Children with spinal deformities benefit from early detection and appropriate treatment, whether that means monitoring, bracing or surgery. Pediatric orthopedic surgeon Ishaan Swarup, MD, breaks down the two most common conditions and explains key tools – from smartphone scoliometers to well-positioned X-rays – to increase diagnostic accuracy and efficiency. He clarifies which patients should be referred and offers educational resources to share with parents.
mm. All right. Um thanks everyone for this opportunity and for joining us this afternoon. Again, I'm I'm one of the pediatric orthopedic surgeons here at UCSF. Um and today I'll be talking to you about pediatric spinal deformity with a specific focus on diagnosis and management. So, first of all here in my disclosures, I do serve on the committees for several professional organizations and I do serve as a consultant. Fourth pediatrics. However, none of these disclosures are relevant to this talk. So what I'd like to do in the next 45 minutes or so is to really kind of first of all, talk about the definitions of the most common pediatric spinal deformity conditions, namely scoliosis and hypothesis. Um Specifically I'd like to talk about ideology a little bit about the epidemiology. The basics of classification. How we think about them as orthopedic surgeons, the evaluation and management. Specifically, we'll look at some conditions such as idiopathic scoliosis, which is by far the most common type of spinal deformity that we see in Children. We'll also talk about other types of scoliosis, including congenital scoliosis, neuromuscular syndrome scoliosis. And then at the very end we'll talk a little bit about psychosis as well. The objectives of my talk today are first and foremost describe the different types of scoliosis and the folks that can happen in Children. This guy described the characteristic physical exam in radiographic findings that we see in these Children and then explain basic treatment options for these conditions. So first of all, what is scoliosis and the best way to think about it is that scoliosis is really a three dimensional deformity. I oftentimes use the analogy to patients about a wet towel and wringing out a wet towel is kind of like what happens to the spine. It starts to kind of it's more rotational than anything else. We oftentimes visualize it two dimensionally and that's why it looks like a lateral curvature on the X ray. But it is a three dimensional deformity. Um scoliosis can be self classified as various different types including idiopathic which can be further broken down into three different types which we'll talk about in a few minutes. Congenital scoliosis which really is the formation, failure of formation or failure of segmentation in utero um neuromuscular scoliosis. So this is the type of scoliosis that happens in Children with neuropathic diseases such as cereal. Real Policy. My empathic scoliosis. So this is patients that have Duchenne ends are often bred casus um syndrome scoliosis. Um These are the ones that are associated with known syndromes such as neurofibromatosis or a large Danlos. And then there's compensatory scoliosis which often times could be due to things like leg length discrepancy. In terms of infosys infosys is defined as a sagittal or a lateral plane deformity and so in this in this case we all have normal cervical Lord doses thoracic infosys and lumbar lower doses in chaotic deformities. You can have thoracic hyper hypothesis increased high posts and thoracic spine. And this because really this really breaks down into two basic types. One is postural hypothesis and the other is rigid hypothesis, which is oftentimes named Sherman's disease, which we'll talk about towards the end of talk. So let's start by first talking about idiopathic scoliosis. First and foremost, Idiopathic scoliosis um ideology of it is really still unknown in 2021. We do think it is multifactorial and there's certainly some kind of genetic component involved. Um there have been some studies that have shown that there it could be on a single dominant, however, there is incomplete penetrates so it can skip generations in terms of the problems or the occurrence of it in in families. Um idiopathic scoliosis can be sub classified based on the age at the time of onset. So for example, if a child is diagnosed between the ages of 0-3, it's oftentimes called infantile scoliosis between the ages of 3-10, it's juvenile and 11 or older, it's adolescent by far adolescent idiopathic scoliosis. TEM is the most common type that we see in clinical practice. What is really the prevalence of scoliosis? Well, it is quite prevalent in our In Children and the problems is known to be about 2- 3%. However, the majority of these curves are small. So if we start to think about significant deformity and the prevalence of significant deformity that's much smaller in the population and so as you can see in the table here curves greater than 30°. For example, the prevalence of that is 0.1 0.3%. So it is quite small. It is important to note though, that more severe curbs are more likely to occur in girls compared to boys. So there is a a sex distribution that is skewed towards girls having more severe curves and boys on clinical evaluation. What are we really looking at for idiopathic scoliosis? Well, oftentimes the complaints that patients have or the most common thing that's picked up by parents, family members, friends is a change in cosmetic appearance. Oftentimes this can be a symmetry, you know, shoulder asymmetry, chest wall asymmetry trunk asymmetry. So those are the things that oftentimes, you know, lead to suspicion of scoliosis history and physical is really important since idiopathic scoliosis is a diagnosis of exclusion, right? It has the word idiopathic in it. And since it's important to do like all other causes for scoliosis, it is important to get a good history and physical. So oftentimes what is that comprised of? Well, for history, it's important to know if there is any family history. Um, if there are any atypical findings or complaints such as back pain which is really not commonly seen in idiopathic scoliosis, that's an atypical finding. If there's been rapid progression. Things like that would would all I'll be part of the history. It would be important to recognize on exam. Um it really all starts with inspection and so this is where a couple of things to look at is relatively looking at shoulder heights. Looking at shoulder height can be misleading sometimes because if you look at the trapezius muscle, um there can be a symmetry in the bulk of that muscle. Um And so I would say shoulder, it's probably a little bit less um sensitive in picking up idiopathic scoliosis, but it's something we still look at trunk and waste. Priest Asymmetry. Now these that's more of a significant finding, especially in kids that have a curved that's lower down in their spine and their lumbar spine. And oftentimes you'll see that one of the waste crease goes and more compared to the other. Um And then of course on asymmetry in the poster chest wall and four bending is really one of the early signs that we see. And so this is what is called the atoms for bending tests in which you have a child bend forward and one side, either the thoracic or lumbar spine, maybe a little bit higher compared to the other. And the reason why this test is positive is because again, going back to the definition of scoliosis is a three dimensional deformity. And so one part of the spine is rotating upwards compared to the other. And so that's probably one of the most important parts of the physical exam. A skin exam is also helpful again, because this is a diagnosis of exclusion. You want to look at other potential causes for scoliosis. For example, if you have cafe au lait spots or harry patches, things that would make you think about neurofibromatosis or make you think about myelodysplasia. Um Those would all be important considerations on the skin exam and then a neurological exam. And in this one, this is specifically critical in the younger age group, especially the infant and juvenile group. And the reason it's critical in that group is because studies have shown that in patients, with for example, juvenile idiopathic scoliosis, about 20 or 25% of them may have some kind of neural access abnormalities such as a ceramics or a chiari malformation. Um Oftentimes those are the patients we are getting MRI's routinely um an orthopedic practice. Um but again, I would recommend just kind of a much more focused neurological exam in in that group of patients. So clinical evaluation going a little bit deeper into measuring forward um in terms of forward bending and how do we measure that? So school geometry is an instrument that is commonly used in clinical practice. It really measures the degree of asymmetry and we often have do it on the Adams forward bending test. Typically with a referral is warranted if the curve on the Scalia meter. Sorry, the degree measurement Scalia meter is greater than 5 to 7 degrees. And so this is kind of an important part of this talk in terms of when do you refer based on your school geometry measurement. And again this is due to the rotational component like I previously alluded to. Now if you don't have a Scalia motor, there's other options and other tools available. Um One of the things there's various smartphone apps available which have a skully on better. Some are free some you have to pay for. In fact there have been several studies done now which have shown that even the free apps are as sensitive as the school geometry er is. Um And so sorry as effective as a school geometry is so oftentimes that can be used in the standing if you don't have a skull diameter in terms of imaging. Well what do we do for imaging for idiopathic scoliosis? Um Similar to all other types scoliosis, our workhorse workhorse is a standing high quality P. A. And lateral radiograph of the entire spine. So one of the things I like to emphasis on this this part of the talk is that it is really important to get imaging at a place that does scoliosis x rays. And there's a couple of reasons for that one is because technique varies from from technician technician. It's important to have a technician who is experienced and well versed and stitching X rays together so that it's done as accurately as possible. Additionally it's important to have radiologists to review scoliosis X rays to do measurements, especially if you're doing them before referral. It's really helpful to get something more accurate from a radiologist, especially a degree of deformity. So you know how how urgent urgently to refer the patient. Now, what do we do on these X rays? Well what we do is we measure something called the cobb angle. And so this is where we draw a line along the end plate of the superior and inferior vertebra and the angle that is created between a perpendicular line to these is the one that we use as our cobb angle. What else do we get out of our standing X rays? The other is looking at skeletal maturity. So there's something that we call the reserved sign and you've probably seen this in and notes from from either our our clinic or from other providers and really what the reserved sign tells us is a rough estimate of skeletal maturity and that has implications to management, which we'll talk about in the next couple of slides as well. Um there are some more emerging technologies that are coming up in idiopathic scoliosis as well. Um there's something, you know, we're trying constantly to decrease the amount of radiation that that we administered during these x rays. So there's some low dose imaging modalities that have been developed and are available. There's also something called surface topography in which we really use surface landmarks as a way to kind of use that as a proxy of spinal deformity. Um there's still a lot more work to be done on that. but that could be coming down the pipeline in the next couple of years as a non ionizing radiation means to check for deformity. Well what about M. R. I. Well not every patient idiopathic scoliosis needs an M. R. I. Um And you know the indications for it are quite variable and controversial. Um It is indicated for certain diagnoses. For example, like I mentioned juvenile idiopathic scoliosis. That's a condition that we clearly know as a high risk of neural access abnormalities. So we'll oftentimes get an MRI at some point during the during the Diagnosis and management course for a child with juvenile idiopathic scoliosis. So again that's the group between 3-10. Who else is an M. R. I. Well, if there are any abnormal exam findings, right? So things like a typical reflexes atypical or asymmetric abdominal reflexes. Things that would make you think about a ceramics or things like that that would necessitate an M. R. E. Evaluation. Um A typical curve patterns. So generally the majority of adolescent idiopathic curves are right. Main threw acid curves. Um And there are certain certain curves that are atypical. So for example if you have a left thoracic curve, the one that goes towards your heart versus away from the heart. Um Or if you have um uh you know sharp angular curves curves that are not really more gradual. They're more acute. Um Those are something findings that are what we consider a typical and oftentimes necessitate evaluation. M. R. I. Pain I would say is another reason to get an M. R. I. Again like I mentioned, pain is atypical and idiopathic scoliosis. We generally think of scoliosis is being painless. Um And so that would be another reason that we would recommend getting an M. R. I. Um in these patients. Um In my practice I would say these all of these factors apply to what I just said. I am certainly routinely getting an M. R. I. Prior to surgery in my patients. And the reason for that is you know, to assess for any neurological abnormalities. Um and to know if there are any findings prior to proceeding with surgery. Um And I would say that even though the literature is all over the place whether that's you know um standard of care or not, the majority of places across the country are starting to do that, especially for the patients that are requiring spinal fusion surgery um is to get an MRI prior to private surgery. So treatment. Well first and foremost, why should we treat scoliosis? Well there's a couple of different reasons to treat scoliosis. Um first and foremost it's um in severe curves, cardiopulmonary compromise can be seen. The studies have shown that if you have curves creating 80-90° which is obviously quite a significant curve. There can be differences in P. F. T. S. Um And it can lead to cardiopulmonary dysfunction and sometimes compromise. Um Why other reasons pain. Right. As I mentioned, pain is not common when you're first diagnosed with scoliosis. However, oftentimes the scoliosis untreated as a young child as an adolescent or as a child. Oftentimes later on can lead to degeneration and lead to pain later in life. And studies have shown that for example, if you have an adolescent idiopathic scoliosis as a as a child, um your risk of back pain as an adult is about 65% compared to 35% um in the general population. Um Other reasons deformity and osmosis right of course. Now that is not something that I would hang my hat on. But it is a certain, you know, patients are definitely distraught by their deformity because it's you know, it's visual, you can see it um It's comparable to other people and so that's another reason that oftentimes patients wish to proceed with surgery. Now, what are the options for treatment? Um And the options really are, there's a couple and it all kind of depends on the magnitude of the deformity and the amount of growth the child has left. So the most basic option you have is observation and that may apply to smaller magnitude curves in either scale the immature or mature patients because not all curves do progress. Gracing is something we consider, especially in kids that have a mild to moderate deformity. I'll go into that in a little bit as well as growth remaining. And that's the key if you have growth remaining with a significant, with a significant enough curve embracing could be an option and then surgical management is really considered for more significant curves in which there is a risk of progression even after skeletal maturity. And again, I'll go into a little bit of that in the next couple of slides. The name of the game really is assessing risk for progression. Right? That's kind of how we help counsel families as to how to proceed the treatment and the risk for progression really depends on a few things. Um it depends on your sex, girls are more likely to progress more than boys. It depends on the curve magnitude at the time of diagnosis, for example, a higher curve magnitude, the time of diagnosis is more likely progress in a smaller curved magnitude. So, for example, a kid who said to my clinic who has a 45° curve at the time presentation has a much higher risk of progressing than a child who's got a much smaller curve. And that could be because they're curve just went really developed very quickly over the last couple of months and therefore they're on a much, much more rapid progression or much more rapid trajectory of progression for their deformity and then skeletal maturity remaining, skeletal maturity. And so if you're pre monarchical and you have a significant amount of growth left, there is a significant risk of progression vs a postman article female who is 18 years old, much lower risk of progression in that patient. So how do we know all of this? Well, we know all of this because of really one major study that's been done, which has looked at the natural history of Idiopathic Scoliosis. So there's this group out at the University of Iowa, led by Stuart Weinstein in which they basically monitored 133 curves For about 40 years and they were able to kind of look at what are the risks of progression and what are the risk factors involved the progression and what is the rate of progression? And so that's how we've been able to kind of put together that girls are more at risk curve magnitude matters, skeletal maturity matters remaining skeletal growth matters. So let's dig a little deeper into management. Well, observation is generally a good option for scale the immature or mature heads With curves less than 20 to 25°. So, first of all, um, it's important to recognize that scoliosis by definition has to be greater than 10°. Right? So anything less than 10° is not really scoliosis, it's finally symmetry. Um, and oftentimes that that does not need any subsequent follow up with an orthopedic surgeon. But for a true diagnosis of scoliosis curves greater than 10 but less than 20 or 25. Oftentimes observation is the way to go. The frequency of observation now can be tailored to the patient, so occupation to scale the immature. I oftentimes see them back much sooner every 4-6 months compared to a patient that's more skeleton mature and has a lower risk of progression. Um And so that's how you can kind of tear your follow up for those patients. Now curves may sometimes progress even after skeletal maturity. And so generally what we say is thoracic curves less than 30, rarely progress. Um but then curves that go above 45 or 50°. Those are the ones that tend to progress by roughly about a degree a year for the rest of your life. And again this is data that comes from those natural history studies that were done in Iowa even after skeletal maturity. So even after they've left your clinics, my practice and gone on and become adults. Um we still recommend that they continue to have monitoring for progression after skeletal maturity and generally every five years. Um is a good, Good Ball Park or a good recommendation for curve for patients that are curved greater than 30° at the time of skeletal maturity. So bracing who qualifies for that. Well, again, like I mentioned, this is for the mild, moderate deformity in a child that has growth remaining. So curves between 25 to 45° of growth remaining are the ones in my practice that I recommend for bracing. Now the really a couple of interesting a couple of important take home points for bracing is oftentimes tell families the point of bracing is not to make the scoliosis go away. Unfortunately, I cannot do that. But what it can do is it can stop the progression. And so again we would like to stop. So for example 30° curve at 30° because we know again from the natural history studies if that curve progressed about 45 or 50° and that child is at a significant risk will continue progression even into adulthood. So uh embracing, you know, we don't just recommend it to everybody because it is a commitment. Um and oftentimes it's really important for families to understand that bracing only works if you do it and in fact there is a dose response effect. And so you can see on the table around the graph on the upper right there That as you start to increase your number of hours in the brace, especially if you get about 18 hours a day and embrace the efficacy significantly improves. And so generally um in my practice I recommend that patients wear the brace for 18 hours a day, which again is a real commitment for patients. Um The other thing too, to emphasize to Children is that this is not forever right. We often tend to embracing again during the most rapid part of their growth and there are ways that I assessed that whether it's through looking at their growth charts are looking at other radiographic markers. It's really important to convey that to families so that they understand there is some light at the end of the tunnel and then of course during treatment with bracing we do get periodic x rays to monitor for uh effect or a progression of the curve. One of the other things that I do in my practice is we oftentimes use something called compliance monitors so you can see the bottom images there. It looks like a little button, but it's really a thermal sensor. And so oftentimes, what I do is before patients come to see me for like a six month follow up embracing, I'll have to get their compliance report which really take the button out and you put it into a computer software and prints out how many hours a day roughly. Um they've been wearing it and what that helps you with is ensure how they're doing. And it also helps me kind of work with them and counsel them on days. That might be particularly difficult. So for example, if weekends are much harder than weekdays or a particular day of the week is worse than the others. Um then that's a way to kind of focus my counseling um in terms of improving compliance for bracing. So aside from observation, embracing, what else do we have? What we have surgery and surgery in 2021 is still predominantly comprised of something we call a post your spinal fusion. Oftentimes this is recommended for patients that have curves greater than 45-50°. Um And the goal of surgery is to really stop the progression and to achieve a balanced spine. So again I tell families the goal is not to make the spine as straight as an arrow. The goal of the surgery is to get through it safely to get the spine to fuse and stop progression and to make sure that the position refused the spine is provides a child with a balanced spine and the balance part which is going to be on the scope of this talk. But it's really and it puts the person in a biomechanical advantage over time so that their head is about balance over their pelvis. And so they're able to live a functional life without consuming more energy than anyone who without school use would have to. Um so what are our techniques here? As I mentioned, poster spinal fusion is really our workhorse technique in 2021. Um In this procedure what we typically do is replace medical screws into the particles of the vertebra. Um There's various ways to do this. And at U. C. S. F. We do it uh using what we call intra operative navigation technology which makes it safer um and more efficient. Um And so that's something that we have recently adopted. Um and have had very good outcomes with and we're good experience with? So we're placing screws carefully into the spine using rods to correct a scoliosis, not just in those corona lol and casual planes, but it's really again three dimensional, going back to the underlying deformity and then the rods and screws hold everything in place to allow the spine to fuse. There are some other techniques. So there are some techniques which allow which include anti r spinal fusion. Again that's rare for us to do for idiopathic scoliosis, it's usually done for more severe curves. Um And then there are other techniques like halo traction. So halo traction is basically a staged technique in which you would apply a halo followed by a spinal fusion. And this again is done for more severe curves. Which in North America is atypical for a video catholic trip to get become very severe. But it's a more common technique in patients with things like no mustard scoliosis. And then there are some more emerging technologies are just spying tethering um in which we do that generally for younger Children with less significant curves. And the thought behind that is could we harness the growth remaining to control scoliosis. Um The jury is still out on that in terms of outcomes and the indications are still quite unclear. And so there's probably more to come on that before we kind of fully understand how that fits into the whole treatment paradigm for idiopathic scoliosis. So how is all of this relevant to you? So one of the more important questions for for the audience here today is you know, when do you refer? So often times I tell uh providers is that you know a p pediatric with the Society of North America and the scoliosis Research Society srs all have recommended for screening in patients. And so screening is obviously something that is worth doing. And there's a nice algorithm here published in Jama a couple of years ago which I think does a nice job of showing which patients would benefit from referral. And so if there is concern for scoliosis on history exam and of course those patients should be preferred and patients that may have syndromes and conditions associated scoliosis is those would also be good ones to refer to us. I often times understand referral doesn't happen overnight. And so what can you do in the meantime? Well, a couple of things, one is to get an X ray and again I'm getting a high quality x ray at a place that does these x rays is a good way to proceed at least allows you to quantify the deformity and to kind of do all that work prior to the referral. Um other things you can do is provide families with some education and of course I totally understand everyone has a very busy clinical practice. But all of these societies including the scoliosis Research society, the american Academy of orthopedic Surgery, pediatric orthopedic society And even the ap they all have educational resources for patients and in fact a lot of them have spanish language resources as well which is very specific to the population that we serve here in the Bay Area. Mm So peri operatively. What are the considerations? Well I oftentimes tell families um and pc PS when I talk to them on the phone is you know surgery is a team sport. Um And then we all have a role to play in the patient getting through scoliosis surgery. And so uh pre operatively for me here at UCSF patients oftentimes get an evaluation from anesthesia. They oftentimes get various clearances especially if they have any underlying medical comorbidities. Um I got preoperative labs and all of my patients and those are really just screening labs to pick up things like and iron deficiency anemia or coagulation abnormalities. And every year I'll pick up a couple of those and oftentimes we will delay surgery a little bit just to make sure it's initially worked up because at the end of the day this is elective surgery and we need to make it as safe as possible for Children. Um And then skin evaluation that's another part of practice and not really is to make sure that we minimize the risk of any kind of infection. Um staph aureus continues to remain the most common bacteria associated infection in spine surgery. And so we try to make sure that, you know, we're looking at the skin and treating any german logic issues prior to proceeding with spinal fusion surgery and the post operatively, You know, one of the more important things is goal directed care and pathways. So this is really one of the benefits of working for me working at insurance hospital is that first of all, we're all pediatric providers and we've all established pathways for these patients to safely get in and out of the hospital. Um and so that's, you know, we have pathways that books on pain control and diet on activity. So really the goal is to provide patients with a way to quickly um rehabilitate and get home after safe, get home safely after surgery and the last topic idiopathic scoliosis. Well, we've talked a lot about surgery. Um that sounds pretty scary and I totally understand it is, But I would say that generally poster spinal fusion is quite safe in 2021. So there was actually a large study that was published here which looked at a prospective cohort of patients. And even though you can see the overall complication rate is quite high, the types of complications that happened were For less morbid and therefore generally in 2021 as our technology improves as their techniques improved as a preoperative management improves, um surgeon continues to remain extremities gets safer and safer for families. So what about other types of scoliosis quick word about congenital scoliosis, not congenital scoliosis as I alluded to earlier results from abnormal growth or development of the material column. This typically happens around the 6th week of gestation. Um And it happens quite early in gestation and there's really two types of this abnormality. One is failure of formation and the other is failure segmentation. Um And sometimes you can have a mixed type as well so you can see kind of at the bottom there a failure formation is basically a heavy vertebra that forms and failure segmentation is the failure of one vertebra to separate from the other. And then there's the mixed type which I mentioned as well. Now the most important take home that I would like to convey to you for congenital scoliosis is that it's important to rule out other abnormalities, especially in a child that has congenital scoliosis. Specifically. It's important to rule out to generate problems with genital urinary system and the cardiac system. And so again this goes back to the time of gestation when this happens which is often times when the G. U. And the cardiac systems are also developing. And so the G. You abnormalities can be seen. About 20 to 40% of patients with congenital scoliosis. And cardiac anomalies can be seen in about 10-25% of patients. So oftentimes when I see these patients we are which is often very young in life. A couple of tests that I oftentimes get or I will recommend it that they get is a renal ultrasound as well as a cardiac echocardiogram. So those are all kind of screening tests. When you see this diagnosis, treatment for congenital scoliosis a little bit more gray compared to what we just went over for idiopathic scoliosis. For idiopathic scoliosis, it's a little bit more regimented uh general scoliosis a little bit more uh gray and in the sense that we don't quite know what is the role for bracing for these patients because there aren't very good studies supporting bracing. Um and oftentimes we do recommend surgery, especially for types of congenital malformations that have a high risk of progression or have already shown progression. Um And so again that goes into a little bit of nuance is beyond the scope of this talk. But the things that we're looking at for these patients long term is the curve progressing, is it changing their balance? Um and is it causing any other consequences? Um you know, to cardiopulmonary issues or sitting balance, standing things like that. And then lastly on the topic of scoliosis neuromuscular syndrome. X scoliosis are probably the other big types that we all see in practice. So this is commonly seen in patients that have cerebral palsy for example or muscular dystrophy and certain syndromes. Um We think that the ideology of neuromuscular and syndrome scoliosis. I'm lumping them together just for simplicity um is really due to weakness, muscle imbalances plasticity, which would certainly results in imbalance difficulty with care and compromised pulmonary function, neuromuscular and syndrome a curves look different than idiopathic curves. And oftentimes they can have this long C shaped curve um with quite a bit of pelvic a public witty. So one hemi pelvis being elevated, prepared to the other. This patient on the right is one of my patients with Tourette's syndrome who presented with this curve and you can see that when she sets um she's loading and we're looking at her from from from the back and so she's loading her right issue a lot more than her left. And so that's going to have significant sitting balance skin breakdown things of that nature In general. We recommend surgery for these patients when the curve progresses to about 50°. Um and the important thing though, for this condition to take home for for for you guys is one is surgery for syndrome is a neurological conditions, has higher complication rates compared to idiopathic scoliosis. And part of that is because these patients are just more medically complex. Um And again, being at a specialized pediatric center, we often times do change our treatments carry operatively for these patients, including antibiotics, you know, time in the ICU, things like that. And so it's really important to make sure that these Children are getting um cared experience specialized centers because that is something that can help to improve their post operative course. So in the last few minutes here we'll shift gears and talk a little about the hypothesis. Soak infosys um as I mentioned, there's really two types um and again this is a more simplified version, but it's it's really helpful to think about it this way. So the first and most common type is what we call postural psychosis, and this is something that I'm sure your offices are inundated with complaints from parents that their child is just slouching forward. Um And you know, is there something that is that, is that pathologic, is that associate with some kind of condition is associated back pain? And generally what I tell families is that this is a cosmetic concern which can be corrected voluntarily. So if you tell the child sit up straight, they can correct their hypothesis. And from what we know of the literature, it has not been significantly associated with any pain or progression. Um and so, you know, despite, you know, despite what all of our parents and grandmothers and grandparents told us, um there may be some truth to that, but it's hard for me to pinpoint a study um that that's that shows that, but the important thing to recognize is that possible psychosis does not getting treatment. Um Oftentimes reassurances enough. Um but there are some here families that I will send for some hyper hyper extension exercise training. Um And so this is basically helping to develop the core muscles, you know teaching better posture. Um And and it's part of the reassurance of what we provide to families and providing care to them. Now there is something called structural hypothesis though, which is basically rigid ketosis. So this is the type of psychosis in which you tell a child to sit straight, they cannot sit straight. Um And so this is something that is a structural problem. And the most common type of psychosis that falls into this bucket is called Sherman's disease. Um in which where in which we have what we call rigid hyperhidrosis increased hypothesis that is rigid with wedging of three consecutive vertebra, which we look at an X ray. Um and so you can see on the image on the right there, that's one of my patients with Sherman's psychosis who underwent surgery a few months ago and you can see he's got a fair amount of thoracic hypothesis with wedging of his a pickle vertebra right here now, treatment for psychosis is a little bit more well known. And so what is the treatment? Well, generally surgery treatment is based on the degree of the deformity in the presence of symptoms For mild ketosis. The curves that are kind of hypothesis that's kind of, you know, 50-70°. We can oftentimes think of things like physical therapy, bracing, especially in the child that's still growing. Um and so those are things to consider in that group. But then surgery is generally considered when curves get above 75° and certainly uh curves or starting thoracic, I post gets over 90° because those have been shown to progress. Um in fact curves, thoracic boasts over 100°, is shown to have shown to lead to pulmonary dysfunction. Um, and so those are kind of a general outline of what we do for treatment. So I just want to take a few minutes here and show you a couple of examples of treatment that we do for scoliosis. And so for example, this is a patient who has adolescent idiopathic scoliosis. And you can see on the image on the very left is when she first came to see me. So she's skeletal immature and has what we call a lumbar curve because the majority of her scoliosis in the lumbar spine. And you can see, we started bracing because she was still scale the immature. And this is her image in the brace, which shows that the curve doesn't go down to zero in the brace. But it does get a little bit better. And she did very well in terms of compliance and was wearing the brace for upwards of 18 hours a day. And the image on the right is when she reached skeletal maturity. And again, the way we assess that is by looking at our growth charts looking at some various skeletal markers of maturity and that's the curve. She was left with this skeletal maturity, which is very similar to the curve she had before she went to her rapid rapid growth berg. And so to me this would be a home run if you can hold this curve which I'm guessing is probably in the high twenties, low thirties. Um that is functionally gonna do very well for the rest of her life. And so this is this is what bracing can do and it is a very effective way to manage scoliosis. Now, a couple other examples. So this one here is what it pushes spinal fusion looks like. So this is a boy who has a right thoracic curve Measuring in the 60's um that underwent a poster spinal fusion. So you can see there those are the medical screws and the rods to correct the scoliosis. And again, the goal here is to maintain his head above his pelvis and to let the spine fused in that position. And so this is what we would recommend for more significant curves in patients with idiopathic scoliosis. Now, sometimes you have to get creative right. So what if a child is too young to fuse their spine? You can't fuse very kids at a very young age because then they'll be left with a short torso and you'll also compromise or stunt to their culinary development, leading to pulmonary insufficiency later in life. And so we get creative and we do things like what we call it growing rod. So for example, this is a girl who had um syndrome scoliosis of Ehlers Danlos um with a 100 degree curves. And for her, what I did was we did halo traction for a couple of weeks in the hospital to help stretch the spine to also work on her nutrition optimizer for safe surgery. And then we did what we call the traditional growing rod. And so this is these are rods that we put in with screws in the top of the bottom and over time, what you can do is you can loosen the screws here and here and lengthen the rod so that as she continues to grow, we can also continue to lengthen her spine and correct her deformity over time. I'll contend this is a bridge to something at some point she will reach skull the maturity and at that point we would do a definitive fusion and then there is new technology as well. So for example, there's something called magic rods which are magnetic controlled growing rods um in which in the previous example you have to go back to surgery every six months to lengthen those rods. In this case you can actually use an internal magnet that's built in to apply an external magnet to the skin, which allows the rods to distract over time. So this is an example of a child who has no Moscow scoliosis um in which we did magic rods. Um and we're allowed to lengthen her without returning to the operating room, which again has significant benefits um in terms of decreasing risk of anesthesia, which again can be risky in these patients. So in conclusion spinal deformity can be seen in Children of all ages. It is important to evaluate both for scoliosis and typhus as per the guidelines established by our professional societies. If in doubt, obtain an X ray and refer for further evaluation, consider associated conditions for patients with certain diagnoses. So these would be the syndromes that are characteristically associated with scoliosis observation, embracing our successful strategies as long as it's thoughtfully uh thoughtfully administered and thoughtfully discussed with the family spine surgery is major surgery but it is generally safe and its associated with good outcomes. Peri operative management is really critical to patient safety outcomes and satisfaction. So the key here is goal directed care and really having a care team that takes care of these patients throughout their preoperative course. So with that I'd like to graduate the information for our group here at UCSF. And so this is how you'll be able to actually get access to our pediatric access center and to be able to send patients to us um to evaluate them further for pediatric spinal deformities. And this is my group that I work with on both sides of the bay. So we have um clinic locations in the East Bay as well as the West Bay. And even though I know we're talking most about spinal deformity, which is an area that I love. Various, various of my partners take care of all general and subspecialty orthopedic conditions, um, and so, you know, feel free to kind of reach out to us. Um, if you have questions, questions about referrals were all very accessible and open to talking with you.
