1 00:00:00,100 --> 00:00:02,266 cc >> Thank you very much. 2 00:00:02,266 --> 00:00:04,400 Can everyone hear me okay? I really want to thank Ellen 3 00:00:04,400 --> 00:00:06,466 and everyone for inviting me here. 4 00:00:06,466 --> 00:00:08,333 This is really an honor. It's also an incredibly exciting 5 00:00:08,333 --> 00:00:11,133 time to be here and be part of the new Children's Hospital. 6 00:00:11,133 --> 00:00:16,366 It is one thing that I really look forward to, the ability 7 00:00:16,366 --> 00:00:21,133 to interact with the colleagues here, and be part of the 8 00:00:21,133 --> 00:00:24,833 incredibly high quality of care that I've seen delivered 9 00:00:24,833 --> 00:00:27,733 even in my short period of time here. 10 00:00:27,733 --> 00:00:30,066 x*This morning I'm going to talk a little bit about scoliosis, 11 00:00:30,066 --> 00:00:32,566 and really focus on the evaluation and treatment. 12 00:00:32,566 --> 00:00:35,633 There will be certainly plenty of time for questions. 13 00:00:35,633 --> 00:00:40,000 And I wrote a couple of learning objectives here. 14 00:00:40,000 --> 00:00:41,933 One is to be able to identify children's scoliosis 15 00:00:41,933 --> 00:00:43,800 from clinical exam. And I think probably most 16 00:00:43,800 --> 00:00:46,233 people can do that already, but I'll show a few examples 17 00:00:46,233 --> 00:00:49,900 and we'll go through that. Two, to understand the natural 18 00:00:49,900 --> 00:00:53,533 history of idiopathic scoliosis, so you know which ones you 19 00:00:53,533 --> 00:00:55,500 really need to worry about, and which ones you probably 20 00:00:55,500 --> 00:00:58,033 don't need to worry about. And then three, to know the 21 00:00:58,033 --> 00:01:01,366 clinical findings that suggest a diagnose other than scoliosis. 22 00:01:01,366 --> 00:01:03,333 I think one of the things, hopefully, you'll take away 23 00:01:03,333 --> 00:01:06,700 is the idea that scoliosis really is quite different. 24 00:01:06,700 --> 00:01:10,766 So not all scoliosis is the same. 25 00:01:10,766 --> 00:01:14,733 x*There are a couple of disclaimers. 26 00:01:14,733 --> 00:01:17,200 This really is a discussion to the orthopedic treatment 27 00:01:17,200 --> 00:01:20,133 of scoliosis. There are some therapy options 28 00:01:20,133 --> 00:01:23,566 that people have talked about, and I'll touch on that briefly. 29 00:01:23,566 --> 00:01:26,133 But this is really sort of our semi-skewed perspective 30 00:01:26,133 --> 00:01:29,233 of scoliosis. Really the emphasis at this 31 00:01:29,233 --> 00:01:32,233 point is on the identification of scoliosis, and a little bit 32 00:01:32,233 --> 00:01:34,766 less on the treatment. Although I'll show you some 33 00:01:34,766 --> 00:01:36,733 of the treatment options and some of the newer things 34 00:01:36,733 --> 00:01:40,866 people are starting to do. x*So this is the outline 35 00:01:40,866 --> 00:01:42,833 of the talk. It's not really as arduous 36 00:01:42,833 --> 00:01:44,833 as this outline looks. But we'll talk briefly about the 37 00:01:44,833 --> 00:01:48,000 anatomy, the simplified version. A little bit about etiology, 38 00:01:48,000 --> 00:01:52,000 the physical exam, the radiographic exam, 39 00:01:52,000 --> 00:01:54,166 demographics, non-surgical treatment, 40 00:01:54,166 --> 00:01:56,400 surgical treatment and then new ideas and new ways 41 00:01:56,400 --> 00:02:02,566 we're treating this. x*So I want to start with a case, 42 00:02:02,566 --> 00:02:07,066 maybe not a typical case, but it's a 7-year-old female 43 00:02:07,066 --> 00:02:10,533 that presented to us with a bump on her back. 44 00:02:10,533 --> 00:02:12,533 People present a lot of different ways and this is 45 00:02:12,533 --> 00:02:16,066 what the x-rays showed. She has a little bit of 46 00:02:16,066 --> 00:02:18,333 scoliosis and you can see that her head is offset just a little 47 00:02:18,333 --> 00:02:22,200 bit, which probably is, what we like to see is the head directly 48 00:02:22,200 --> 00:02:25,266 over the pelvis. But it's not, and I think that 49 00:02:25,266 --> 00:02:29,266 may have been one of the things that bothered her the most. 50 00:02:29,266 --> 00:02:32,700 She, of course, is seven, so she's a little bit young. 51 00:02:32,700 --> 00:02:35,866 That's the lateral x-ray, which shows a relatively normal 52 00:02:35,866 --> 00:02:40,300 contour. We'll get back to that case 53 00:02:40,300 --> 00:02:45,166 and how we treated that patient. x*So scoliosis, as probably 54 00:02:45,166 --> 00:02:47,800 most of you know, is Greek and it really means a lateral 55 00:02:47,800 --> 00:02:50,733 curvature of the spine. So really any curvature 56 00:02:50,733 --> 00:02:52,766 of the spine would be considered scoliosis, but we typically 57 00:02:52,766 --> 00:02:55,933 don't define it until it's at least 10 degrees. 58 00:02:55,933 --> 00:02:57,900 As I tell a lot of patients, if you lean to one side, you're 59 00:02:57,900 --> 00:03:04,000 going to have a scoliosis. x*And if you want to take 60 00:03:04,000 --> 00:03:06,733 the really simplest approach to anatomy, if you look at 61 00:03:06,733 --> 00:03:10,733 the spine from the front, it really should be straight, 62 00:03:10,733 --> 00:03:12,866 unless there's some particular issue. 63 00:03:12,866 --> 00:03:15,500 But if you look at the spine from the side or the lateral 64 00:03:15,500 --> 00:03:19,433 view, you should have a curve. And the curve is about 65 00:03:19,433 --> 00:03:22,966 40 degrees in thoracic spine and then it varies 66 00:03:22,966 --> 00:03:26,166 down to a lumbar curve that balances that out. 67 00:03:26,166 --> 00:03:33,900 So overall, the head should be over the sacrum. 68 00:03:33,900 --> 00:03:36,700 x*Scoliosis classification is fairly straightforward. 69 00:03:36,700 --> 00:03:38,933 In general, there's two broad types of scoliosis. 70 00:03:38,933 --> 00:03:41,466 One is idiopathic, which just means we don't know 71 00:03:41,466 --> 00:03:45,066 what causes it, and I'll talk about the possible causes. 72 00:03:45,066 --> 00:03:47,533 And then there's a whole other branch with a known etiology. 73 00:03:47,533 --> 00:03:50,200 And probably the most important thing, other than identifying 74 00:03:50,200 --> 00:03:53,033 scoliosis, is being able to fret out which one of those 75 00:03:53,033 --> 00:03:56,133 is idiopathic and which one has an underlying cause, 76 00:03:56,133 --> 00:03:58,933 because if it has a cause, for various reasons, we obviously 77 00:03:58,933 --> 00:04:03,366 want to know about that. x*So I'll just talk about some 78 00:04:03,366 --> 00:04:06,700 of the non-idiopathic scoliosis. Because idiopathic scoliosis 79 00:04:06,700 --> 00:04:08,800 is the dominant form of scoliosis, and 80 00:04:08,800 --> 00:04:11,800 what we treat the most often. I'll focus most of my talk 81 00:04:11,800 --> 00:04:15,133 on that, but just to touch on neuromuscular scoliosis. 82 00:04:15,133 --> 00:04:17,066 It's important to realize, as we just talked about, 83 00:04:17,066 --> 00:04:19,333 not all scoliosis is idiopathic, so it's always important 84 00:04:19,333 --> 00:04:21,400 to search for etiology. x*So every patient that 85 00:04:21,400 --> 00:04:23,666 has scoliosis, the first question I ask 86 00:04:23,666 --> 00:04:27,000 is what's the underlying cause. Nine out of ten times, 87 00:04:27,000 --> 00:04:30,000 the underlying cause is idiopathic. 88 00:04:30,000 --> 00:04:32,400 But that one out of ten times will be something else. 89 00:04:32,400 --> 00:04:34,666 x*This is a patient with neurofibromatosis, so they had 90 00:04:34,666 --> 00:04:37,000 the classic cafe au lait spots. And they tend to have 91 00:04:37,000 --> 00:04:39,533 different kinds of curves. So there are some clues 92 00:04:39,533 --> 00:04:41,866 that will tell you that this may not be idiopathic. 93 00:04:41,866 --> 00:04:44,166 If you have a long, sort of gradual curve, 94 00:04:44,166 --> 00:04:46,633 a C-shaped curve, a long S-shaped curve, 95 00:04:46,633 --> 00:04:53,666 that is consistent with the neuromuscular scoliosis. 96 00:04:53,666 --> 00:04:56,833 x*If you have a very short, sharp curve, that's also 97 00:04:56,833 --> 00:05:00,700 not consistent with idiopathic scoliosis. 98 00:05:00,700 --> 00:05:04,300 And that can be very consistent with the congenital scoliosis. 99 00:05:04,300 --> 00:05:06,766 Now congenital scoliosis is really something you're 100 00:05:06,766 --> 00:05:10,033 born with and the bone just forms abnormally. 101 00:05:10,033 --> 00:05:12,300 And there's really two broad categories 102 00:05:12,300 --> 00:05:15,266 of this congenital scoliosis. In orthopedics, 103 00:05:15,266 --> 00:05:17,866 we like to keep it very simple. It's either a failure 104 00:05:17,866 --> 00:05:20,200 of formation or failure of segmentation. 105 00:05:20,200 --> 00:05:23,033 So you may have a situation where you don't actually 106 00:05:23,033 --> 00:05:29,800 segment like this bar that's shown here. 107 00:05:29,800 --> 00:05:32,566 So that area's not segmented. Or you may have a failure 108 00:05:32,566 --> 00:05:36,733 of formation, where the vertebra has not formed completely. 109 00:05:36,733 --> 00:05:41,633 So those are the two. Over time, congenital scoliosis 110 00:05:41,633 --> 00:05:44,466 can get worse or it can stay the same. 111 00:05:44,466 --> 00:05:47,266 So a child may be born with a 30 degrees curve, and 112 00:05:47,266 --> 00:05:49,833 that may stay the same forever, or it may get worse. 113 00:05:49,833 --> 00:05:53,500 So with congenital scoliosis, we follow that over time. 114 00:05:53,500 --> 00:05:56,866 If we see it getting worse, then we consider treatment. 115 00:05:56,866 --> 00:05:59,233 x*Probably the most important thing to realize is about 30% 116 00:05:59,233 --> 00:06:02,800 have underlying urogenical problems, especially renal 117 00:06:02,800 --> 00:06:06,233 issues or cardiac issues, and those need to be evaluated. 118 00:06:06,233 --> 00:06:08,766 And classically, we evaluate them with a renal ultrasound 119 00:06:08,766 --> 00:06:16,433 or a cardiac ultrasound. So those are two of the most 120 00:06:16,433 --> 00:06:18,633 common other forms. But certainly children 121 00:06:18,633 --> 00:06:21,366 with cerebral palsy and other disorders 122 00:06:21,366 --> 00:06:24,700 will have scoliosis as well. x*The number one cause, 123 00:06:24,700 --> 00:06:27,200 nine out of ten children will have idiopathic scoliosis. 124 00:06:27,200 --> 00:06:29,366 And the question is why do they have that. 125 00:06:29,366 --> 00:06:31,866 And we don't really know. We don't even really know 126 00:06:31,866 --> 00:06:35,666 why the vast majority of those curves are right-sided curves. 127 00:06:35,666 --> 00:06:38,866 Various different theories have been brought forward. 128 00:06:38,866 --> 00:06:41,900 Melatonin is one that in the 1990s 129 00:06:41,900 --> 00:06:45,966 had a fair amount of support. If you take the pineal gland 130 00:06:45,966 --> 00:06:48,600 out of chickens, they would develop scoliosis. 131 00:06:48,600 --> 00:06:51,233 Then you treat these chickens with melatonin 132 00:06:51,233 --> 00:06:54,033 and the scoliosis would go away. And we looked at that in humans, 133 00:06:54,033 --> 00:06:57,933 it was really much more complex. Melatonin levels 134 00:06:57,933 --> 00:07:00,066 would go up and down, and it was hard to determine 135 00:07:00,066 --> 00:07:02,366 if that was related to it. It sort of fell out of favor, 136 00:07:02,366 --> 00:07:04,766 and now it's starting to get into favor again. 137 00:07:04,766 --> 00:07:07,000 x*We know that children's scoliosis have changes in the 138 00:07:07,000 --> 00:07:09,666 equilibrium and proprioception, and that may be related 139 00:07:09,666 --> 00:07:12,233 to scoliosis. And certainly some of these 140 00:07:12,233 --> 00:07:14,966 have platelet abnormalities. So we don't really know 141 00:07:14,966 --> 00:07:17,366 what the cause is. And I don't think there's 142 00:07:17,366 --> 00:07:19,666 any reason to focus too much at this point, 143 00:07:19,666 --> 00:07:23,666 until we find the cause. x*But there probably is 144 00:07:23,666 --> 00:07:27,400 an underlying genetic etiology or at least a predisposition. 145 00:07:27,400 --> 00:07:30,266 We know that because in general the chance of having scoliosis 146 00:07:30,266 --> 00:07:32,866 goes up if you have a family history of that. 147 00:07:32,866 --> 00:07:35,533 So it's up to 11% with a first-degree relative 148 00:07:35,533 --> 00:07:42,000 and 1.4% with a third-degree relative. 149 00:07:42,000 --> 00:07:44,433 x*The scoliosis exam is fairly straightforward. 150 00:07:44,433 --> 00:07:47,166 These are actual pictures taken from a fairly old textbook, 151 00:07:47,166 --> 00:07:49,533 as you can see. But in general, 152 00:07:49,533 --> 00:07:53,733 you want to look at the patient. It's important to be able 153 00:07:53,733 --> 00:07:58,866 to look at their hips and their shoulders, 154 00:07:58,866 --> 00:08:02,800 because often that will be their primary complaint. 155 00:08:02,800 --> 00:08:05,166 So you want to make sure their shoulders and hips are balanced. 156 00:08:05,166 --> 00:08:07,400 But you can still have a scoliosis that's balanced 157 00:08:07,400 --> 00:08:10,433 and it can not be so obvious. It really is amazing. 158 00:08:10,433 --> 00:08:13,033 x*I remember a next door neighbor who was 8 years old. 159 00:08:13,033 --> 00:08:15,466 She had a fairly significant scoliosis we ended up treating, 160 00:08:15,466 --> 00:08:17,733 but when you would looked at her, you wouldn't know, 161 00:08:17,733 --> 00:08:19,866 because she had a very balanced curve. 162 00:08:19,866 --> 00:08:22,233 So hips and shoulders are very important. 163 00:08:22,233 --> 00:08:24,766 And it's important for decision-making, but it's also 164 00:08:24,766 --> 00:08:27,400 important to exam the spine carefully. 165 00:08:27,400 --> 00:08:29,800 x*And the easiest way to do that is the Adams Forward Bend Test. 166 00:08:29,800 --> 00:08:32,133 And that's where they have their feet together, and 167 00:08:32,133 --> 00:08:34,866 they slowly bend forward and you really look for asymmetry. 168 00:08:34,866 --> 00:08:37,933 It's termed a rib hump, which is probably not a very 169 00:08:37,933 --> 00:08:40,800 complimentary term. But it's really fairly obvious, 170 00:08:40,800 --> 00:08:43,366 and it's due to rotation of the spine, 171 00:08:43,366 --> 00:08:45,966 not a curve of the spine. So in scoliosis, it's not just 172 00:08:45,966 --> 00:08:48,500 a curve, but it's truly 3-dimensional through rotation. 173 00:08:48,500 --> 00:08:51,666 As the ribs are rotated back, and they bend forward, 174 00:08:51,666 --> 00:08:54,200 it becomes obvious. x*The one caveat to that is 175 00:08:54,200 --> 00:08:56,466 somewhat the significant leg length inequality 176 00:08:56,466 --> 00:08:59,300 will almost always have either a lumbar prominence, 177 00:08:59,300 --> 00:09:03,066 or more likely a rib hump. So it can be very deceiving 178 00:09:03,066 --> 00:09:05,733 if you exam someone with a leg length inequality. 179 00:09:05,733 --> 00:09:08,233 So one of the important things to do is to make sure that 180 00:09:08,233 --> 00:09:10,500 you exam them, that they don't have a leg length inequality. 181 00:09:10,500 --> 00:09:12,900 And really the easiest way to do that is just to examine 182 00:09:12,900 --> 00:09:15,333 them standing up with their knees extended 183 00:09:15,333 --> 00:09:17,866 and look at their pelvis, because you'll be able to tell 184 00:09:17,866 --> 00:09:20,133 if there's a leg length inequality greater than 185 00:09:20,133 --> 00:09:22,400 a centimeter, simply by looking at them. 186 00:09:22,400 --> 00:09:24,633 Using a tape measure is much more difficult 187 00:09:24,633 --> 00:09:26,933 and much less accurate. So make sure they don't have 188 00:09:26,933 --> 00:09:29,166 leg length inequality. x*Have them do 189 00:09:29,166 --> 00:09:31,500 the Adams Forward Bend Test. You'll screen out just about 190 00:09:31,500 --> 00:09:33,700 everyone with curves under 20 degrees with this test. 191 00:09:33,700 --> 00:09:36,066 So it's unlikely to have a curve that's greater than 20 degrees 192 00:09:36,066 --> 00:09:39,433 that you won't identify with this test. 193 00:09:39,433 --> 00:09:42,900 x*The second thing is to always exam them from the side. 194 00:09:42,900 --> 00:09:45,566 Look at the lateral view, because they may have 195 00:09:45,566 --> 00:09:47,600 a kyphosis. And a lot of people 196 00:09:47,600 --> 00:09:50,166 have a kyphosis. Here you can see a fairly 197 00:09:50,166 --> 00:09:54,166 dramatic kyphosis. And it's actually termed 198 00:09:54,166 --> 00:09:56,566 a gibbous, if it's not a gentle curve, but instead 199 00:09:56,566 --> 00:09:59,533 it's a fairly dramatic curve. It's a gibbous 200 00:09:59,533 --> 00:10:02,066 and that's abnormal. So a gentle curve is normal 201 00:10:02,066 --> 00:10:04,500 and routine. But a more significant curve 202 00:10:04,500 --> 00:10:07,066 isn't, and that has to be evaluated. 203 00:10:07,066 --> 00:10:09,633 And interesting enough, children with scoliosis, 204 00:10:09,633 --> 00:10:12,366 idiopathic scoliosis, actually tend to have 205 00:10:12,366 --> 00:10:15,066 decreased kyphosis, or a straighter back. 206 00:10:15,066 --> 00:10:18,866 I will show examples of that and why that's important. 207 00:10:18,866 --> 00:10:25,033 x*If you see a scoliosis, the next step then is to do a 208 00:10:25,033 --> 00:10:28,800 fairly careful neurologic exam. Because, again, the most 209 00:10:28,800 --> 00:10:31,700 important thing to do, obviously, is to identify 210 00:10:31,700 --> 00:10:34,033 the scoliosis. The second most important 211 00:10:34,033 --> 00:10:36,333 thing to do is to rule out other causes. 212 00:10:36,333 --> 00:10:38,666 The best way to rule that out is with a careful 213 00:10:38,666 --> 00:10:40,866 neurologic exam. x*Abnormal neurologic exam should 214 00:10:40,866 --> 00:10:43,300 raise a red flag that this is not idiopathic scoliosis, 215 00:10:43,300 --> 00:10:50,133 or at least deserves and needs further evaluation. 216 00:10:50,133 --> 00:10:53,066 x*School screening is a little bit controversial. 217 00:10:53,066 --> 00:10:55,033 It fell very much in favor on the east coast. 218 00:10:55,033 --> 00:10:56,900 It's fallen very much out of favor over the last 219 00:10:56,900 --> 00:10:59,800 couple of years. And I think that's in part 220 00:10:59,800 --> 00:11:02,700 because school screenings predicated on the idea that 221 00:11:02,700 --> 00:11:05,433 if you find someone with a scoliosis at early age, 222 00:11:05,433 --> 00:11:08,766 you've got a reasonable way to treat that patient 223 00:11:08,766 --> 00:11:14,733 that is effective, and is less of a burden 224 00:11:14,733 --> 00:11:17,433 than other forms of treatment. So in general, what that means 225 00:11:17,433 --> 00:11:19,900 is you have to believe and feel that bracing 226 00:11:19,900 --> 00:11:22,533 is a reasonable option. Many people no longer feel that 227 00:11:22,533 --> 00:11:26,966 bracing is a reasonable option. I'll talk about that 228 00:11:26,966 --> 00:11:30,333 a little bit under treatment. It's also not particularly 229 00:11:30,333 --> 00:11:32,600 cost-effective to screen hundreds and hundreds 230 00:11:32,600 --> 00:11:36,366 of patients, so it's gone in and out of favor. 231 00:11:36,366 --> 00:11:39,066 I certainly think, personally, that school screening is 232 00:11:39,066 --> 00:11:41,300 a very reasonable thing to do, and I actually believe in 233 00:11:41,300 --> 00:11:47,633 bracing, but that is subject to some controversy. 234 00:11:47,633 --> 00:11:51,066 x*There are different ways to do a school screening, 235 00:11:51,066 --> 00:11:53,466 but if you use a scoliometer, which is that little device 236 00:11:53,466 --> 00:11:57,333 that shows you how much of a trunk asymmetry there is, 237 00:11:57,333 --> 00:12:01,733 what number, what degree you use will depend 238 00:12:01,733 --> 00:12:04,200 on your referral rate. So in you've got a fairly high 239 00:12:04,200 --> 00:12:06,666 cut off of seven or eight degrees, you're going 240 00:12:06,666 --> 00:12:09,800 to refer very few patients. Unfortunately, you are more 241 00:12:09,800 --> 00:12:12,266 likely to miss a few patients that have scoliosis. 242 00:12:12,266 --> 00:12:15,400 And just the opposite's true if you use a fairly low number 243 00:12:15,400 --> 00:12:17,633 as a cut off. So in general, the number to 244 00:12:17,633 --> 00:12:20,533 use, if you use a scoliometer, is somewhere between five 245 00:12:20,533 --> 00:12:22,733 and seven. And I think most people use 246 00:12:22,733 --> 00:12:26,033 about a six degree cut off for when to refer patients 247 00:12:26,033 --> 00:12:31,166 and when not to. Some people have said this is 248 00:12:31,166 --> 00:12:33,533 not a very valuable test. The Adams Forward Bending Test 249 00:12:33,533 --> 00:12:35,633 is not that accurate, scoliometers 250 00:12:35,633 --> 00:12:38,000 are not that useful. But the truth is 251 00:12:38,000 --> 00:12:40,766 it actually is fairly accurate. It's got a sensitivity of about 252 00:12:40,766 --> 00:12:44,966 85%, specificity of over 90%, and that's from a study 253 00:12:44,966 --> 00:12:47,633 that wanted to disprove its usefulness. 254 00:12:47,633 --> 00:12:51,500 So I think it's a fairly useful exam. 255 00:12:51,500 --> 00:12:53,733 x*If we see patients, we have the luxury of having x-rays. 256 00:12:53,733 --> 00:12:55,800 So we really, not that we don't examine the patient, but we now 257 00:12:55,800 --> 00:12:59,800 have a lot more information, and it's very reasonable to get 258 00:12:59,800 --> 00:13:02,466 an x-ray if you're concerned about scoliosis. 259 00:13:02,466 --> 00:13:04,533 How you get the x-ray is important. 260 00:13:04,533 --> 00:13:06,633 If you get an x-ray with a patient standing 261 00:13:06,633 --> 00:13:09,300 with a leg length inequality, they may have a scoliosis 262 00:13:09,300 --> 00:13:12,566 they wouldn't normally have. So how you get the x-ray 263 00:13:12,566 --> 00:13:15,000 is fairly important. We typically get standing x-rays 264 00:13:15,000 --> 00:13:17,266 assuming they don't have a leg length inequality. 265 00:13:17,266 --> 00:13:19,800 If they do, then we'll get a sitting x-ray. 266 00:13:19,800 --> 00:13:23,000 And if they are unable to stand because they have got 267 00:13:23,000 --> 00:13:25,966 other conditions or disorders, then we can do supine x-ray. 268 00:13:25,966 --> 00:13:28,266 We always include a lateral x-ray. 269 00:13:28,266 --> 00:13:30,333 And the reason we include a lateral x-ray is because 270 00:13:30,333 --> 00:13:34,933 we worry about kyphosis, an abnormal kyphosis, which 271 00:13:34,933 --> 00:13:38,300 occurs in about 10% of patients. Spinal listhesis, which can 272 00:13:38,300 --> 00:13:41,066 occur either independently or associated with scoliosis, 273 00:13:41,066 --> 00:13:44,466 occurs about 5% of the time. And then you can get 274 00:13:44,466 --> 00:13:48,166 a thoracic lordosis. And that's actually very common 275 00:13:48,166 --> 00:13:51,500 in idiopathic scoliosis. So hypokyphosis 276 00:13:51,500 --> 00:13:54,966 or lordosis or a flat back, that's quite common. 277 00:13:54,966 --> 00:13:56,966 And if it's very severe, it can actually affect 278 00:13:56,966 --> 00:14:01,666 pulmonary function. x*If we get to the point where 279 00:14:01,666 --> 00:14:04,100 we do treatment, then we look at bending films, 280 00:14:04,100 --> 00:14:06,566 and that gives us some idea of the flexibility 281 00:14:06,566 --> 00:14:12,033 of the curve. How much it bends back 282 00:14:12,033 --> 00:14:14,833 and forth. x*For those that aren't familiar 283 00:14:14,833 --> 00:14:17,233 with the Cobb angle, this is what we use to determine 284 00:14:17,233 --> 00:14:19,366 the degree of curve. If you think too much 285 00:14:19,366 --> 00:14:21,766 about this, it will give you a little bit of a headache, 286 00:14:21,766 --> 00:14:24,066 but this is not the only way to describe a curve. 287 00:14:24,066 --> 00:14:26,333 A sharp curve and a gentle curve may get the same number 288 00:14:26,333 --> 00:14:28,633 and be very different curves. But this is how it's been 289 00:14:28,633 --> 00:14:30,966 described, and I think it's probably still the best way. 290 00:14:30,966 --> 00:14:33,233 There are other things that we use, but this is probably 291 00:14:33,233 --> 00:14:35,433 a reasonable marker. x*The Cobb angle, simply, 292 00:14:35,433 --> 00:14:37,600 is taken from an x-ray. And what you do is 293 00:14:37,600 --> 00:14:39,800 you measure down until you get the vertebra 294 00:14:39,800 --> 00:14:42,266 that's the most tilted. And once you find the vertebra 295 00:14:42,266 --> 00:14:44,666 that's the most tilted, in this case, it's the sixth 296 00:14:44,666 --> 00:14:47,433 thoracic vertebra, you draw a line that's parallel 297 00:14:47,433 --> 00:14:52,066 to the disk or to the end plate, and 298 00:14:52,066 --> 00:14:56,266 just take that out laterally or medially, and that's 299 00:14:56,266 --> 00:15:00,733 this line right here. Let's see if I can do this. 300 00:15:00,733 --> 00:15:03,000 That's this line right there. Then you do the same thing 301 00:15:03,000 --> 00:15:05,266 here. And where these two meet, 302 00:15:05,266 --> 00:15:07,633 that angle is the Cobb angle. Now sometimes where they meet 303 00:15:07,633 --> 00:15:10,033 is so far off the x-ray, you just have to make a right angle 304 00:15:10,033 --> 00:15:12,900 for each and measure that angle. But as basic trigonometry 305 00:15:12,900 --> 00:15:16,033 tells you it's the same angle, it's just that our x-rays 306 00:15:16,033 --> 00:15:18,300 aren't wide enough to draw it way out here. 307 00:15:18,300 --> 00:15:20,900 Is that's all the Cobb angle is. x*And it gives you a general idea 308 00:15:20,900 --> 00:15:23,733 of what the curve is, and if the curve is better 309 00:15:23,733 --> 00:15:26,133 or it's getting worse. People will come in and say 310 00:15:26,133 --> 00:15:29,300 they've got a 15% curve, which is really a degree curve, 311 00:15:29,300 --> 00:15:31,500 but they all know what that number is. 312 00:15:31,500 --> 00:15:33,700 Patients all know what that number is. 313 00:15:33,700 --> 00:15:35,600 x*How you get the x-ray is kind of interesting, because 314 00:15:35,600 --> 00:15:37,633 we get a straight AP x-ray. But we said that 315 00:15:37,633 --> 00:15:40,166 curves aren't really bent, they are actually rotated. 316 00:15:40,166 --> 00:15:42,666 So if you really wanted to get an accurate x-ray, 317 00:15:42,666 --> 00:15:45,133 you'd have to get an x-ray with the beam coming in at an angle, 318 00:15:45,133 --> 00:15:47,266 and that's called the Stagnera view, 319 00:15:47,266 --> 00:15:49,666 and occasionally we'll do that. And it's very interesting. 320 00:15:49,666 --> 00:15:51,900 If get that x-ray, you may take a 30-degree curve 321 00:15:51,900 --> 00:15:54,066 and find out it's really a 60-degree curve, 322 00:15:54,066 --> 00:16:01,333 because now you're getting it at its greatest deformity. 323 00:16:01,333 --> 00:16:04,166 x*We look a lot at kyphosis. As we said, idiopathic scoliosis 324 00:16:04,166 --> 00:16:07,000 won't be kyphotic, they won't have increased 325 00:16:07,000 --> 00:16:09,566 round back or hump back. They'll actually be straighter. 326 00:16:09,566 --> 00:16:12,366 And in fact, as we'll show you, if you see someone 327 00:16:12,366 --> 00:16:15,333 that's got increased kyphosis and a scoliosis, 328 00:16:15,333 --> 00:16:18,166 that raises a red flag, that you have to think 329 00:16:18,166 --> 00:16:20,300 there's something else going on. x*This is not idiopathic 330 00:16:20,300 --> 00:16:23,366 scoliosis. You can measure kyphosis, 331 00:16:23,366 --> 00:16:26,000 exactly like you measure the Cobb angle, and measure that 332 00:16:26,000 --> 00:16:29,033 curve in an identical fashion. Draw your lines 333 00:16:29,033 --> 00:16:31,533 parallel to the end plates and getting that angle. 334 00:16:31,533 --> 00:16:34,500 It's a little bit hard to do because of the soft tissue. 335 00:16:34,500 --> 00:16:37,000 As you get up in the thoracic spine, it's hard 336 00:16:37,000 --> 00:16:40,866 to actually see the vertebra. So you can measure 337 00:16:40,866 --> 00:16:44,866 from the upper thoracic curve, to the T-12, and if that 338 00:16:44,866 --> 00:16:47,300 is greater than 40 degrees, you start thinking 339 00:16:47,300 --> 00:16:50,833 they have increased kyphosis. Because that's hard to measure, 340 00:16:50,833 --> 00:16:54,433 there's a test you can use from T-5 to T-12. 341 00:16:54,433 --> 00:16:57,200 And if that's over 32 degrees, it's been shown-- 342 00:16:57,200 --> 00:16:59,533 If it's under 32 degrees, it's not kyphosis. 343 00:16:59,533 --> 00:17:02,033 If it's over 32 degrees, then it's a pretty good 344 00:17:02,033 --> 00:17:04,366 screening test that something else may be going on. 345 00:17:04,366 --> 00:17:07,500 So that's a reasonable screening test to do 346 00:17:07,500 --> 00:17:11,000 on a spinal x-ray. x*It's also important to 347 00:17:11,000 --> 00:17:13,400 look down at the lumbar spine, to see if there's any slippage 348 00:17:13,400 --> 00:17:20,266 or spondylolisthesis, and those two tend to go together. 349 00:17:20,266 --> 00:17:22,433 x*So again, this is kyphosis, this is actually 350 00:17:22,433 --> 00:17:24,733 one of our partners. Kyphosis is very common, 351 00:17:24,733 --> 00:17:27,133 a round back is not uncommon. But when you see this 352 00:17:27,133 --> 00:17:31,666 sharp curve or gibbous, then that raises a greater concern. 353 00:17:31,666 --> 00:17:34,500 Kyphosis in itself, though, is not an issue. 354 00:17:34,500 --> 00:17:37,133 Mark Spitz, for example, won seven gold medals. 355 00:17:37,133 --> 00:17:39,200 And they think it may be related to the fact that he did have 356 00:17:39,200 --> 00:17:41,400 kyphosis, and he had a larger lung volume. 357 00:17:41,400 --> 00:17:44,000 So kyphosis in itself that's not painful, and not getting worse, 358 00:17:44,000 --> 00:17:46,766 is not particularly a problem. x*Interestingly enough, just the 359 00:17:46,766 --> 00:17:49,300 opposite, the decreased kyphosis can be an issue, 360 00:17:49,300 --> 00:17:51,966 and can decrease lung volume if it's severe. 361 00:17:51,966 --> 00:17:55,766 x*We've discussed a little bit about this not just being 362 00:17:55,766 --> 00:17:58,600 a lateral curvature, but also a rotation. 363 00:17:58,600 --> 00:18:00,633 And there are some ways you can estimate how much rotation 364 00:18:00,633 --> 00:18:03,400 just by looking at the x-ray. One way is to look at 365 00:18:03,400 --> 00:18:05,933 the pedicles. So if you look at the x-rays, 366 00:18:05,933 --> 00:18:08,933 you can see the pedicles on end. Pedicles are very important 367 00:18:08,933 --> 00:18:11,400 to the spine, because you always want to see two pedicles. 368 00:18:11,400 --> 00:18:15,633 A missing pedicle is a big issue and can be consistent, 369 00:18:15,633 --> 00:18:20,133 especially with different metastatic diseases. 370 00:18:20,133 --> 00:18:22,266 So always try to identify the pedicles. 371 00:18:22,266 --> 00:18:24,533 x*On scoliosis, you may not see it, because it's rotated. 372 00:18:24,533 --> 00:18:27,300 It may, as the spine rotates, the pedicles may actually rotate 373 00:18:27,300 --> 00:18:30,833 and you may not see them. And if you look at the pedicles, 374 00:18:30,833 --> 00:18:33,300 you can get some idea of how much rotation they are. 375 00:18:33,300 --> 00:18:36,200 So here's where the pedicles should lie. 376 00:18:36,200 --> 00:18:38,666 And as it starts to rotate, the pedicles look like 377 00:18:38,666 --> 00:18:41,200 they're coming off the spine, and you can grade it, one, this 378 00:18:41,200 --> 00:18:45,200 pedicle's right on the curve and so as the pedicle rotates 379 00:18:45,200 --> 00:18:48,900 to it's midline, it's three. Across midline, it's four. 380 00:18:48,900 --> 00:18:50,900 So you get some idea of how much rotation's 381 00:18:50,900 --> 00:18:54,033 associated with the curve. x*Rotation is important to note, 382 00:18:54,033 --> 00:18:56,500 because if you would try to recreate a scoliosis, 383 00:18:56,500 --> 00:18:59,000 if you just bend to one side, you'd get a curve, 384 00:18:59,000 --> 00:19:01,033 but you wouldn't get any rotation in it. 385 00:19:01,033 --> 00:19:03,266 Or, if they have a leg length inequality, typically 386 00:19:03,266 --> 00:19:05,666 you'll get a curve, but you won't get a rotation. 387 00:19:05,666 --> 00:19:07,766 So if you see a curve, and you're thinking 388 00:19:07,766 --> 00:19:09,966 is this a real curve or maybe they're standing funny, 389 00:19:09,966 --> 00:19:16,366 and you see a lot of rotation, then you know it's a real curve. 390 00:19:16,366 --> 00:19:19,566 x*So, I'm sure everyone here is very good 391 00:19:19,566 --> 00:19:22,066 at identifying scoliosis. We've looked at how 392 00:19:22,066 --> 00:19:24,533 it's measured on x-ray. Some of these patients 393 00:19:24,533 --> 00:19:27,466 really deserve to get an MRI. And the reason is a certain 394 00:19:27,466 --> 00:19:30,833 percentage, it's really a small percentage of children, 395 00:19:30,833 --> 00:19:34,266 who have scoliosis will have interspinal pathology. 396 00:19:34,266 --> 00:19:36,566 And by that, that doesn't usually mean a tumor, 397 00:19:36,566 --> 00:19:40,566 it usually means a hydromyelia, or there could be 398 00:19:40,566 --> 00:19:45,633 a little fibrous band across the spine or to the cord. 399 00:19:45,633 --> 00:19:49,000 A small percentage, somewhere between one and four percent 400 00:19:49,000 --> 00:19:51,866 will have interspinal pathology. And there are ways 401 00:19:51,866 --> 00:19:54,633 you can identify that. x*So different people have 402 00:19:54,633 --> 00:19:57,233 looked at different ways of identifying that. 403 00:19:57,233 --> 00:19:59,766 I think any patient under age 11 who has scoliosis, 404 00:19:59,766 --> 00:20:04,466 is probably worth getting an MRI. 405 00:20:04,466 --> 00:20:07,666 If you look at a number of different studies, 406 00:20:07,666 --> 00:20:12,200 it shows a much higher incidence of interspinal abnormalities 407 00:20:12,200 --> 00:20:15,066 in children under 11. So across the board, it's small, 408 00:20:15,066 --> 00:20:23,433 but under 11, it's about 15% I'm sorry, about 50%. 409 00:20:23,433 --> 00:20:26,300 x*The other issue is that people have different changes 410 00:20:26,300 --> 00:20:28,800 on physical exam, and what kind of changes? 411 00:20:28,800 --> 00:20:31,766 It can be a persistent headache. It can be neck and back pain. 412 00:20:31,766 --> 00:20:34,533 It can be abnormal neurologic exam. 413 00:20:34,533 --> 00:20:37,600 And the one exam that we've looked at is abdominal reflexes. 414 00:20:37,600 --> 00:20:40,533 So if you lightly touch the abdomen, you'll see 415 00:20:40,533 --> 00:20:42,566 the abdominal muscles contract. And that should be symmetrical 416 00:20:42,566 --> 00:20:44,566 on four quadrants. If you use umbilicus 417 00:20:44,566 --> 00:20:47,633 as a midpoint, you can do upper left, upper right, 418 00:20:47,633 --> 00:20:50,666 lower right, lower left. You should have fairly symmetric 419 00:20:50,666 --> 00:20:53,600 abdominal reflexes. If you don't have that, 420 00:20:53,600 --> 00:20:55,633 that's a consideration they may have an abnormal 421 00:20:55,633 --> 00:20:58,700 neurologic exam. And your standard neurologic 422 00:20:58,700 --> 00:21:01,166 exam, which I'm sure you do more carefully than we do, 423 00:21:01,166 --> 00:21:03,900 is important. And if that's abnormal, 424 00:21:03,900 --> 00:21:06,366 then those are things to raise a red flag and say look, 425 00:21:06,366 --> 00:21:11,733 we should get an MRI. x*Any left thoracic curve. 426 00:21:11,733 --> 00:21:13,700 For some reason, idiopathic scoliosis 427 00:21:13,700 --> 00:21:17,200 is always to the right. If it's left, about a third 428 00:21:17,200 --> 00:21:19,900 will have underlying neurologic etiology. 429 00:21:19,900 --> 00:21:22,933 It could be something obvious. It could be cerebral palsy 430 00:21:22,933 --> 00:21:26,233 or some other diagnosis, so those are the reasons. 431 00:21:26,233 --> 00:21:28,933 Under 11, abnormal neurologic exam, or a left curve, or 432 00:21:28,933 --> 00:21:33,233 a curve with increased kyphosis, all deserve further evaluation. 433 00:21:33,233 --> 00:21:35,833 Assuming they don't have any of that, and you're 434 00:21:35,833 --> 00:21:38,566 pretty confident it's idiopathic scoliosis, then the next step 435 00:21:38,566 --> 00:21:40,966 is figuring out, is this really going to get worse or not. 436 00:21:40,966 --> 00:21:43,266 x*Because if it's not going to get worse, who cares? 437 00:21:43,266 --> 00:21:45,800 Scoliosis will not kill you. It's not a tumor, 438 00:21:45,800 --> 00:21:48,466 or a fracture, or an infection. So really the concern is, 439 00:21:48,466 --> 00:21:51,333 is this going to get worse? And it depends, really, 440 00:21:51,333 --> 00:21:53,366 on two things. It depends 441 00:21:53,366 --> 00:21:55,666 on the size of the angle. So if you've got a big curve, 442 00:21:55,666 --> 00:21:58,066 chances are more likely it will get worse. 443 00:21:58,066 --> 00:22:00,300 It's a little bit like the Leaning Tower of Pisa. 444 00:22:00,300 --> 00:22:03,633 The more it leans, the more likely it's going to fall. 445 00:22:03,633 --> 00:22:05,866 So if it's under ten degrees, the chance of it getting worse 446 00:22:05,866 --> 00:22:08,066 in general are small. Over 40, it's greater. 447 00:22:08,066 --> 00:22:10,533 x*But there's other factors that come into play, 448 00:22:10,533 --> 00:22:13,666 and probably the second most important is-- 449 00:22:13,666 --> 00:22:16,233 Well, I'll just touch on female/male ratio. 450 00:22:16,233 --> 00:22:18,566 Scoliosis is much more common in females. 451 00:22:18,566 --> 00:22:21,633 Small curves are almost equally as common. 452 00:22:21,633 --> 00:22:24,200 But the bigger curve you get, the more likely and the more 453 00:22:24,200 --> 00:22:27,400 asymmetric that balance is, so as you get to be big curves, 454 00:22:27,400 --> 00:22:32,533 it's much more common to be females than male. 455 00:22:32,533 --> 00:22:34,466 x*So part of the issue is deciding natural history. 456 00:22:34,466 --> 00:22:37,800 A 25 degree curve, like we see up here on the left, 457 00:22:37,800 --> 00:22:39,933 is really not an issue. It will not effect you, 458 00:22:39,933 --> 00:22:43,066 it should not cause lower back pain or long-term issues. 459 00:22:43,066 --> 00:22:45,000 But some of these curves go on like this one, 460 00:22:45,000 --> 00:22:47,566 and get to be severe, and some of them don't. 461 00:22:47,566 --> 00:22:49,600 And that's really the focus of most of the research now. 462 00:22:49,600 --> 00:22:52,533 Figuring out which one of these curves will stay 25 degrees, 463 00:22:52,533 --> 00:22:55,300 which ones go to 102, because that's what we're going 464 00:22:55,300 --> 00:22:58,733 to need to know when to intervene. 465 00:22:58,733 --> 00:23:02,166 I don't know which ones will necessarily go 466 00:23:02,166 --> 00:23:05,033 and which ones don't. x*But we do have some 467 00:23:05,033 --> 00:23:07,333 information. And so at presentation, 468 00:23:07,333 --> 00:23:10,266 if the child is very young and they have a big curve, 469 00:23:10,266 --> 00:23:12,300 as you might guess, those are much more likely 470 00:23:12,300 --> 00:23:14,866 to get worse. If they're older, they've 471 00:23:14,866 --> 00:23:17,266 gone through the growth spurt and they have a small curve, 472 00:23:17,266 --> 00:23:20,566 it's very unlikely to get worse. And just some general things. 473 00:23:20,566 --> 00:23:23,533 A curve over 20 degrees and under age 10, 474 00:23:23,533 --> 00:23:26,266 is going to progress virtually 100% of the time. 475 00:23:26,266 --> 00:23:28,500 So if you just use as a general marker, 476 00:23:28,500 --> 00:23:30,766 a child is under age 10, a curve over 20 degrees, 477 00:23:30,766 --> 00:23:33,900 this one's going to get worse. You'll want to treat it. 478 00:23:33,900 --> 00:23:36,066 I would treat it, certainly with bracing, 479 00:23:36,066 --> 00:23:38,533 but you want to treat it even at a fairly small curve. 480 00:23:38,533 --> 00:23:41,633 x*If they're over 15, and the curve is under 20 degrees, 481 00:23:41,633 --> 00:23:44,033 it's only a 4% chance of getting worse. 482 00:23:44,033 --> 00:23:46,366 And even then, it's probably never going to get worse to 483 00:23:46,366 --> 00:23:51,866 the point that it requires any kind of significant treatment. 484 00:23:51,866 --> 00:23:53,966 There are a lot of other things you can do, if you wanted 485 00:23:53,966 --> 00:23:56,266 to try to narrow that down a little bit. 486 00:23:56,266 --> 00:23:58,200 I'm not sure they help that much. 487 00:23:58,200 --> 00:24:00,533 x*People have looked at, how can you tell whether 488 00:24:00,533 --> 00:24:04,033 this child is mature or not. I don't do the Tanner Stages, 489 00:24:04,033 --> 00:24:06,166 but we will look at x-rays of the hip 490 00:24:06,166 --> 00:24:09,500 and we can look at the Risser. The Risser score actually 491 00:24:09,500 --> 00:24:13,300 looks at the iliac apophysis to see when it forms. 492 00:24:13,300 --> 00:24:18,400 And if you look down here, there's apophysis. 493 00:24:18,400 --> 00:24:21,566 And it's forming. It has not fully consolidated, 494 00:24:21,566 --> 00:24:24,266 so there's this black line. It kind of starts in front 495 00:24:24,266 --> 00:24:27,066 and works all the way back, to there and you can divide that 496 00:24:27,066 --> 00:24:29,333 into quadrants. Risser one and two is over here. 497 00:24:29,333 --> 00:24:32,366 As it goes back, it's four. And then as you get to be 498 00:24:32,366 --> 00:24:34,633 an adult, it completely fuses, and you can't even see 499 00:24:34,633 --> 00:24:38,000 that line. That's not very accurate, so 500 00:24:38,000 --> 00:24:40,033 I wouldn't spend a lot of time worrying about that, but it's 501 00:24:40,033 --> 00:24:42,433 what's been used historically for years. 502 00:24:42,433 --> 00:24:44,866 If their Risser is zero or one, they're immature, 503 00:24:44,866 --> 00:24:47,233 if they're anything more, they're mature. 504 00:24:47,233 --> 00:24:49,433 The bottom line is by the time you really see this, 505 00:24:49,433 --> 00:24:51,833 they're already mature, so it's not all that helpful. 506 00:24:51,833 --> 00:24:54,166 x*The triradiated cartilage is at the hip, and I apologize, 507 00:24:54,166 --> 00:24:56,833 it's just off this x-ray. But it's where the different 508 00:24:56,833 --> 00:24:59,166 bones of the hip come together, and when that fuses, 509 00:24:59,166 --> 00:25:02,166 once that's fused, they are also skeletally mature. 510 00:25:02,166 --> 00:25:05,266 So open triradiated cartilage in itself is a risk. 511 00:25:05,266 --> 00:25:08,700 If it's open, the chance of progression is about 40%. 512 00:25:08,700 --> 00:25:14,566 x*This is the classic risk factor, so it's looking at 513 00:25:14,566 --> 00:25:17,833 that risk assigned. Again, people who are 514 00:25:17,833 --> 00:25:21,066 less mature, so we're not looking at age, but less mature, 515 00:25:21,066 --> 00:25:24,966 Risser is 0-1 curves that are over 20 degrees, 516 00:25:24,966 --> 00:25:28,966 68% chance of progressing. So I think the age 517 00:25:28,966 --> 00:25:31,033 is easier to look at. x*We know that if they're 518 00:25:31,033 --> 00:25:34,300 under age 10, over 20 degrees, 100% chance of progressing. 519 00:25:34,300 --> 00:25:36,166 But if you want to use the Risser score, 520 00:25:36,166 --> 00:25:39,466 you can do the same. What this really is helpful 521 00:25:39,466 --> 00:25:42,166 is saying is if they have a curve under 20 degrees, 522 00:25:42,166 --> 00:25:44,433 and the iliac apophysis is just about fused, they only have 523 00:25:44,433 --> 00:25:46,400 a one or two percent chance of progressing. 524 00:25:46,400 --> 00:25:51,800 And that's nice to be able to tell the parents that. 525 00:25:51,800 --> 00:25:53,866 x*People focus on some of the other issues as well, 526 00:25:53,866 --> 00:25:57,600 including peak height velocity, which is a little more accurate. 527 00:25:57,600 --> 00:26:00,733 In general, it's 12 in girls and 14 in boys. 528 00:26:00,733 --> 00:26:03,200 So if you just want to age over the age 12 in girls 529 00:26:03,200 --> 00:26:05,466 in general, they are skeletally mature. 530 00:26:05,466 --> 00:26:08,633 Over 14 in boys. Menarche, and axillary hair on 531 00:26:08,633 --> 00:26:12,933 both, are also ways to indicate the end of the growth spurt 532 00:26:12,933 --> 00:26:18,166 and risk of progression of scoliosis. 533 00:26:18,166 --> 00:26:21,500 x*Although boys are less likely to get scoliosis, 534 00:26:21,500 --> 00:26:25,500 the negative for males is that their scoliosis can progress, 535 00:26:25,500 --> 00:26:28,700 even when they're older. So if you are going to brace, 536 00:26:28,700 --> 00:26:31,766 or have a young male that's braced, then you want 537 00:26:31,766 --> 00:26:34,466 to brace them until they're quite a bit older. 538 00:26:34,466 --> 00:26:36,966 Not only do they mature later, but you need to brace them 539 00:26:36,966 --> 00:26:44,233 close to 18 years of age. x*Before you really want to think 540 00:26:44,233 --> 00:26:46,766 about treating any disease, you have to have some idea 541 00:26:46,766 --> 00:26:49,166 of what the natural history of the disease is, because 542 00:26:49,166 --> 00:26:52,200 why treat something that's not going to cause a problem. 543 00:26:52,200 --> 00:26:55,966 There isn't a lot of natural history studies. 544 00:26:55,966 --> 00:27:00,166 Nachemson, which is a researcher in northern Europe in 1968 said, 545 00:27:00,166 --> 00:27:02,666 you know, if you have scoliosis, it increases your mortality 546 00:27:02,666 --> 00:27:05,466 two times. Half the people 547 00:27:05,466 --> 00:27:08,166 are on disability. Most people don't get married. 548 00:27:08,166 --> 00:27:10,500 The problem with that study is that they had large 549 00:27:10,500 --> 00:27:12,666 initial curves. These were not sort of 550 00:27:12,666 --> 00:27:15,300 mild scoliosis, and many of them probably had neuromuscular 551 00:27:15,300 --> 00:27:17,566 disorders. So they had cerebral palsy 552 00:27:17,566 --> 00:27:19,866 and other disorders that were all mixed in the batch. 553 00:27:19,866 --> 00:27:21,800 So it really wasn't a very accurate study. 554 00:27:21,800 --> 00:27:24,566 x*I think people have found since then that scoliosis 555 00:27:24,566 --> 00:27:28,800 does not necessarily have to be a major impediment to life, 556 00:27:28,800 --> 00:27:31,200 that you can work and be independent, 557 00:27:31,200 --> 00:27:33,300 you can get married, almost at the same rate 558 00:27:33,300 --> 00:27:36,000 as the general population. x*So scoliosis, it may cause 559 00:27:36,000 --> 00:27:38,833 a cosmetic deformity, but it rarely causes significant 560 00:27:38,833 --> 00:27:43,466 functional limitations, and that is a little bit controversial. 561 00:27:43,466 --> 00:27:46,200 What kind of functional limitations it causes, 562 00:27:46,200 --> 00:27:48,400 but for day-to-day activities, it rarely causes significant 563 00:27:48,400 --> 00:27:51,500 functional limitations. x*The other issue comes up 564 00:27:51,500 --> 00:27:55,333 with pain. And in general, scoliosis 565 00:27:55,333 --> 00:27:58,333 can cause actually increased-- There is some concern 566 00:27:58,333 --> 00:28:01,866 that long-term scoliosis can cause increased pain. 567 00:28:01,866 --> 00:28:06,200 I think that's probably true. The caveat is children 568 00:28:06,200 --> 00:28:08,266 who have scoliosis don't present with pain. 569 00:28:08,266 --> 00:28:10,533 But long-term, if you have scoliosis, and it progresses, 570 00:28:10,533 --> 00:28:12,933 it can cause a higher incidence of pain. 571 00:28:12,933 --> 00:28:15,066 And the pain may be a little bit more severe. 572 00:28:15,066 --> 00:28:17,433 But if you take into fact that about 80% of adults 573 00:28:17,433 --> 00:28:20,800 will have back pain that's significant enough 574 00:28:20,800 --> 00:28:23,466 they seek medical attention, it's very difficult to sort out 575 00:28:23,466 --> 00:28:26,400 how much worse that is. It depends on who you talk to. 576 00:28:26,400 --> 00:28:29,033 x*So the studies in Iowa show that it's really not that 577 00:28:29,033 --> 00:28:31,300 big of a deal, it doesn't increase pain that much. 578 00:28:31,300 --> 00:28:33,466 Other studies say it's a bigger issue. 579 00:28:33,466 --> 00:28:35,433 And what we don't know, if we fuse the spine 580 00:28:35,433 --> 00:28:37,433 or make it straight, do we decrease 581 00:28:37,433 --> 00:28:39,866 that incidence of pain. So we don't know if our 582 00:28:39,866 --> 00:28:44,700 treatment makes it better. x*So we've sort of ruled out 583 00:28:44,700 --> 00:28:46,600 neuromuscular congenital scoliosis. 584 00:28:46,600 --> 00:28:48,833 We're looking at idiopathic scoliosis, just to make it 585 00:28:48,833 --> 00:28:50,600 a little more confusing, idiopathic scoliosis 586 00:28:50,600 --> 00:28:53,800 tends to come in three flavors and is set by age. 587 00:28:53,800 --> 00:28:57,066 And this is really arbitrary. Anything under age 3, 588 00:28:57,066 --> 00:29:00,166 is called infantile and over age 10 is adolescent, 589 00:29:00,166 --> 00:29:02,266 which is by far the most common. 590 00:29:02,266 --> 00:29:05,833 Adolescent idiopathic scoliosis, typically referred to as AIS. 591 00:29:05,833 --> 00:29:08,966 And then in between is juvenile. I'll talk briefly about these, 592 00:29:08,966 --> 00:29:11,866 but you can see infantile is very small, about 5%, 593 00:29:11,866 --> 00:29:16,933 juvenile is 15% and adolescent is 80%. 594 00:29:16,933 --> 00:29:21,300 x*This is infantile scoliosis. And I refer to it 595 00:29:21,300 --> 00:29:24,000 as Bazaro Scoliosis, because everything's backwards. 596 00:29:24,000 --> 00:29:26,900 It's just different than idiopathic scoliosis. 597 00:29:26,900 --> 00:29:29,200 It tends to occur young, it's more common in boys 598 00:29:29,200 --> 00:29:33,600 than girls. Right-sided curves are uncommon. 599 00:29:33,600 --> 00:29:35,533 And we looked at something called the rib-vertebral 600 00:29:35,533 --> 00:29:38,400 angle difference. But the bottom line is 601 00:29:38,400 --> 00:29:42,166 curves under about 35 degrees tend to actually get better. 602 00:29:42,166 --> 00:29:45,033 That is something that doesn't happen in idiopathic scoliosis. 603 00:29:45,033 --> 00:29:48,633 Curves over 30 degrees-- That is rib-vertebral angles 604 00:29:48,633 --> 00:29:51,333 over 20 degrees, tend to progress. 605 00:29:51,333 --> 00:29:53,533 If you want to measure it, it's a little bit hard 606 00:29:53,533 --> 00:29:56,166 to measure. What you do is you find the 607 00:29:56,166 --> 00:29:58,766 curve, the apex of the curve, so that's where the curve 608 00:29:58,766 --> 00:30:01,733 is the worst, and you measure the rib angle 609 00:30:01,733 --> 00:30:03,966 with the vertebra, with the horizontal 610 00:30:03,966 --> 00:30:06,133 right here. Here's the rib, draw a line up. 611 00:30:06,133 --> 00:30:09,300 And then this is the angle it takes with the vertical. 612 00:30:09,300 --> 00:30:12,100 You do it on the other side and you take the difference 613 00:30:12,100 --> 00:30:14,433 between the two angles. And if the difference 614 00:30:14,433 --> 00:30:17,266 is more than 20 degrees, it will tend to progress. 615 00:30:17,266 --> 00:30:20,500 The others actually tend to get better. 616 00:30:20,500 --> 00:30:22,933 x*The problem is the ones that don't get better, now you 617 00:30:22,933 --> 00:30:25,366 have a real problem, because you have this little spine 618 00:30:25,366 --> 00:30:28,066 and it's going to get worse and they're very, very young. 619 00:30:28,066 --> 00:30:30,833 We don't have a great treatment. This is Dr. Meta, 620 00:30:30,833 --> 00:30:34,066 the older one on the left, who developed the angle. 621 00:30:34,066 --> 00:30:37,666 And she really has focused on bracing and casting techniques 622 00:30:37,666 --> 00:30:40,233 for this, and really feels this is important. 623 00:30:40,233 --> 00:30:44,500 It was printed in our major journal, the JBJS, about two 624 00:30:44,500 --> 00:30:47,133 or three years ago. And people are starting 625 00:30:47,133 --> 00:30:49,400 to do these casts. It's starting to catch on, 626 00:30:49,400 --> 00:30:51,500 but whether or not it works, and how well it works is still 627 00:30:51,500 --> 00:30:55,133 a little bit up for debate. x*Some people feel that casting 628 00:30:55,133 --> 00:30:58,133 a child from this young of age and forcing them to wear a brace 629 00:30:58,133 --> 00:31:00,333 for the rest of their life is really not a fair thing 630 00:31:00,333 --> 00:31:02,866 to do. So it's not clear whether 631 00:31:02,866 --> 00:31:04,866 casting is the right way to go or not. 632 00:31:04,866 --> 00:31:07,766 But we did, where I trained, had a casting program. 633 00:31:07,766 --> 00:31:10,700 We would place this cast on, and that's a picture of a child 634 00:31:10,700 --> 00:31:12,700 in the cast. The cast is obviously 635 00:31:12,700 --> 00:31:15,300 trimmed down, but it does go up fairly high around the neck. 636 00:31:15,300 --> 00:31:17,866 There's a cutout for the abdomen. 637 00:31:17,866 --> 00:31:20,900 In Dr. Meta's hands, it has shown that it provides 638 00:31:20,900 --> 00:31:23,666 relatively reasonable correction. 639 00:31:23,666 --> 00:31:25,866 She, by the way, has a really significant scoliosis 640 00:31:25,866 --> 00:31:28,533 and obviously is doing just fine. 641 00:31:28,533 --> 00:31:30,766 Newer treatments and probably what most people 642 00:31:30,766 --> 00:31:32,833 here in North America are doing are various different types of 643 00:31:32,833 --> 00:31:35,733 what they call growing rods, which is a misnomer. 644 00:31:35,733 --> 00:31:37,766 They're now using a titanium rib or adapter to try 645 00:31:37,766 --> 00:31:41,600 to get some correction and be used as a temporary splint, 646 00:31:41,600 --> 00:31:44,733 allowing the spine to grow and do more definitive treatment 647 00:31:44,733 --> 00:31:47,233 as the child grows. I'll show examples of some of 648 00:31:47,233 --> 00:31:52,400 those in just a little bit. x*Juvenile scoliosis is sort of 649 00:31:52,400 --> 00:31:54,833 a mixed bag, because now you're dealing with kids 650 00:31:54,833 --> 00:31:57,166 between four and ten. Their curves, if they're 651 00:31:57,166 --> 00:31:59,700 younger, tend to be a little bit more like infantile. 652 00:31:59,700 --> 00:32:02,066 If they're older, they tend to be a little more like 653 00:32:02,066 --> 00:32:04,066 idiopathic. So there seems to be 654 00:32:04,066 --> 00:32:06,000 a higher genetic predisposition influence. 655 00:32:06,000 --> 00:32:07,966 It's children between age four and ten, by definition, 656 00:32:07,966 --> 00:32:11,066 at diagnosis. And about generally, 657 00:32:11,066 --> 00:32:14,300 one-third don't progress, one-third can be braced 658 00:32:14,300 --> 00:32:16,866 and do well with bracing. Actually, you can get correction 659 00:32:16,866 --> 00:32:20,000 in the brace. About a third go on to surgery. 660 00:32:20,000 --> 00:32:22,166 A fair number of these have abnormal MRIs, 661 00:32:22,166 --> 00:32:25,333 so these are ones that you want to get an MRI on. 662 00:32:25,333 --> 00:32:31,500 x*And this is a patient that had juvenile scoliosis, 663 00:32:31,500 --> 00:32:34,066 was braced, was very diligent about the bracing, 664 00:32:34,066 --> 00:32:36,066 and you can see the curve actually improved. 665 00:32:36,066 --> 00:32:38,066 That is something you won't see with idiopathic scoliosis, 666 00:32:38,066 --> 00:32:40,166 you can't make the curve better with idiopathic. 667 00:32:40,166 --> 00:32:42,533 But with juvenile, there is a potential to do that. 668 00:32:42,533 --> 00:32:45,666 x*Most of the treatment now will focus on the idiopathic 669 00:32:45,666 --> 00:32:51,300 scoliosis in adolescence. Adolescent idiopathic scoliosis. 670 00:32:51,300 --> 00:32:54,033 So this is our algorithm for the vast majority of patients 671 00:32:54,033 --> 00:32:56,433 that come in our door. So we've ruled out other forms 672 00:32:56,433 --> 00:32:59,066 of idiopathic scoliosis. We know it's adolescent. 673 00:32:59,066 --> 00:33:01,166 And this is in general, how we treat it. 674 00:33:01,166 --> 00:33:03,733 Curves less than 20 degrees, we observe, we don't treat. 675 00:33:03,733 --> 00:33:09,333 Curves, whether they're mature or not immature. 676 00:33:09,333 --> 00:33:11,500 If their mature, and it's less than 45 degrees, 677 00:33:11,500 --> 00:33:13,433 we observe it, because there's very little chance 678 00:33:13,433 --> 00:33:15,433 of this progressing. By observation, is doesn't mean 679 00:33:15,433 --> 00:33:17,600 necessarily just saying good-bye, but it probably 680 00:33:17,600 --> 00:33:20,233 is worth a follow-up every one to two years. 681 00:33:20,233 --> 00:33:22,033 So once they've gone through their growth spurt, 682 00:33:22,033 --> 00:33:25,566 if they're less than 45 degrees, then we don't do anything. 683 00:33:25,566 --> 00:33:28,300 x*Curves, if they're immature and it's greater than 30 degrees 684 00:33:28,300 --> 00:33:30,866 or we see it progressing beyond about 25 degrees, we 685 00:33:30,866 --> 00:33:34,766 think it's reasonable to brace. That's the standard treatment. 686 00:33:34,766 --> 00:33:37,200 This has been around for ten years or so. 687 00:33:37,200 --> 00:33:40,166 It's really undergoing scrutiny. There's now a randomized 688 00:33:40,166 --> 00:33:42,200 double blind study where they're looking at 689 00:33:42,200 --> 00:33:44,433 the value of bracing. And unfortunately this study, 690 00:33:44,433 --> 00:33:46,866 from my understanding, has only had a very few people 691 00:33:46,866 --> 00:33:49,300 that they were able to recruit, because you're asking someone 692 00:33:49,300 --> 00:33:51,366 either to have bracing or not bracing. 693 00:33:51,366 --> 00:33:54,033 And most people don't want to be randomized to that, 694 00:33:54,033 --> 00:33:56,833 so we'll see if they can get information from that. 695 00:33:56,833 --> 00:33:59,233 x*But there are clearly some surgeons that believe 696 00:33:59,233 --> 00:34:01,033 curves will progress or won't progress 697 00:34:01,033 --> 00:34:03,166 whether you brace them, and bracing does nothing. 698 00:34:03,166 --> 00:34:05,500 Yet there is some pretty good evidence that bracing works. 699 00:34:05,500 --> 00:34:08,733 So, I still certainly believe that bracing is important. 700 00:34:08,733 --> 00:34:13,833 And if it's done right, it can make the difference. 701 00:34:13,833 --> 00:34:16,233 x*And then finally, if you have a patient with a curve 702 00:34:16,233 --> 00:34:19,366 over 50 degrees, especially if they're skeletally immature, 703 00:34:19,366 --> 00:34:21,166 those are ones we may consider surgery, 704 00:34:21,166 --> 00:34:24,633 depending on the various different circumstances. 705 00:34:24,633 --> 00:34:26,766 x*So here are all the different kinds of braces that we use. 706 00:34:26,766 --> 00:34:28,566 The Milwaukee Braces are the gold standard. 707 00:34:28,566 --> 00:34:31,166 It's a large brace. And it actually has a collar 708 00:34:31,166 --> 00:34:33,366 that goes around the neck. It's somewhat unsightly, 709 00:34:33,366 --> 00:34:35,466 and kids hate it. And the collar's designed, 710 00:34:35,466 --> 00:34:37,333 actually, not to push against the neck, 711 00:34:37,333 --> 00:34:39,666 but to irritate enough so that the child stands 712 00:34:39,666 --> 00:34:43,166 in a straighter position. So an upper thoracic curve, 713 00:34:43,166 --> 00:34:45,566 that's really the only brace that works. 714 00:34:45,566 --> 00:34:48,533 But now more and more people use one of these other braces. 715 00:34:48,533 --> 00:34:50,800 x*This is a Molded TLSO, some people refer to it 716 00:34:50,800 --> 00:34:53,200 as the Boston Brace. And it's actually designed 717 00:34:53,200 --> 00:34:56,000 to correct the curve, but it goes under the arms, 718 00:34:56,000 --> 00:34:59,666 and it's less obvious to wear. x*There are a couple of things 719 00:34:59,666 --> 00:35:01,966 about braces, and it's very important. 720 00:35:01,966 --> 00:35:04,000 You can't just prescribe this brace. 721 00:35:04,000 --> 00:35:05,500 This is a brace that has to be prescribed, 722 00:35:05,500 --> 00:35:07,900 and it has to be fitted. Then we have to make sure 723 00:35:07,900 --> 00:35:10,200 that the brace is actually causing correction. 724 00:35:10,200 --> 00:35:12,600 Because if you have a curve, and you put a brace on and it's not 725 00:35:12,600 --> 00:35:14,733 making the curve straighter, it's really not 726 00:35:14,733 --> 00:35:17,066 going to do anything. So the concept 727 00:35:17,066 --> 00:35:19,333 was to get the brace. We see them back after they've 728 00:35:19,333 --> 00:35:22,200 had the brace for about a month and it's fitting, 729 00:35:22,200 --> 00:35:24,400 we know it's fitting well. We make sure the curve 730 00:35:24,400 --> 00:35:26,800 is decreased by about 50%. If you have a 40-degree curve, 731 00:35:26,800 --> 00:35:28,866 you'll want it less than 20 degrees. 732 00:35:28,866 --> 00:35:30,666 And the second issue, if they don't wear it, obviously 733 00:35:30,666 --> 00:35:33,433 it's not going to do anything. x*So what we found is that 734 00:35:33,433 --> 00:35:35,900 people, on average, will wear the brace about two-thirds 735 00:35:35,900 --> 00:35:39,000 what they say they wear it, just as a general rule. 736 00:35:39,000 --> 00:35:41,866 And often people don't wear the brace quite as much 737 00:35:41,866 --> 00:35:44,233 as you think. On the other hand, you wonder 738 00:35:44,233 --> 00:35:47,000 how much of that is people who have sort of given up 739 00:35:47,000 --> 00:35:49,333 on braces, and aren't strongly promoting it. 740 00:35:49,333 --> 00:35:51,500 I think it's part of our responsibility to say 741 00:35:51,500 --> 00:35:54,533 that there's good evidence that this works, if you wear it. 742 00:35:54,533 --> 00:35:57,200 And if you wear it, it may make a difference. 743 00:35:57,200 --> 00:36:01,733 So it's a little bit hard to know how effective they are. 744 00:36:01,733 --> 00:36:03,800 But I'll show some studies that actually show 745 00:36:03,800 --> 00:36:06,300 there is some good evidence that say they work. 746 00:36:06,300 --> 00:36:10,000 x*How do braces work? Well, this is a couple 747 00:36:10,000 --> 00:36:12,766 different studies that show that if you decrease the curve 748 00:36:12,766 --> 00:36:15,766 to 20 degrees, you increase stability of the curve 749 00:36:15,766 --> 00:36:19,166 from 50-80% of normal. So again, it's a little like 750 00:36:19,166 --> 00:36:21,300 the Leaning Tower of Pisa. You can't make it straight, 751 00:36:21,300 --> 00:36:24,200 but you can sort of hoist it up. And if you can keep them 752 00:36:24,200 --> 00:36:26,400 to a smaller curve to the point of skeletal maturity, 753 00:36:26,400 --> 00:36:28,466 then the curve should not progress. 754 00:36:28,466 --> 00:36:30,433 So if you keep the curve under 50 degrees, 755 00:36:30,433 --> 00:36:33,600 it probably won't progress. x*The biggest study came out 756 00:36:33,600 --> 00:36:36,666 in 1995 was again Nachemson, and you may remember this name. 757 00:36:36,666 --> 00:36:39,433 Same person from before. Did a multi-center study, 758 00:36:39,433 --> 00:36:42,700 looking at 247 patients. Now there's a big dropout, 759 00:36:42,700 --> 00:36:45,200 so there's hundreds of patients that didn't have follow up, 760 00:36:45,200 --> 00:36:47,600 but of the patients that had, they looked at electrical 761 00:36:47,600 --> 00:36:50,300 stimulation, observation, and they had a failure rate 762 00:36:50,300 --> 00:36:53,366 of about 67%. But those that had bracing, 763 00:36:53,366 --> 00:36:57,833 had a failure rate of 26%. It's a little bit hard to say, 764 00:36:57,833 --> 00:37:00,233 because they had such a huge dropout in the study, but 765 00:37:00,233 --> 00:37:02,800 at least it's about the best and largest study we have to say 766 00:37:02,800 --> 00:37:06,000 bracing makes a difference. x*Rowe, two years later, 767 00:37:06,000 --> 00:37:09,066 did a meta-analysis of nearly 2,000 patients. 768 00:37:09,066 --> 00:37:13,166 He found a fairly significant improvement with bracing. 769 00:37:13,166 --> 00:37:15,033 It's not 100%, but it's certainly better 770 00:37:15,033 --> 00:37:17,066 than electrical stimulation, which had actually made things 771 00:37:17,066 --> 00:37:22,666 a little worse than observation. x*Physical therapy 772 00:37:22,666 --> 00:37:24,733 would be great. If you could send someone to 773 00:37:24,733 --> 00:37:27,166 therapy to correct their curve, that would be wonderful. 774 00:37:27,166 --> 00:37:29,366 But there's really no good evidence at this point 775 00:37:29,366 --> 00:37:31,900 to say physical therapy is effective. 776 00:37:31,900 --> 00:37:34,266 But there are some interesting studies out there 777 00:37:34,266 --> 00:37:36,800 which have shown increasing trunkal strength may actually 778 00:37:36,800 --> 00:37:40,566 long-term improve scoliosis. But the follow-up 779 00:37:40,566 --> 00:37:43,866 hasn't been there. So, in general, I don't know 780 00:37:43,866 --> 00:37:46,900 of anyone today that prescribes physical therapy 781 00:37:46,900 --> 00:37:49,866 for scoliosis. We will for people 782 00:37:49,866 --> 00:37:58,466 that have mild kyphosis, but we won't do it for scoliosis. 783 00:37:58,466 --> 00:38:01,333 This is just a little bit on physical therapy for surgery, 784 00:38:01,333 --> 00:38:04,366 I'll skip over that. x*So once we get to the point 785 00:38:04,366 --> 00:38:06,366 where we believe it's a surgical curve, 786 00:38:06,366 --> 00:38:08,366 we actually try to define the curve. 787 00:38:08,366 --> 00:38:10,700 And this is a classic King Classification, which looks 788 00:38:10,700 --> 00:38:13,000 at where the curve is: if it's a thoracic curve, 789 00:38:13,000 --> 00:38:15,633 if it's a lumbar curve, if it's a combination of both. 790 00:38:15,633 --> 00:38:18,600 And it's supposed to help us decide when to fuse the spine. 791 00:38:18,600 --> 00:38:20,733 x*People have now gone to a different curve 792 00:38:20,733 --> 00:38:23,300 classification system named after Larry Lenke. 793 00:38:23,300 --> 00:38:26,300 It was developed at a number of different institutions. 794 00:38:26,300 --> 00:38:29,366 It actually breaks curve patterns up to a possible 795 00:38:29,366 --> 00:38:31,766 46 different patterns. So it's one of the more 796 00:38:31,766 --> 00:38:34,433 confusing systems that we have in place. 797 00:38:34,433 --> 00:38:36,333 But I think it's important for research to be able to use 798 00:38:36,333 --> 00:38:38,666 a system like that. It classifies a curve both 799 00:38:38,666 --> 00:38:42,400 on sagittal and coronal views. It helps give an idea of, 800 00:38:42,400 --> 00:38:45,200 not only which ones may progress, but from our 801 00:38:45,200 --> 00:38:47,600 standpoint, more importantly, how you would actually 802 00:38:47,600 --> 00:38:52,300 treat them surgically. x*There has been trends 803 00:38:52,300 --> 00:38:54,800 to treat it surgically a lot of different ways. 804 00:38:54,800 --> 00:38:57,733 So there's a big trend to try to fuse the spine anteriorly, 805 00:38:57,733 --> 00:38:59,633 and I'll show a little bit about that. 806 00:38:59,633 --> 00:39:01,833 The trend has now gone back to basically fusing people 807 00:39:01,833 --> 00:39:04,400 posteriorly. There's an obvious advantage. 808 00:39:04,400 --> 00:39:06,466 The spine is very superficial posteriorly. 809 00:39:06,466 --> 00:39:08,800 You don't have to go through the abdomen or the pelvis. 810 00:39:08,800 --> 00:39:11,166 And in that regard, it's quite a bit a safer. 811 00:39:11,166 --> 00:39:12,900 There are disadvantages to going posteriorly. 812 00:39:12,900 --> 00:39:15,066 But with the new instrumentation that we're using today 813 00:39:15,066 --> 00:39:17,400 which include pedicle screws, it seems like we can get 814 00:39:17,400 --> 00:39:21,833 fairly significant correction by going posteriorly. 815 00:39:21,833 --> 00:39:24,166 x*And this is just a straight posterior incision. 816 00:39:24,166 --> 00:39:26,800 It's very straightforward. You go straight down the midline 817 00:39:26,800 --> 00:39:29,233 and you dissect the musculature laterally. 818 00:39:29,233 --> 00:39:33,766 And then the concept is you want to fuse the spine. 819 00:39:33,766 --> 00:39:35,533 That's really what you want to do. 820 00:39:35,533 --> 00:39:37,433 The instrumentation and stuff we put in 821 00:39:37,433 --> 00:39:41,400 is absolutely secondary. So most children fuse very well, 822 00:39:41,400 --> 00:39:44,166 even historically, they would just strip off 823 00:39:44,166 --> 00:39:46,566 all the soft tissue, put bone down 824 00:39:46,566 --> 00:39:48,800 and put them in a cast, most of those fused. 825 00:39:48,800 --> 00:39:51,266 x*Now we use instrumentation mainly just to get rid of 826 00:39:51,266 --> 00:39:53,700 the cast part and get a little better correction. 827 00:39:53,700 --> 00:39:56,166 Instrumentation has varied. About ten years ago, pedicle 828 00:39:56,166 --> 00:40:00,400 hooks, which you can see here, were the primary device used. 829 00:40:00,400 --> 00:40:04,500 There are little wires that go under the lamina, right here, 830 00:40:04,500 --> 00:40:07,666 called lamina wires. x*Dr. Drummond developed wires 831 00:40:07,666 --> 00:40:10,400 here in Madison, called Wisconsin Wires, which 832 00:40:10,400 --> 00:40:13,366 are probably the safest device, which actually goes through 833 00:40:13,366 --> 00:40:16,300 the spinous processes and stay completely out of the spine. 834 00:40:16,300 --> 00:40:18,900 x*And now pedicle screws, which obviously can have a problem. 835 00:40:18,900 --> 00:40:21,933 If you put it incorrectly it can obviously hit the spinal cord, 836 00:40:21,933 --> 00:40:24,600 major vessels. But pedicle screws 837 00:40:24,600 --> 00:40:27,633 give you great fixation. More and more people 838 00:40:27,633 --> 00:40:32,433 are using pedicle screws today to get fixation. 839 00:40:32,433 --> 00:40:34,266 x*This is just an example of what you get. 840 00:40:34,266 --> 00:40:36,633 In general, if you have a curve that's 80 degrees, you'll get 841 00:40:36,633 --> 00:40:41,566 about 50-70% correction. This is a curve that started 842 00:40:41,566 --> 00:40:44,066 at 82 degrees, and it went down to 28. 843 00:40:44,066 --> 00:40:46,633 I think that's about the correction you'll get, 844 00:40:46,633 --> 00:40:49,700 which is fine. I'd be very happy 845 00:40:49,700 --> 00:40:52,866 with a correction of 28 degrees. x*But probably the more important 846 00:40:52,866 --> 00:40:55,066 thing is you want the patient to be balanced. 847 00:40:55,066 --> 00:40:57,466 So if their curve is small and their head is over their pelvis, 848 00:40:57,466 --> 00:41:01,166 and then they have a good sagittal profile, 849 00:41:01,166 --> 00:41:04,666 they're going to be very happy regardless of what the curve is. 850 00:41:04,666 --> 00:41:07,066 I think as a surgeon, you want to get the curve 851 00:41:07,066 --> 00:41:09,233 as small as possible. That's really not the most 852 00:41:09,233 --> 00:41:11,400 important thing for the patient. The most important thing 853 00:41:11,400 --> 00:41:15,166 is balance. x*We've found that from 854 00:41:15,166 --> 00:41:18,233 a functional standpoint, that it's really balance 855 00:41:18,233 --> 00:41:20,966 from a side view that matters, or the sagittal alignment 856 00:41:20,966 --> 00:41:23,233 that makes all the difference, and especially down 857 00:41:23,233 --> 00:41:25,700 in the lumbar region, so we work hard 858 00:41:25,700 --> 00:41:28,266 to restore that as best we can. x*Neuromuscular scoliosis 859 00:41:28,266 --> 00:41:30,366 classically has been treated a little differently, because you 860 00:41:30,366 --> 00:41:32,566 don't fuse part of the spine. So, in neuropathic scoliosis 861 00:41:32,566 --> 00:41:34,866 you just treat the curve, for the most part. 862 00:41:34,866 --> 00:41:37,066 In neuromuscular, you treat the whole spine, because 863 00:41:37,066 --> 00:41:39,433 if you don't, they tend to get curves above and below. 864 00:41:39,433 --> 00:41:42,633 x*So this is a patient that had cerebral palsy, and 865 00:41:42,633 --> 00:41:45,866 they actually had a hip issue. We addressed the hip issue first 866 00:41:45,866 --> 00:41:48,733 and the hip actually is seated nicely, but they have a 867 00:41:48,733 --> 00:41:51,400 great deal of pelvic obliquity. Pelvic obliquity is actually 868 00:41:51,400 --> 00:41:54,166 what puts the hip at risk. And treating the hip will never 869 00:41:54,166 --> 00:41:57,433 treat the pelvic obliquity. Often, people will actually 870 00:41:57,433 --> 00:42:00,166 address the spine first to even out the pelvis, and 871 00:42:00,166 --> 00:42:03,300 then treat the hip as needed. In this case, 872 00:42:03,300 --> 00:42:05,466 the hip was treated first. They had a fairly significant 873 00:42:05,466 --> 00:42:07,866 curve. We knew this was progressing. 874 00:42:07,866 --> 00:42:10,066 They had difficulty sitting in their wheelchair. 875 00:42:10,066 --> 00:42:12,433 We treated them with the standard posterior spinal fusion 876 00:42:12,433 --> 00:42:15,433 and this is the final correction. 877 00:42:15,433 --> 00:42:18,566 So you can get really pretty good correction. 878 00:42:18,566 --> 00:42:20,700 And again, even if it's not perfect, it really does 879 00:42:20,700 --> 00:42:22,500 seem to make a difference in their lives. 880 00:42:22,500 --> 00:42:24,366 And some people argue that you don't need to do surgery, 881 00:42:24,366 --> 00:42:26,566 and clearly it's a long discussion you have 882 00:42:26,566 --> 00:42:28,866 with the patients and family. But caregivers, in every study 883 00:42:28,866 --> 00:42:31,366 I've looked at are extremely happy with the results, 884 00:42:31,366 --> 00:42:35,066 and 80-90, 90-95% of caregivers really believe that surgical 885 00:42:35,066 --> 00:42:38,833 treatment for scoliosis is beneficial. 886 00:42:38,833 --> 00:42:41,566 x*There are a lot of complications, especially 887 00:42:41,566 --> 00:42:44,266 in neuromuscular scoliosis. Most of those you can work 888 00:42:44,266 --> 00:42:47,600 through. And fortunately, we have 889 00:42:47,600 --> 00:42:51,266 a lot of people in the hospital help us get through 890 00:42:51,266 --> 00:42:53,633 these issues. But postoperatively, 891 00:42:53,633 --> 00:42:56,566 it's a big surgery. They almost always require 892 00:42:56,566 --> 00:42:58,800 blood. They have huge fluid changes. 893 00:42:58,800 --> 00:43:02,300 It's not quite as much of an issue in idiopathic scoliosis, 894 00:43:02,300 --> 00:43:05,500 so complication rate, the big one we worry about obviously, 895 00:43:05,500 --> 00:43:07,933 is neurologic complication rate is about 1 in 1,000. 896 00:43:07,933 --> 00:43:10,633 That's the question you get, what's the chance 897 00:43:10,633 --> 00:43:13,166 of a neurologic injury. A permanent neurologic injury 898 00:43:13,166 --> 00:43:16,000 is about 1 in 1,000. That doesn't mean the spinal 899 00:43:16,000 --> 00:43:19,066 cord injury, but some type of neurologic injury. 900 00:43:19,066 --> 00:43:22,433 Infection is fairly uncommon. It's about 5%, 901 00:43:22,433 --> 00:43:24,966 or a little bit less. Often that can be treated 902 00:43:24,966 --> 00:43:27,800 without removing the hardware. And then there are always 903 00:43:27,800 --> 00:43:31,166 pulmonary type issues, that are a little more common. 904 00:43:31,166 --> 00:43:34,600 x*About five to ten years ago, there was a big push to try to 905 00:43:34,600 --> 00:43:37,066 go anteriorly, so that was making an incision in the front, 906 00:43:37,066 --> 00:43:39,600 putting instrumentation in the front, and it actually 907 00:43:39,600 --> 00:43:42,000 works relatively well. The reason why you might want 908 00:43:42,000 --> 00:43:44,300 to do that, is because you could fuse less of your spine. 909 00:43:44,300 --> 00:43:46,833 And even though we really don't know what the consequences 910 00:43:46,833 --> 00:43:49,400 are of fusing the spine to the rest of the spine, 911 00:43:49,400 --> 00:43:51,666 it just make sense, you want to fuse as little 912 00:43:51,666 --> 00:43:53,666 as possible. There's a big push to go 913 00:43:53,666 --> 00:43:56,000 anteriorly. I won't go into great detail, 914 00:43:56,000 --> 00:43:58,266 but as you can see, it's a big incision. 915 00:43:58,266 --> 00:44:00,600 I'll show you some pictures. You can see that's the rib, and 916 00:44:00,600 --> 00:44:02,966 you have to move the rib aside. Pull the lung out of the way. 917 00:44:02,966 --> 00:44:05,933 There's significant changes in pulmonary function for up to 918 00:44:05,933 --> 00:44:08,700 one to two years afterwards. And then you put in 919 00:44:08,700 --> 00:44:10,900 instrumentation. x*Instrumentation 920 00:44:10,900 --> 00:44:13,033 is actually fairly easy. We typically perform this with 921 00:44:13,033 --> 00:44:17,233 pediatric surgery colleagues. But the instrumentation 922 00:44:17,233 --> 00:44:19,733 and the surgery part actually is fairly straightforward, 923 00:44:19,733 --> 00:44:21,766 because the spine is right there. 924 00:44:21,766 --> 00:44:24,900 And this is the type of correction that you can get. 925 00:44:24,900 --> 00:44:29,466 Here's another example. x*When anterior versus posterior 926 00:44:29,466 --> 00:44:31,900 instrumentation was compared, basically what was found 927 00:44:31,900 --> 00:44:34,200 that in certain curves, you can actually save a couple 928 00:44:34,200 --> 00:44:36,600 of levels, but the actual correction is not any different. 929 00:44:36,600 --> 00:44:39,000 So if you have that particular curve, where you may be able 930 00:44:39,000 --> 00:44:41,366 to not fuse a couple of levels, it still may be reasonable 931 00:44:41,366 --> 00:44:43,400 to go anteriorly, but I think that is only time 932 00:44:43,400 --> 00:44:46,166 people are doing that. The other advantage to going 933 00:44:46,166 --> 00:44:48,666 anteriorly, is you can do arthroscopic techniques, 934 00:44:48,666 --> 00:44:51,233 that is through small band-aid type incisions. 935 00:44:51,233 --> 00:44:55,600 That's done less commonly now, but it can be done. 936 00:44:55,600 --> 00:44:59,233 And doing surgery that way in experienced hands 937 00:44:59,233 --> 00:45:01,666 really gives about the same correction as doing it 938 00:45:01,666 --> 00:45:04,166 through a big incision. It just takes 939 00:45:04,166 --> 00:45:06,800 about four times as long. x*This is post-op activities. 940 00:45:06,800 --> 00:45:09,333 Our post-op regimen has changed quite a bit, depending on 941 00:45:09,333 --> 00:45:11,466 the quality of fixation and the patient. 942 00:45:11,466 --> 00:45:13,866 But in general, for up to a year, we want people 943 00:45:13,866 --> 00:45:17,200 lifting less than 50 pounds. For the first six months, 944 00:45:17,200 --> 00:45:20,733 we often limit their bending at the hips and lifting as well. 945 00:45:20,733 --> 00:45:24,633 So after scoliosis surgery, it's very important that 946 00:45:24,633 --> 00:45:26,966 they limit their activities. And most backpacks now seem to 947 00:45:26,966 --> 00:45:31,466 weigh about 100 pounds, so that limits their backpacks. 948 00:45:31,466 --> 00:45:34,533 x*There are new treatments coming out and one of the big pushes 949 00:45:34,533 --> 00:45:38,166 is how can we correct this curve without fusing it, because 950 00:45:38,166 --> 00:45:40,333 it just doesn't make sense. We were born with a spine 951 00:45:40,333 --> 00:45:42,900 that's mobile, why would we fuse it and make it solid. 952 00:45:42,900 --> 00:45:44,633 And one of the ways is using these 953 00:45:44,633 --> 00:45:48,233 memory shaped alloy staples. In a long bone, if you put 954 00:45:48,233 --> 00:45:52,000 a staple or some kind of tether on one side of the growth plate, 955 00:45:52,000 --> 00:45:54,666 the leg will grow asymmetrically. 956 00:45:54,666 --> 00:45:57,233 The thought is maybe we can do the same thing with the spine. 957 00:45:57,233 --> 00:46:00,700 We can put these on the convex curve, and put them 958 00:46:00,700 --> 00:46:02,866 into a small little incision, and the spine might 959 00:46:02,866 --> 00:46:05,566 start to grow straight. And so that's the concept. 960 00:46:05,566 --> 00:46:07,566 x*Unfortunately what happened in the '50s, this was done, and 961 00:46:07,566 --> 00:46:10,166 all the staples would fall out and they would go into things 962 00:46:10,166 --> 00:46:13,500 like the heart and other places you don't want them to be. 963 00:46:13,500 --> 00:46:15,700 x*So that was sort of poo-pooed, until we found the staples 964 00:46:15,700 --> 00:46:18,433 that stay in and they're a shape memory alloy. 965 00:46:18,433 --> 00:46:21,266 So unless your body temperature goes below about 20 degrees 966 00:46:21,266 --> 00:46:25,266 Celsius, they will stay in. And this is that 7-year-old 967 00:46:25,266 --> 00:46:29,500 that had a bump on her back. She's seven years old, this 968 00:46:29,500 --> 00:46:33,066 curve is now over 20 degrees. We know this is going to 969 00:46:33,066 --> 00:46:35,633 progress. And one option is bracing. 970 00:46:35,633 --> 00:46:38,033 And certainly, this was a patient that was offered 971 00:46:38,033 --> 00:46:41,833 and tried bracing. I hate to say wasn't compliant, 972 00:46:41,833 --> 00:46:46,733 but didn't use a bracing regimen and went on-- 973 00:46:46,733 --> 00:46:50,233 Here's a fairly flexible curve though. 974 00:46:50,233 --> 00:46:52,800 Went on to have these staples placed on the convex 975 00:46:52,800 --> 00:46:55,700 of both curves. And over time-- 976 00:46:55,700 --> 00:46:57,866 this is how they're placed, so they're actually placed 977 00:46:57,866 --> 00:47:00,166 through small incisions. It's not technically 978 00:47:00,166 --> 00:47:03,433 that difficult to put these in. x*So that basically showed 979 00:47:03,433 --> 00:47:05,900 that over time, the curve basically did not 980 00:47:05,900 --> 00:47:08,466 progress over time, which saves a larger surgery 981 00:47:08,466 --> 00:47:13,066 down the road. And we looked at our first about 982 00:47:13,066 --> 00:47:17,666 40 patients and in general, it's very unlikely for a curve 983 00:47:17,666 --> 00:47:21,333 to progress to a point where it needs surgery, and 984 00:47:21,333 --> 00:47:24,533 some curves actually improved. So if you can keep a 20-degree 985 00:47:24,533 --> 00:47:26,966 curve at about 20 degrees, and one where you know 986 00:47:26,966 --> 00:47:29,233 that the natural history is for it to progress, 987 00:47:29,233 --> 00:47:31,866 I think that's probably a victory. 988 00:47:31,866 --> 00:47:37,233 Other options. For the very young patients 989 00:47:37,233 --> 00:47:39,500 is to use what we call a titanium rib or adapter 990 00:47:39,500 --> 00:47:41,800 and this is something that stays out of the spine. 991 00:47:41,800 --> 00:47:44,366 It goes on the rib and down to the pelvis. 992 00:47:44,366 --> 00:47:46,566 And by doing that, you can actually get correction. 993 00:47:46,566 --> 00:47:49,466 It's a temporary thing, so the idea is when they're older, 994 00:47:49,466 --> 00:47:52,533 you can do more formal surgery. And so those are some of 995 00:47:52,533 --> 00:47:54,366 the different treatment options that are being used, 996 00:47:54,366 --> 00:47:56,533 newer treatment options that are being used today. 997 00:47:56,533 --> 00:47:58,966 And that was really it, just some of these pictures. 998 00:47:58,966 --> 00:48:02,966 Thank you very much. Any questions at all?