 31:02.866 --> 31:04.866 align:left position:10% line:83% size:80% casting is the right way to go or not. 31:04.866 --> 31:07.766 align:left position:10% line:83% size:80% But we did, where I trained, had a casting program. 31:07.766 --> 31:10.700 align:left position:10% line:83% size:80% We would place this cast on, and that's a picture of a child 31:10.700 --> 31:12.700 align:left position:30% line:83% size:60% in the cast. The cast is obviously 31:12.700 --> 31:15.300 align:left position:10% line:83% size:80% trimmed down, but it does go up fairly high around the neck. 31:15.300 --> 31:17.866 align:left position:30% line:83% size:60% There's a cutout for the abdomen. 31:17.866 --> 31:20.900 align:left position:20% line:83% size:70% In Dr. Meta's hands, it has shown that it provides 31:20.900 --> 31:23.666 align:left position:20% line:83% size:70% relatively reasonable correction. 31:23.666 --> 31:25.866 align:left position:10% line:83% size:80% She, by the way, has a really significant scoliosis 31:25.866 --> 31:28.533 align:left position:30% line:83% size:60% and obviously is doing just fine. 31:28.533 --> 31:30.766 align:left position:10% line:83% size:80% Newer treatments and probably what most people 31:30.766 --> 31:32.833 align:left position:10% line:83% size:80% here in North America are doing are various different types of 31:32.833 --> 31:35.733 align:left position:10% line:83% size:80% what they call growing rods, which is a misnomer. 31:35.733 --> 31:37.766 align:left position:20% line:83% size:70% They're now using a titanium rib or adapter to try 31:37.766 --> 31:41.600 align:left position:10% line:83% size:80% to get some correction and be used as a temporary splint, 31:41.600 --> 31:44.733 align:left position:10% line:83% size:80% allowing the spine to grow and do more definitive treatment 31:44.733 --> 31:47.233 align:left position:20% line:83% size:70% as the child grows. I'll show examples of some of 31:47.233 --> 31:52.400 align:left position:10% line:83% size:80% those in just a little bit. x*Juvenile scoliosis is sort of 31:52.400 --> 31:54.833 align:left position:20% line:83% size:70% a mixed bag, because now you're dealing with kids 31:54.833 --> 31:57.166 align:left position:20% line:83% size:70% between four and ten. Their curves, if they're 31:57.166 --> 31:59.700 align:left position:10% line:83% size:80% younger, tend to be a little bit more like infantile. 31:59.700 --> 32:02.066 align:left position:20% line:83% size:70% If they're older, they tend to be a little more like 32:02.066 --> 32:04.066 align:left position:30% line:83% size:60% idiopathic. So there seems to be 32:04.066 --> 32:06.000 align:left position:30% line:83% size:60% a higher genetic predisposition influence. 32:06.000 --> 32:07.966 align:left position:20% line:83% size:70% It's children between age four and ten, by definition, 32:07.966 --> 32:11.066 align:left position:30% line:83% size:60% at diagnosis. And about generally, 32:11.066 --> 32:14.300 align:left position:10% line:83% size:80% one-third don't progress, one-third can be braced 32:14.300 --> 32:16.866 align:left position:10% line:83% size:80% and do well with bracing. Actually, you can get correction 32:16.866 --> 32:20.000 align:left position:30% line:83% size:60% in the brace. About a third go on to surgery. 32:20.000 --> 32:22.166 align:left position:20% line:83% size:70% A fair number of these have abnormal MRIs, 32:22.166 --> 32:25.333 align:left position:20% line:83% size:70% so these are ones that you want to get an MRI on. 32:25.333 --> 32:31.500 align:left position:20% line:83% size:70% x*And this is a patient that had juvenile scoliosis, 32:31.500 --> 32:34.066 align:left position:10% line:83% size:80% was braced, was very diligent about the bracing, 32:34.066 --> 32:36.066 align:left position:10% line:83% size:80% and you can see the curve actually improved. 32:36.066 --> 32:38.066 align:left position:10% line:83% size:80% That is something you won't see with idiopathic scoliosis, 32:38.066 --> 32:40.166 align:left position:10% line:83% size:80% you can't make the curve better with idiopathic. 32:40.166 --> 32:42.533 align:left position:10% line:83% size:80% But with juvenile, there is a potential to do that. 32:42.533 --> 32:45.666 align:left position:10% line:83% size:80% x*Most of the treatment now will focus on the idiopathic 32:45.666 --> 32:51.300 align:left position:10% line:83% size:80% scoliosis in adolescence. Adolescent idiopathic scoliosis. 32:51.300 --> 32:54.033 align:left position:10% line:83% size:80% So this is our algorithm for the vast majority of patients 32:54.033 --> 32:56.433 align:left position:20% line:83% size:70% that come in our door. So we've ruled out other forms 32:56.433 --> 32:59.066 align:left position:20% line:83% size:70% of idiopathic scoliosis. We know it's adolescent. 32:59.066 --> 33:01.166 align:left position:20% line:83% size:70% And this is in general, how we treat it. 33:01.166 --> 33:03.733 align:left position:10% line:83% size:80% Curves less than 20 degrees, we observe, we don't treat. 33:03.733 --> 33:09.333 align:left position:10% line:83% size:80% Curves, whether they're mature or not immature. 33:09.333 --> 33:11.500 align:left position:30% line:83% size:60% If their mature, and it's less than 45 degrees, 33:11.500 --> 33:13.433 align:left position:20% line:83% size:70% we observe it, because there's very little chance 33:13.433 --> 33:15.433 align:left position:20% line:83% size:70% of this progressing. By observation, is doesn't mean 33:15.433 --> 33:17.600 align:left position:20% line:83% size:70% necessarily just saying good-bye, but it probably 33:17.600 --> 33:20.233 align:left position:20% line:83% size:70% is worth a follow-up every one to two years. 33:20.233 --> 33:22.033 align:left position:10% line:83% size:80% So once they've gone through their growth spurt, 33:22.033 --> 33:25.566 align:left position:10% line:83% size:80% if they're less than 45 degrees, then we don't do anything. 33:25.566 --> 33:28.300 align:left position:10% line:83% size:80% x*Curves, if they're immature and it's greater than 30 degrees 33:28.300 --> 33:30.866 align:left position:20% line:83% size:70% or we see it progressing beyond about 25 degrees, we 33:30.866 --> 33:34.766 align:left position:10% line:83% size:80% think it's reasonable to brace. That's the standard treatment. 33:34.766 --> 33:37.200 align:left position:20% line:83% size:70% This has been around for ten years or so. 33:37.200 --> 33:40.166 align:left position:10% line:83% size:80% It's really undergoing scrutiny. There's now a randomized 33:40.166 --> 33:42.200 align:left position:20% line:83% size:70% double blind study where they're looking at 33:42.200 --> 33:44.433 align:left position:20% line:83% size:70% the value of bracing. And unfortunately this study, 33:44.433 --> 33:46.866 align:left position:20% line:83% size:70% from my understanding, has only had a very few people 33:46.866 --> 33:49.300 align:left position:10% line:83% size:80% that they were able to recruit, because you're asking someone 33:49.300 --> 33:51.366 align:left position:20% line:83% size:70% either to have bracing or not bracing. 33:51.366 --> 33:54.033 align:left position:10% line:83% size:80% And most people don't want to be randomized to that, 33:54.033 --> 33:56.833 align:left position:10% line:83% size:80% so we'll see if they can get information from that. 33:56.833 --> 33:59.233 align:left position:10% line:83% size:80% x*But there are clearly some surgeons that believe 33:59.233 --> 34:01.033 align:left position:20% line:83% size:70% curves will progress or won't progress 34:01.033 --> 34:03.166 align:left position:20% line:83% size:70% whether you brace them, and bracing does nothing. 34:03.166 --> 34:05.500 align:left position:10% line:83% size:80% Yet there is some pretty good evidence that bracing works. 34:05.500 --> 34:08.733 align:left position:10% line:83% size:80% So, I still certainly believe that bracing is important. 34:08.733 --> 34:13.833 align:left position:20% line:83% size:70% And if it's done right, it can make the difference. 34:13.833 --> 34:16.233 align:left position:10% line:83% size:80% x*And then finally, if you have a patient with a curve 34:16.233 --> 34:19.366 align:left position:10% line:83% size:80% over 50 degrees, especially if they're skeletally immature, 34:19.366 --> 34:21.166 align:left position:30% line:83% size:60% those are ones we may consider surgery, 34:21.166 --> 34:24.633 align:left position:20% line:83% size:70% depending on the various different circumstances. 34:24.633 --> 34:26.766 align:left position:10% line:83% size:80% x*So here are all the different kinds of braces that we use. 34:26.766 --> 34:28.566 align:left position:20% line:83% size:70% The Milwaukee Braces are the gold standard. 34:28.566 --> 34:31.166 align:left position:20% line:83% size:70% It's a large brace. And it actually has a collar 34:31.166 --> 34:33.366 align:left position:10% line:83% size:80% that goes around the neck. It's somewhat unsightly, 34:33.366 --> 34:35.466 align:left position:20% line:83% size:70% and kids hate it. And the collar's designed, 34:35.466 --> 34:37.333 align:left position:20% line:83% size:70% actually, not to push against the neck, 34:37.333 --> 34:39.666 align:left position:20% line:83% size:70% but to irritate enough so that the child stands 34:39.666 --> 34:43.166 align:left position:10% line:83% size:80% in a straighter position. So an upper thoracic curve, 34:43.166 --> 34:45.566 align:left position:10% line:83% size:80% that's really the only brace that works. 34:45.566 --> 34:48.533 align:left position:10% line:83% size:80% But now more and more people use one of these other braces. 34:48.533 --> 34:50.800 align:left position:20% line:83% size:70% x*This is a Molded TLSO, some people refer to it 34:50.800 --> 34:53.200 align:left position:20% line:83% size:70% as the Boston Brace. And it's actually designed 34:53.200 --> 34:56.000 align:left position:20% line:83% size:70% to correct the curve, but it goes under the arms, 34:56.000 --> 34:59.666 align:left position:10% line:83% size:80% and it's less obvious to wear. x*There are a couple of things 34:59.666 --> 35:01.966 align:left position:30% line:83% size:60% about braces, and it's very important. 35:01.966 --> 35:04.000 align:left position:20% line:83% size:70% You can't just prescribe this brace. 35:04.000 --> 35:05.500 align:left position:30% line:83% size:60% This is a brace that has to be prescribed, 35:05.500 --> 35:07.900 align:left position:20% line:83% size:70% and it has to be fitted. Then we have to make sure 35:07.900 --> 35:10.200 align:left position:30% line:83% size:60% that the brace is actually causing correction. 35:10.200 --> 35:12.600 align:left position:10% line:83% size:80% Because if you have a curve, and you put a brace on and it's not 35:12.600 --> 35:14.733 align:left position:10% line:83% size:80% making the curve straighter, it's really not 35:14.733 --> 35:17.066 align:left position:20% line:83% size:70% going to do anything. So the concept 35:17.066 --> 35:19.333 align:left position:20% line:83% size:70% was to get the brace. We see them back after they've 35:19.333 --> 35:22.200 align:left position:10% line:83% size:80% had the brace for about a month and it's fitting, 35:22.200 --> 35:24.400 align:left position:10% line:83% size:80% we know it's fitting well. We make sure the curve 35:24.400 --> 35:26.800 align:left position:10% line:83% size:80% is decreased by about 50%. If you have a 40-degree curve, 35:26.800 --> 35:28.866 align:left position:30% line:83% size:60% you'll want it less than 20 degrees. 35:28.866 --> 35:30.666 align:left position:20% line:83% size:70% And the second issue, if they don't wear it, obviously 35:30.666 --> 35:33.433 align:left position:10% line:83% size:80% it's not going to do anything. x*So what we found is that 35:33.433 --> 35:35.900 align:left position:10% line:83% size:80% people, on average, will wear the brace about two-thirds 35:35.900 --> 35:39.000 align:left position:10% line:83% size:80% what they say they wear it, just as a general rule. 35:39.000 --> 35:41.866 align:left position:10% line:83% size:80% And often people don't wear the brace quite as much 35:41.866 --> 35:44.233 align:left position:30% line:83% size:60% as you think. On the other hand, you wonder 35:44.233 --> 35:47.000 align:left position:10% line:83% size:80% how much of that is people who have sort of given up 35:47.000 --> 35:49.333 align:left position:30% line:83% size:60% on braces, and aren't strongly promoting it. 35:49.333 --> 35:51.500 align:left position:20% line:83% size:70% I think it's part of our responsibility to say 35:51.500 --> 35:54.533 align:left position:10% line:83% size:80% that there's good evidence that this works, if you wear it. 35:54.533 --> 35:57.200 align:left position:20% line:83% size:70% And if you wear it, it may make a difference. 35:57.200 --> 36:01.733 align:left position:10% line:83% size:80% So it's a little bit hard to know how effective they are. 36:01.733 --> 36:03.800 align:left position:10% line:83% size:80% But I'll show some studies that actually show 36:03.800 --> 36:06.300 align:left position:10% line:83% size:80% there is some good evidence that say they work. 36:06.300 --> 36:10.000 align:left position:20% line:83% size:70% x*How do braces work? Well, this is a couple 36:10.000 --> 36:12.766 align:left position:10% line:83% size:80% different studies that show that if you decrease the curve 36:12.766 --> 36:15.766 align:left position:10% line:83% size:80% to 20 degrees, you increase stability of the curve 36:15.766 --> 36:19.166 align:left position:20% line:83% size:70% from 50-80% of normal. So again, it's a little like 36:19.166 --> 36:21.300 align:left position:10% line:83% size:80% the Leaning Tower of Pisa. You can't make it straight, 36:21.300 --> 36:24.200 align:left position:10% line:83% size:80% but you can sort of hoist it up. And if you can keep them 36:24.200 --> 36:26.400 align:left position:10% line:83% size:80% to a smaller curve to the point of skeletal maturity, 36:26.400 --> 36:28.466 align:left position:30% line:83% size:60% then the curve should not progress. 36:28.466 --> 36:30.433 align:left position:20% line:83% size:70% So if you keep the curve under 50 degrees, 36:30.433 --> 36:33.600 align:left position:10% line:83% size:80% it probably won't progress. x*The biggest study came out 36:33.600 --> 36:36.666 align:left position:10% line:83% size:80% in 1995 was again Nachemson, and you may remember this name. 36:36.666 --> 36:39.433 align:left position:20% line:83% size:70% Same person from before. Did a multi-center study, 36:39.433 --> 36:42.700 align:left position:20% line:83% size:70% looking at 247 patients. Now there's a big dropout, 36:42.700 --> 36:45.200 align:left position:10% line:83% size:80% so there's hundreds of patients that didn't have follow up, 36:45.200 --> 36:47.600 align:left position:10% line:83% size:80% but of the patients that had, they looked at electrical 36:47.600 --> 36:50.300 align:left position:10% line:83% size:80% stimulation, observation, and they had a failure rate 36:50.300 --> 36:53.366 align:left position:30% line:83% size:60% of about 67%. But those that had bracing, 36:53.366 --> 36:57.833 align:left position:10% line:83% size:80% had a failure rate of 26%. It's a little bit hard to say, 36:57.833 --> 37:00.233 align:left position:10% line:83% size:80% because they had such a huge dropout in the study, but 37:00.233 --> 37:02.800 align:left position:10% line:83% size:80% at least it's about the best and largest study we have to say 37:02.800 --> 37:06.000 align:left position:10% line:83% size:80% bracing makes a difference. x*Rowe, two years later, 37:06.000 --> 37:09.066 align:left position:20% line:83% size:70% did a meta-analysis of nearly 2,000 patients. 37:09.066 --> 37:13.166 align:left position:10% line:83% size:80% He found a fairly significant improvement with bracing. 37:13.166 --> 37:15.033 align:left position:30% line:83% size:60% It's not 100%, but it's certainly better 37:15.033 --> 37:17.066 align:left position:10% line:83% size:80% than electrical stimulation, which had actually made things 37:17.066 --> 37:22.666 align:left position:10% line:83% size:80% a little worse than observation. x*Physical therapy 37:22.666 --> 37:24.733 align:left position:30% line:83% size:60% would be great. If you could send someone to 37:24.733 --> 37:27.166 align:left position:10% line:83% size:80% therapy to correct their curve, that would be wonderful. 37:27.166 --> 37:29.366 align:left position:20% line:83% size:70% But there's really no good evidence at this point 37:29.366 --> 37:31.900 align:left position:20% line:83% size:70% to say physical therapy is effective. 37:31.900 --> 37:34.266 align:left position:20% line:83% size:70% But there are some interesting studies out there 37:34.266 --> 37:36.800 align:left position:10% line:83% size:80% which have shown increasing trunkal strength may actually 37:36.800 --> 37:40.566 align:left position:10% line:83% size:80% long-term improve scoliosis. But the follow-up 37:40.566 --> 37:43.866 align:left position:20% line:83% size:70% hasn't been there. So, in general, I don't know 37:43.866 --> 37:46.900 align:left position:30% line:83% size:60% of anyone today that prescribes physical therapy 37:46.900 --> 37:49.866 align:left position:30% line:83% size:60% for scoliosis. We will for people 37:49.866 --> 37:58.466 align:left position:10% line:83% size:80% that have mild kyphosis, but we won't do it for scoliosis. 37:58.466 --> 38:01.333 align:left position:10% line:83% size:80% This is just a little bit on physical therapy for surgery, 38:01.333 --> 38:04.366 align:left position:20% line:83% size:70% I'll skip over that. x*So once we get to the point 38:04.366 --> 38:06.366 align:left position:30% line:83% size:60% where we believe it's a surgical curve, 38:06.366 --> 38:08.366 align:left position:30% line:83% size:60% we actually try to define the curve. 38:08.366 --> 38:10.700 align:left position:20% line:83% size:70% And this is a classic King Classification, which looks 38:10.700 --> 38:13.000 align:left position:20% line:83% size:70% at where the curve is: if it's a thoracic curve, 38:13.000 --> 38:15.633 align:left position:20% line:83% size:70% if it's a lumbar curve, if it's a combination of both. 38:15.633 --> 38:18.600 align:left position:10% line:83% size:80% And it's supposed to help us decide when to fuse the spine. 38:18.600 --> 38:20.733 align:left position:20% line:83% size:70% x*People have now gone to a different curve 38:20.733 --> 38:23.300 align:left position:20% line:83% size:70% classification system named after Larry Lenke. 38:23.300 --> 38:26.300 align:left position:10% line:83% size:80% It was developed at a number of different institutions. 38:26.300 --> 38:29.366 align:left position:20% line:83% size:70% It actually breaks curve patterns up to a possible 38:29.366 --> 38:31.766 align:left position:20% line:83% size:70% 46 different patterns. So it's one of the more 38:31.766 --> 38:34.433 align:left position:20% line:83% size:70% confusing systems that we have in place. 38:34.433 --> 38:36.333 align:left position:10% line:83% size:80% But I think it's important for research to be able to use 38:36.333 --> 38:38.666 align:left position:20% line:83% size:70% a system like that. It classifies a curve both 38:38.666 --> 38:42.400 align:left position:10% line:83% size:80% on sagittal and coronal views. It helps give an idea of, 38:42.400 --> 38:45.200 align:left position:20% line:83% size:70% not only which ones may progress, but from our 38:45.200 --> 38:47.600 align:left position:10% line:83% size:80% standpoint, more importantly, how you would actually 38:47.600 --> 38:52.300 align:left position:20% line:83% size:70% treat them surgically. x*There has been trends 38:52.300 --> 38:54.800 align:left position:20% line:83% size:70% to treat it surgically a lot of different ways. 38:54.800 --> 38:57.733 align:left position:10% line:83% size:80% So there's a big trend to try to fuse the spine anteriorly, 38:57.733 --> 38:59.633 align:left position:10% line:83% size:80% and I'll show a little bit about that. 38:59.633 --> 39:01.833 align:left position:10% line:83% size:80% The trend has now gone back to basically fusing people 39:01.833 --> 39:04.400 align:left position:30% line:83% size:60% posteriorly. There's an obvious advantage. 39:04.400 --> 39:06.466 align:left position:10% line:83% size:80% The spine is very superficial posteriorly. 39:06.466 --> 39:08.800 align:left position:10% line:83% size:80% You don't have to go through the abdomen or the pelvis. 39:08.800 --> 39:11.166 align:left position:20% line:83% size:70% And in that regard, it's quite a bit a safer. 39:11.166 --> 39:12.900 align:left position:20% line:83% size:70% There are disadvantages to going posteriorly. 39:12.900 --> 39:15.066 align:left position:10% line:83% size:80% But with the new instrumentation that we're using today 39:15.066 --> 39:17.400 align:left position:10% line:83% size:80% which include pedicle screws, it seems like we can get 39:17.400 --> 39:21.833 align:left position:10% line:83% size:80% fairly significant correction by going posteriorly. 39:21.833 --> 39:24.166 align:left position:10% line:83% size:80% x*And this is just a straight posterior incision. 39:24.166 --> 39:26.800 align:left position:10% line:83% size:80% It's very straightforward. You go straight down the midline 39:26.800 --> 39:29.233 align:left position:10% line:83% size:80% and you dissect the musculature laterally. 39:29.233 --> 39:33.766 align:left position:20% line:83% size:70% And then the concept is you want to fuse the spine. 39:33.766 --> 39:35.533 align:left position:20% line:83% size:70% That's really what you want to do. 39:35.533 --> 39:37.433 align:left position:20% line:83% size:70% The instrumentation and stuff we put in 39:37.433 --> 39:41.400 align:left position:20% line:83% size:70% is absolutely secondary. So most children fuse very well, 39:41.400 --> 39:44.166 align:left position:20% line:83% size:70% even historically, they would just strip off 39:44.166 --> 39:46.566 align:left position:20% line:83% size:70% all the soft tissue, put bone down 39:46.566 --> 39:48.800 align:left position:20% line:83% size:70% and put them in a cast, most of those fused. 39:48.800 --> 39:51.266 align:left position:10% line:83% size:80% x*Now we use instrumentation mainly just to get rid of 39:51.266 --> 39:53.700 align:left position:20% line:83% size:70% the cast part and get a little better correction. 39:53.700 --> 39:56.166 align:left position:10% line:83% size:80% Instrumentation has varied. About ten years ago, pedicle 39:56.166 --> 40:00.400 align:left position:10% line:83% size:80% hooks, which you can see here, were the primary device used. 40:00.400 --> 40:04.500 align:left position:10% line:83% size:80% There are little wires that go under the lamina, right here, 40:04.500 --> 40:07.666 align:left position:20% line:83% size:70% called lamina wires. x*Dr. Drummond developed wires 40:07.666 --> 40:10.400 align:left position:30% line:83% size:60% here in Madison, called Wisconsin Wires, which 40:10.400 --> 40:13.366 align:left position:10% line:83% size:80% are probably the safest device, which actually goes through 40:13.366 --> 40:16.300 align:left position:10% line:83% size:80% the spinous processes and stay completely out of the spine. 40:16.300 --> 40:18.900 align:left position:10% line:83% size:80% x*And now pedicle screws, which obviously can have a problem. 40:18.900 --> 40:21.933 align:left position:10% line:83% size:80% If you put it incorrectly it can obviously hit the spinal cord, 40:21.933 --> 40:24.600 align:left position:30% line:83% size:60% major vessels. But pedicle screws 40:24.600 --> 40:27.633 align:left position:20% line:83% size:70% give you great fixation. More and more people 40:27.633 --> 40:32.433 align:left position:10% line:83% size:80% are using pedicle screws today to get fixation. 40:32.433 --> 40:34.266 align:left position:20% line:83% size:70% x*This is just an example of what you get. 40:34.266 --> 40:36.633 align:left position:10% line:83% size:80% In general, if you have a curve that's 80 degrees, you'll get 40:36.633 --> 40:41.566 align:left position:20% line:83% size:70% about 50-70% correction. This is a curve that started 40:41.566 --> 40:44.066 align:left position:30% line:83% size:60% at 82 degrees, and it went down to 28. 40:44.066 --> 40:46.633 align:left position:20% line:83% size:70% I think that's about the correction you'll get, 40:46.633 --> 40:49.700 align:left position:30% line:83% size:60% which is fine. I'd be very happy 40:49.700 --> 40:52.866 align:left position:10% line:83% size:80% with a correction of 28 degrees. x*But probably the more important 40:52.866 --> 40:55.066 align:left position:10% line:83% size:80% thing is you want the patient to be balanced. 40:55.066 --> 40:57.466 align:left position:10% line:83% size:80% So if their curve is small and their head is over their pelvis, 40:57.466 --> 41:01.166 align:left position:10% line:83% size:80% and then they have a good sagittal profile, 41:01.166 --> 41:04.666 align:left position:10% line:83% size:80% they're going to be very happy regardless of what the curve is. 41:04.666 --> 41:07.066 align:left position:20% line:83% size:70% I think as a surgeon, you want to get the curve 41:07.066 --> 41:09.233 align:left position:20% line:83% size:70% as small as possible. That's really not the most 41:09.233 --> 41:11.400 align:left position:10% line:83% size:80% important thing for the patient. The most important thing 41:11.400 --> 41:15.166 align:left position:30% line:83% size:60% is balance. x*We've found that from 41:15.166 --> 41:18.233 align:left position:20% line:83% size:70% a functional standpoint, that it's really balance 41:18.233 --> 41:20.966 align:left position:10% line:83% size:80% from a side view that matters, or the sagittal alignment 41:20.966 --> 41:23.233 align:left position:10% line:83% size:80% that makes all the difference, and especially down 41:23.233 --> 41:25.700 align:left position:20% line:83% size:70% in the lumbar region, so we work hard 41:25.700 --> 41:28.266 align:left position:10% line:83% size:80% to restore that as best we can. x*Neuromuscular scoliosis 41:28.266 --> 41:30.366 align:left position:10% line:83% size:80% classically has been treated a little differently, because you 41:30.366 --> 41:32.566 align:left position:10% line:83% size:80% don't fuse part of the spine. So, in neuropathic scoliosis 41:32.566 --> 41:34.866 align:left position:10% line:83% size:80% you just treat the curve, for the most part. 41:34.866 --> 41:37.066 align:left position:10% line:83% size:80% In neuromuscular, you treat the whole spine, because 41:37.066 --> 41:39.433 align:left position:10% line:83% size:80% if you don't, they tend to get curves above and below. 41:39.433 --> 41:42.633 align:left position:10% line:83% size:80% x*So this is a patient that had cerebral palsy, and 41:42.633 --> 41:45.866 align:left position:10% line:83% size:80% they actually had a hip issue. We addressed the hip issue first 41:45.866 --> 41:48.733 align:left position:10% line:83% size:80% and the hip actually is seated nicely, but they have a 41:48.733 --> 41:51.400 align:left position:10% line:83% size:80% great deal of pelvic obliquity. Pelvic obliquity is actually 41:51.400 --> 41:54.166 align:left position:10% line:83% size:80% what puts the hip at risk. And treating the hip will never 41:54.166 --> 41:57.433 align:left position:10% line:83% size:80% treat the pelvic obliquity. Often, people will actually 41:57.433 --> 42:00.166 align:left position:20% line:83% size:70% address the spine first to even out the pelvis, and 42:00.166 --> 42:03.300 align:left position:10% line:83% size:80% then treat the hip as needed. In this case, 42:03.300 --> 42:05.466 align:left position:10% line:83% size:80% the hip was treated first. They had a fairly significant 42:05.466 --> 42:07.866 align:left position:40% line:83% size:50% curve. We knew this was progressing. 42:07.866 --> 42:10.066 align:left position:10% line:83% size:80% They had difficulty sitting in their wheelchair. 42:10.066 --> 42:12.433 align:left position:20% line:83% size:70% We treated them with the standard posterior spinal fusion 42:12.433 --> 42:15.433 align:left position:30% line:83% size:60% and this is the final correction. 42:15.433 --> 42:18.566 align:left position:20% line:83% size:70% So you can get really pretty good correction. 42:18.566 --> 42:20.700 align:left position:10% line:83% size:80% And again, even if it's not perfect, it really does 42:20.700 --> 42:22.500 align:left position:10% line:83% size:80% seem to make a difference in their lives. 42:22.500 --> 42:24.366 align:left position:10% line:83% size:80% And some people argue that you don't need to do surgery, 42:24.366 --> 42:26.566 align:left position:20% line:83% size:70% and clearly it's a long discussion you have 42:26.566 --> 42:28.866 align:left position:10% line:83% size:80% with the patients and family. But caregivers, in every study 42:28.866 --> 42:31.366 align:left position:10% line:83% size:80% I've looked at are extremely happy with the results, 42:31.366 --> 42:35.066 align:left position:10% line:83% size:80% and 80-90, 90-95% of caregivers really believe that surgical 42:35.066 --> 42:38.833 align:left position:20% line:83% size:70% treatment for scoliosis is beneficial. 42:38.833 --> 42:41.566 align:left position:20% line:83% size:70% x*There are a lot of complications, especially 42:41.566 --> 42:44.266 align:left position:10% line:83% size:80% in neuromuscular scoliosis. Most of those you can work 42:44.266 --> 42:47.600 align:left position:40% line:83% size:50% through. And fortunately, we have 42:47.600 --> 42:51.266 align:left position:10% line:83% size:80% a lot of people in the hospital help us get through 42:51.266 --> 42:53.633 align:left position:30% line:83% size:60% these issues. But postoperatively, 42:53.633 --> 42:56.566 align:left position:20% line:83% size:70% it's a big surgery. They almost always require 42:56.566 --> 42:58.800 align:left position:40% line:83% size:50% blood. They have huge fluid changes. 42:58.800 --> 43:02.300 align:left position:10% line:83% size:80% It's not quite as much of an issue in idiopathic scoliosis, 43:02.300 --> 43:05.500 align:left position:10% line:83% size:80% so complication rate, the big one we worry about obviously, 43:05.500 --> 43:07.933 align:left position:10% line:83% size:80% is neurologic complication rate is about 1 in 1,000. 43:07.933 --> 43:10.633 align:left position:10% line:83% size:80% That's the question you get, what's the chance 43:10.633 --> 43:13.166 align:left position:20% line:83% size:70% of a neurologic injury. A permanent neurologic injury 43:13.166 --> 43:16.000 align:left position:20% line:83% size:70% is about 1 in 1,000. That doesn't mean the spinal 43:16.000 --> 43:19.066 align:left position:10% line:83% size:80% cord injury, but some type of neurologic injury. 43:19.066 --> 43:22.433 align:left position:10% line:83% size:80% Infection is fairly uncommon. It's about 5%, 43:22.433 --> 43:24.966 align:left position:20% line:83% size:70% or a little bit less. Often that can be treated 43:24.966 --> 43:27.800 align:left position:10% line:83% size:80% without removing the hardware. And then there are always 43:27.800 --> 43:31.166 align:left position:20% line:83% size:70% pulmonary type issues, that are a little more common. 43:31.166 --> 43:34.600 align:left position:10% line:83% size:80% x*About five to ten years ago, there was a big push to try to 43:34.600 --> 43:37.066 align:left position:10% line:83% size:80% go anteriorly, so that was making an incision in the front, 43:37.066 --> 43:39.600 align:left position:20% line:83% size:70% putting instrumentation in the front, and it actually 43:39.600 --> 43:42.000 align:left position:20% line:83% size:70% works relatively well. The reason why you might want 43:42.000 --> 43:44.300 align:left position:10% line:83% size:80% to do that, is because you could fuse less of your spine. 43:44.300 --> 43:46.833 align:left position:10% line:83% size:80% And even though we really don't know what the consequences 43:46.833 --> 43:49.400 align:left position:20% line:83% size:70% are of fusing the spine to the rest of the spine, 43:49.400 --> 43:51.666 align:left position:20% line:83% size:70% it just make sense, you want to fuse as little 43:51.666 --> 43:53.666 align:left position:30% line:83% size:60% as possible. There's a big push to go 43:53.666 --> 43:56.000 align:left position:30% line:83% size:60% anteriorly. I won't go into great detail, 43:56.000 --> 43:58.266 align:left position:20% line:83% size:70% but as you can see, it's a big incision. 43:58.266 --> 44:00.600 align:left position:10% line:83% size:80% I'll show you some pictures. You can see that's the rib, and 44:00.600 --> 44:02.966 align:left position:10% line:83% size:80% you have to move the rib aside. Pull the lung out of the way. 44:02.966 --> 44:05.933 align:left position:10% line:83% size:80% There's significant changes in pulmonary function for up to 44:05.933 --> 44:08.700 align:left position:10% line:83% size:80% one to two years afterwards. And then you put in 44:08.700 --> 44:10.900 align:left position:30% line:83% size:60% instrumentation. x*Instrumentation 44:10.900 --> 44:13.033 align:left position:20% line:83% size:70% is actually fairly easy. We typically perform this with 44:13.033 --> 44:17.233 align:left position:10% line:83% size:80% pediatric surgery colleagues. But the instrumentation 44:17.233 --> 44:19.733 align:left position:10% line:83% size:80% and the surgery part actually is fairly straightforward, 44:19.733 --> 44:21.766 align:left position:20% line:83% size:70% because the spine is right there. 44:21.766 --> 44:24.900 align:left position:20% line:83% size:70% And this is the type of correction that you can get. 44:24.900 --> 44:29.466 align:left position:20% line:83% size:70% Here's another example. x*When anterior versus posterior 44:29.466 --> 44:31.900 align:left position:10% line:83% size:80% instrumentation was compared, basically what was found 44:31.900 --> 44:34.200 align:left position:20% line:83% size:70% that in certain curves, you can actually save a couple 44:34.200 --> 44:36.600 align:left position:10% line:83% size:80% of levels, but the actual correction is not any different. 44:36.600 --> 44:39.000 align:left position:10% line:83% size:80% So if you have that particular curve, where you may be able 44:39.000 --> 44:41.366 align:left position:10% line:83% size:80% to not fuse a couple of levels, it still may be reasonable 44:41.366 --> 44:43.400 align:left position:10% line:83% size:80% to go anteriorly, but I think that is only time 44:43.400 --> 44:46.166 align:left position:20% line:83% size:70% people are doing that. The other advantage to going 44:46.166 --> 44:48.666 align:left position:10% line:83% size:80% anteriorly, is you can do arthroscopic techniques, 44:48.666 --> 44:51.233 align:left position:20% line:83% size:70% that is through small band-aid type incisions. 44:51.233 --> 44:55.600 align:left position:10% line:83% size:80% That's done less commonly now, but it can be done. 44:55.600 --> 44:59.233 align:left position:10% line:83% size:80% And doing surgery that way in experienced hands 44:59.233 --> 45:01.666 align:left position:20% line:83% size:70% really gives about the same correction as doing it 45:01.666 --> 45:04.166 align:left position:20% line:83% size:70% through a big incision. It just takes 45:04.166 --> 45:06.800 align:left position:10% line:83% size:80% about four times as long. x*This is post-op activities. 45:06.800 --> 45:09.333 align:left position:10% line:83% size:80% Our post-op regimen has changed quite a bit, depending on 45:09.333 --> 45:11.466 align:left position:20% line:83% size:70% the quality of fixation and the patient. 45:11.466 --> 45:13.866 align:left position:10% line:83% size:80% But in general, for up to a year, we want people 45:13.866 --> 45:17.200 align:left position:10% line:83% size:80% lifting less than 50 pounds. For the first six months, 45:17.200 --> 45:20.733 align:left position:10% line:83% size:80% we often limit their bending at the hips and lifting as well. 45:20.733 --> 45:24.633 align:left position:10% line:83% size:80% So after scoliosis surgery, it's very important that 45:24.633 --> 45:26.966 align:left position:10% line:83% size:80% they limit their activities. And most backpacks now seem to 45:26.966 --> 45:31.466 align:left position:20% line:83% size:70% weigh about 100 pounds, so that limits their backpacks. 45:31.466 --> 45:34.533 align:left position:10% line:83% size:80% x*There are new treatments coming out and one of the big pushes 45:34.533 --> 45:38.166 align:left position:10% line:83% size:80% is how can we correct this curve without fusing it, because 45:38.166 --> 45:40.333 align:left position:10% line:83% size:80% it just doesn't make sense. We were born with a spine 45:40.333 --> 45:42.900 align:left position:20% line:83% size:70% that's mobile, why would we fuse it and make it solid. 45:42.900 --> 45:44.633 align:left position:20% line:83% size:70% And one of the ways is using these 45:44.633 --> 45:48.233 align:left position:10% line:83% size:80% memory shaped alloy staples. In a long bone, if you put 45:48.233 --> 45:52.000 align:left position:10% line:83% size:80% a staple or some kind of tether on one side of the growth plate, 45:52.000 --> 45:54.666 align:left position:20% line:83% size:70% the leg will grow asymmetrically. 45:54.666 --> 45:57.233 align:left position:10% line:83% size:80% The thought is maybe we can do the same thing with the spine. 45:57.233 --> 46:00.700 align:left position:10% line:83% size:80% We can put these on the convex curve, and put them 46:00.700 --> 46:02.866 align:left position:10% line:83% size:80% into a small little incision, and the spine might 46:02.866 --> 46:05.566 align:left position:20% line:83% size:70% start to grow straight. And so that's the concept. 46:05.566 --> 46:07.566 align:left position:10% line:83% size:80% x*Unfortunately what happened in the '50s, this was done, and 46:07.566 --> 46:10.166 align:left position:10% line:83% size:80% all the staples would fall out and they would go into things 46:10.166 --> 46:13.500 align:left position:10% line:83% size:80% like the heart and other places you don't want them to be. 46:13.500 --> 46:15.700 align:left position:10% line:83% size:80% x*So that was sort of poo-pooed, until we found the staples 46:15.700 --> 46:18.433 align:left position:30% line:83% size:60% that stay in and they're a shape memory alloy. 46:18.433 --> 46:21.266 align:left position:10% line:83% size:80% So unless your body temperature goes below about 20 degrees 46:21.266 --> 46:25.266 align:left position:10% line:83% size:80% Celsius, they will stay in. And this is that 7-year-old 46:25.266 --> 46:29.500 align:left position:10% line:83% size:80% that had a bump on her back. She's seven years old, this 46:29.500 --> 46:33.066 align:left position:10% line:83% size:80% curve is now over 20 degrees. We know this is going to 46:33.066 --> 46:35.633 align:left position:30% line:83% size:60% progress. And one option is bracing. 46:35.633 --> 46:38.033 align:left position:20% line:83% size:70% And certainly, this was a patient that was offered 46:38.033 --> 46:41.833 align:left position:20% line:83% size:70% and tried bracing. I hate to say wasn't compliant, 46:41.833 --> 46:46.733 align:left position:20% line:83% size:70% but didn't use a bracing regimen and went on-- 46:46.733 --> 46:50.233 align:left position:10% line:83% size:80% Here's a fairly flexible curve though. 46:50.233 --> 46:52.800 align:left position:10% line:83% size:80% Went on to have these staples placed on the convex 46:52.800 --> 46:55.700 align:left position:30% line:83% size:60% of both curves. And over time-- 46:55.700 --> 46:57.866 align:left position:10% line:83% size:80% this is how they're placed, so they're actually placed 46:57.866 --> 47:00.166 align:left position:20% line:83% size:70% through small incisions. It's not technically 47:00.166 --> 47:03.433 align:left position:10% line:83% size:80% that difficult to put these in. x*So that basically showed 47:03.433 --> 47:05.900 align:left position:30% line:83% size:60% that over time, the curve basically did not 47:05.900 --> 47:08.466 align:left position:20% line:83% size:70% progress over time, which saves a larger surgery 47:08.466 --> 47:13.066 align:left position:30% line:83% size:60% down the road. And we looked at our first about 47:13.066 --> 47:17.666 align:left position:10% line:83% size:80% 40 patients and in general, it's very unlikely for a curve 47:17.666 --> 47:21.333 align:left position:20% line:83% size:70% to progress to a point where it needs surgery, and 47:21.333 --> 47:24.533 align:left position:10% line:83% size:80% some curves actually improved. So if you can keep a 20-degree 47:24.533 --> 47:26.966 align:left position:10% line:83% size:80% curve at about 20 degrees, and one where you know 47:26.966 --> 47:29.233 align:left position:20% line:83% size:70% that the natural history is for it to progress, 47:29.233 --> 47:31.866 align:left position:20% line:83% size:70% I think that's probably a victory. 47:31.866 --> 47:37.233 align:left position:30% line:83% size:60% Other options. For the very young patients 47:37.233 --> 47:39.500 align:left position:20% line:83% size:70% is to use what we call a titanium rib or adapter 47:39.500 --> 47:41.800 align:left position:20% line:83% size:70% and this is something that stays out of the spine. 47:41.800 --> 47:44.366 align:left position:10% line:83% size:80% It goes on the rib and down to the pelvis. 47:44.366 --> 47:46.566 align:left position:20% line:83% size:70% And by doing that, you can actually get correction. 47:46.566 --> 47:49.466 align:left position:10% line:83% size:80% It's a temporary thing, so the idea is when they're older, 47:49.466 --> 47:52.533 align:left position:10% line:83% size:80% you can do more formal surgery. And so those are some of 47:52.533 --> 47:54.366 align:left position:10% line:83% size:80% the different treatment options that are being used, 47:54.366 --> 47:56.533 align:left position:20% line:83% size:70% newer treatment options that are being used today. 47:56.533 --> 47:58.966 align:left position:20% line:83% size:70% And that was really it, just some of these pictures. 47:58.966 --> 48:02.966 align:left position:20% line:77% size:70% Thank you very much. Any questions at all?</P></SYNC> </Body>