This presentation from pediatric orthopedic surgeon Ishaan Swarup, MD, shines a light on the developing spine. Focusing on scoliosis and kyphosis, he offers definitions, classifications, physical exam and testing pointers, treatment options and associated outcomes, and tips on when to refer.
Yeah. Today we'll try to specifically focus on evaluation and management of this condition, focusing both on scoliosis and ketosis. Um I do have a few disclosures, none of which are relevant to the stock. I do serve on some professional committees for pediatric orthopedic society in the American Academy and I do some consulting work. But again, none of this is relevant to the talk today. So obviously pdf file deformity is a huge topic even though, you know, it might be kind of a very focused area in the care of Children. For me, there's a lot that I see in a lot that I treat in this realm. Um for the purposes of today's talk, we will first go into the definitions of what really is scoliosis and psychosis. What are the technical definitions? Um, one of the things that you know, we should be um we should all know and use when we communicate with each other. Well specifically talk about conditions that are the most commonly seen and these would include things such as idiopathic scoliosis, as well as congenital scoliosis and neuromuscular scoliosis. And then we'll talk about ketosis. Um and really there's two major ones to know when it comes to the hypothesis. And then and for the last couple of minutes I'll just briefly talk about ph orthopedics here at UCSF as well as spine surgery at UCSF, so that everybody is a bit more familiar with with what we do here at this university. So let's jump right in. So what exactly is scoliosis? Well, even though we often times when you use the word scoliosis, you think of a two dimensional deformity, It's usually a lateral curvature of the spine in the frontal plane. But what I'd like to kind of have you understand that this is a three dimensional deformity. And the way I really explain this families is that I say that if you take a wet towel and you ring out the towel and you have a twist, that's essentially what's happening to the spine. It's actually curling upon itself because our imaging modalities are limited. We see this as a two dimensional deformity. But again, this is a three dimensional deformity. And it's important to understand that because that has implications to your physical exam. And for me as a surgeon has implications to what I do surgically now, idiopathic scoliosis. Um sorry, excuse me, scoliosis can be broken down into various different types. And so the big buckets of scoliosis are idiopathic scoliosis, congenital scoliosis, which is essentially a failure of formation or segmentation of the spine during development, neuromuscular scoliosis. So this is patients that may have cerebral palsy read syndrome, some other neuromuscular condition that is attributing that is contributing to their scoliosis. Myopathy is like decisions syndromes like Marfan and Ehlers Danlos and in compensatory scoliosis which could be scoliosis due to a leg length discrepancy, which really isn't scoliosis, but it comes off as an apparent scoliosis. Now on the other hand, what is key emphasis emphasis is looking at the sagittal planes at a lateral X ray and in general all of us have normal parameters of cervical, Lord, Asus, thoracic infosys and lumbar lower doses but thoracic hyperhidrosis can be seen in patients and they're really too big, too big types of that. One is postural, which is essentially flexible and the other is structural and the most common condition that falls under the structural category as Sherman's disease. And we'll talk about that as well. So let's talk um for the briefly about idiopathic scoliosis, since that's the topic that, you know most of us have seen. And um it's definitely something that is commonly seen in the primary care setting. So generally idiopathic scoliosis. What is the ideology of it? Well, it's really unknown. There have been various studies that have been done um, looking at the genetics and there are some studies that have shown that there are some auto zonal dominant traits to idiopathic scoliosis. However, uh, there is incomplete penetrates. So even though as a surgeon, when I see patients with idiopathic scoliosis, I often, I mean I always ask about family history, but it's clear that it does not go from generation to generation overall, we classify, we sub classify idiopathic scoliosis into three types, juvenile, infantile, juvenile and adolescent. And this is purely based off of the age at time of diagnosis. So the infantile group is essentially Children between the ages of zero and three that are diagnosed with idiopathic scoliosis juveniles between three and 10 and an adolescent, which is the most common Um is essentially Children that are over the age of 10 diagnosed with scoliosis. What is the epidemiology? Well, um, scoliosis in general is quite common. It is seen in about 2-3% of Children. However, more severe curves are less common, so you can see there, the prevalence dropped significantly for curves greater than 20°. It is important to note that by definition, in order for a child to have scoliosis, the curve must measure greater than 10°. If it's less than 10°, it is not scoliosis, it is what we consider spinal asymmetry. And in fact the prevalence of spinal symmetries is probably much much larger than even 3% of the population. This is a nice table here which shows that if you look at the distribution of boys and girls with scoliosis for smaller curves occurs between 10 and 20°. The ratio is relatively similar for boys and girls. However, the more severe curves um tend to happen more commonly in girls. And that's the reason why when we think of patients scoliosis, you know, it is often times more commonly seen. More severe curves are more commonly seen in girls than they are in boys. The clinical evaluation, I think this is probably one of the more most important slides that I'll be sharing with you today. I think in general when we see these Children for scoliosis, oftentimes patients come in with a concern or families come in with a concern of cosmetic appearance. And oftentimes either the story is that it's a summer holiday, go to the beach and you notice that you know, something looks different, shoulder height looks different, The pelvis looks different, There's waste crease, asymmetry and oftentimes those are the things that families perceive first, which often times prompt a referral for evaluation. It is important to note that back pain is not commonly seen in idiopathic scoliosis. And actually the back pain is a is a typical and so oftentimes, when I see a patient that has scoliosis and back pain, I'm really scratching my head and thinking about other reasons why a kid may have back pain. And oftentimes I'm thinking about more advanced imaging for that patient because again, that is not a very common finding idiopathic scoliosis. So the history and physical exam are very important, since this is a diagnosis of exclusion. The word has idiopathic in it. And so as a result, we have to do our due diligence and rule out every other potential cost for scoliosis on physical exam. I'll kind of walk you through what I do in my physical exam in. We can talk about how much of that is applicable to the primary care setting. So generally a large part of my exam is inspection. And so what I'm doing is I'm looking at the child from the back, I start from the top and go to the bottom. So I look at shoulder heights, I look at their waist crease, I look at their pelvis. Those are all giving me some subtle ideas of how bad is the deformity it, first of all, is there a deformity? And how bad is the deformity? Then what I'll do is I'll do in atoms forward bending tests. As many of you know, that is just having a child bend forward and this is where I'm looking for thoracic and lumbar prominence. This is exactly where that three dimensional aspect of scoliosis comes into play because it's a rotate. It's derogatory condition. That is why you see one side of the ribs being higher than the other. And so that is what I'm looking at to see what side is higher, which one is more significant. And that's where you would also do your school geometry measurement, which we'll talk about on the next slide on inspection. I'm also looking at their skin. So what am I looking for? What I'm looking for? Cafe ole spots. You know, thinking about neurofibromatosis as possible condition for that's associated scoliosis. Um I'm looking for um harry patches. My thinks about my woman into seals. Um and as a surgeon, it's a surgical candidate. I'm also looking at their skin for things like acne. Um You know, there are some studies that have been published that do show that risk of infection may potentially be higher. And so I'm often times looking at those things, um, as well when I'm, when I'm inspecting a child's back and then I really focus on a neurological exam. Now again in the primary care setting, it's probably more limited than it is in my world. However, Um, it is critical to neurological exam in certain patients. Um specifically, for example, patients that have juvenile idiopathic scoliosis, the patient between the ages of three and 10 Studies have shown that about a 25% of them have an interest spinal abnormality in addition to their scoliosis. So those are the patients that specifically do need a neurological exam in the things that have been known to be found in those patients are things like a chiari or ceramics. And so it's important to do reflexes and do a gross motor and sensory examine those patients. Additionally, it is important to do a neurological exams on patients that have rapid progression of scoliosis. Scoliosis generally doesn't progress very quickly. But when it does, that is another sign of the reason that we should do a thorough neurological exam to make sure there's no abnormality in the neural access that is driving their scoliosis. Um, so that may be another population that would deserve a more thorough neurological exam. Yeah, so moving on to the Scalia motor a little bit more. So this is something that we use commonly in clinical practice, um, essentially a measure of asymmetry. And so it's all done on Adams for bending test and with the patient leaning forward, we measure up and down the spine at different parts of the spine to see how much of a rotational asymmetry there is, and generally If there is more than 5-7° of asymmetry, those are the patients that should be referred. There have been correlation studies because again, this is looking at rotation and so 5-7° Tends to correlate to about 15-20° curve. And so those are patients that have truly have a definite diagnosis of scoliosis and there's definitely the ones that should be followed by an orthopedic surgeon so that we can determine whether they need any kind of treatment. Now, if admittedly, a lot of us don't have a Scalia monitor and actually I don't carry Scalia meter around anymore. And so there are other ways to do this. And so there's a kind of a whole bunch of smartphone apps that have been developed that also do the same thing as a skully ah meter. And in fact if you have just a regular cell phone, you can use your level app which is used in carpentry to kind of do the same thing, which is essentially showing you whether things are level or not. So if there is a suspicion for scoliosis, what do we do next? Well, our first step is to get imaging and imaging for patients of scoliosis is an X ray. So generally it's a standing, high quality papa X ray as well as a lateral luxury of the entire spine. Now, the reason we do P. A X rays, there's a couple of different reasons, but in general, as a spine surgeon were oftentimes looking at patients from the back. And so by convention, as you've probably seen in the X ray up showing already and a couple of X rays that I'll show you all of the extras are looking from the back. So the left is the left and the right is the right. Um In addition we do get lateral x rays as well just to kind of see what, how is the deformity? How is the scoliosis affecting their saddle profile? Um And there are some abnormalities that you can see on the saddle profile, which could be a typical, which again qu into could this be something other than idiopathic scoliosis and some findings that are typical which go with the diagnosis itself. Now, the measurements that we do and oftentimes these are done by a radiologist, is what we call a cobb angle. And this is looking at the most severe curve that you can find in the spine. Oftentimes residents and fellows will ask me, how do you determine where one curve stops and the other one begins? And I tell them, you know, the easiest way to tell is to look at the disk spaces between the vertebra and so you can tell that if there is a right to massacre. For example, in that image on the upper, upper right there, you can see all the vertebra are wedged so that the smaller part of the disk spaces towards the cavity of the curve. Also for imaging, I would say that it's probably best to have imaging done a facility that that routinely does scoliosis measurements and that's for a couple of reasons. One is, it is very technique dependent. Oftentimes these extras have to be stitched together by the radiology tech. And so a place that does this more often um, is uh, is more fast salad doing that. And the other is the measurement. So you want to have a radiologist who does these more than just a handful of a handful of times a year so that we get reliable measurements for these patients. There are some more emerging technologies that are coming out and a lot of these have to do with the fact that we want to minimize the radiation that Children receive, especially for spinal imaging. Um and so there are some things that have been written about are being done um surface topography, which is actually a relatively it's been around for a long time but it actually has some renewed interest in order to see. Is there any any topographic measures, any um and inspection measures that we could correlate with spinal deformity. And so we are starting to do that a bit at UCSF and there's gonna be more to come on that as we start to validate that and use that for clinical decision making. But still, I think that's a couple of years down the road for us now. What about more advanced imaging mris Well, in general, I would say that in the primary care setting it's pretty rare that you would be ordering this. But things that conditions are where I consider an MRI our patients certain diagnoses. So, for example, the juvenile idiopathic scoliosis patient, um you know, if they're old enough to be able to tolerate as an MRI without sedation and if I have a heavy, high enough concern for neural axis abnormality, I will definitely order that um patients that have any abnormal findings on exam. So, a typical, you know, asymmetric reflexes, asymmetric abdominal reflexes or atypical curve patterns. Um if you know, for those of us that look at scoliosis enough, you know, we know that our right thoracic curve is very common. Whenever you see a left thoracic curve, then that's a typical and oftentimes those are the patients that need to have an MRI. And uh and then the last cohort that I usually get an MRI and other patients that we're gonna be doing surgery and there's a couple of reasons for that. One of them is, again, even though the diagnosis, idiopathic scoliosis, um, you know, they're undergoing surgery, they're going to be undergoing, you're monitoring. So if there is an abnormality you would rather know than not know. And the other is it also gives me an idea of their anatomy, especially from a surgical planning point of view. Now, you know, we wrote a paper about this and we found that actually the rates of neural axis abnormalities, even in patients that have idiopathic scoliosis is quite high. But it's important to recognize that a lot of those patients do not need any intervention for their neural axis abnormality. It could be a small cyst, it could be a very small ceramics. Again, none of which may need treatment, but it is again important to recognize those um, those findings. So why do we treat scoliosis? Well, you know, why does this matter so much? And, and this a lot of this information comes from natural history studies that were done in Iowa uh many years ago. And so these studies were done in Iowa because they had a relatively um stable population that they followed from multiple years. So it was a landmark paper, I'm sorry, this may not project so well, but it was a landmark paper by Stuart Weinstein, in which he followed patients for over 40 years with idiopathic scoliosis and generally scoliosis the way I think about it, there's a couple of implications. The biggest and the kind of, the most scary implication is the cardiopulmonary implication of cardio pulmonary function. Now, it is important to note that those implications of changes in PFT s restrictive lung disease, Things like that oftentimes happened when the curve gets above 80 and 90° and thankfully in North America, we oftentimes intervene before Children get to that severe of deformity. Now there are some other implications too, including pain later in life. And there was actually a really good study that showed that patients that had or Children that had idiopathic scoliosis or patients identify scoliosis. Children oftentimes have a higher rate of back pain later in life. And the way that works is because it is simply because you're buying. Mechanics are different when you have scoliosis, your disks are being loaded a different, a different way than they are if you don't have scoliosis and as a result you're probably more prone to developing degenerative changes and so they may have more back pain later in life. And then the most obvious and I think the one that is probably, you know, really the elephant in the room is the is the Cosme Asus and the self image part of this. I do you know, seeing patients with scoliosis, there is a huge part of this which is psychological and um kind of implications to self image. And I think that's an important part of the discussion with families and patients that have scoliosis. Generally the options for treatment depends on, I'm sorry, are threefold one is observation. The other is bracing and the last one is surgical management. I'll talk a little bit more about this in detail in the subsequent slides. The decision for treatment depends all upon the risk, the magnitude of the curve and their risk for progression. So generally curves that are between 10 and 25° are the ones we're observing. And the reason we're observing those is because as you can see from this natural history study by Weinstein, those are the curves that have the lowest risk of progression. Um and so it's fair to watch those and see what happens. Some get worse, but the majority of them don't. Now, the larger the magnitude of the curves, curves that get above 25 and 30° have a higher likelihood of progressing. And so those are the ones that we start to think a little bit more critically about intervening. The other thing that determines risk of curve progression, that kind of the most significant driver of it is growth. So generally scoliosis gets worse as you grow. And so that is something else that plays a huge role in my decision making of what treatment I'm offering to the family. And so what are some factors II or was some things I look at someone is skeletal growth remaining. So oftentimes on that X ray that we've obtained, we can look at their pelvic hypothesis. Um and that reliably closes from lateral to medial. And so there's this thing called the reserve stage, which you've probably seen it in a lot of notes that we all right. And that helps me figure out how much growth the child has left. If it's a female, I'm looking at their menstrual history and age of monarchy because we know that peak growth velocity happens right before monarchy. And then generally growth happens for about a year and a half to two years after monarchy and girls. So that's helping me figure that out. And thirdly, it's actually the growth chart. Um And so I often times, you know, look at the growth chart, it's a patient that's been in our system here at UCSF. I can go and look at the pediatrician's note and look at the growth chart that they have generated and see what are they doing. And so that kind of helps me a lot to figure out treatment as well. So generally observation is recommended for most scale the immature patients with curves less than 20-25°. Now, the frequency of observation, whether I'm seeing them every four months or six months or nine months or a year or two years, all depends on the patient's age and growth potential. So if it's a child who's 10 whose pre monarchical has a 20° curve I'm probably seeing that child back every six months just to make sure that curve is not getting worse because they have a significant amount of growth left. Whereas on the other end of the spectrum with an 18 year old, post monarchical female with a 20° curb, I might, I might, you know, make the follow up there from a year to two years just because their risk of progression is so much lower because their growth potential is so much lower. Now curves that get much larger are the ones that I started to watch more closely. Um, and so 50 to 70° curves. For example, if a curve gets up to 50°, we know those are the ones those are the those are the bad actors and the reason why they're bad actors because even after skilled maturity, those can progress a degree a year for the rest of your life. And so this goes into a little bit of decision making for when we intervene with surgery. So the reason why, you know, oftentimes I get asked what's so magical about 45 or 50 degrees. And the reason is is because, again, natural history studies have shown us because that's the critical number where even after you re scale the maturity those crooks can get can progress about a degree a year for the rest of your life. So if you have a 50 degree curve when you're 18 years old, That can end up being a 75 or 80° curve by the time you're 50, which again, can have implications to cardiopulmonary function, which again, is something that we want to avoid in this, in this, in these patients. So bracing. Who's a good candidate? So we talked about observation and who's a good candidate for bracing, bracing is generally considered for curves that are between 25 and 45° in patients that have growth remaining. And so the goal of bracing. And again, this is a very important point. And something I try to express the patients and families is that the goal of bracing us not to make the scoliosis go away. There's nothing that we can do to do to make it go away. But the goal is to stop it from progressing. And if so, if it's a 30° curve when we started, It would be fantastic if you could keep it at 30° once the child is rescheduled to maturity, bracing is not a walk in the park. It is a commitment and it's a real commitment on behalf of the child. It's a real commitment on behalf of the family. And so oftentimes this is a pretty serious conversation that I'm having the families and oftentimes, you know, these are the families I spend extra time with and um it's one of the perks of being at a place like UCSF where I have support staff who can help me, um counsel families put them in touch with other kids who have done bracing because we know that bracing will only work if the family and the child buys into it. So compliance is really key. There have been good studies which have looked at how how many hours should be. Should we be bracing Children? And so this graph that you can see on the upper right Really shows that you need to have a child and embrace for over 18 hours a day in order to really get the maximum benefit of the brace. And so that's generally what I recommend. And if you can think about your average day, 18 hours, a big chunk of the day. And so again, that's the reason why I think this is a real commitment. But that's the general, that's the reason why we make the journal recommendations for 16, 18 hours a day minimum for bracing is to, because that's where we know it's the most efficacious now on the topic of compliance. The other thing that I've recently started to do my practice and did this as a fellow when I was a fellow in philadelphia is that we would put in compliance monitors. And this isn't trying to be big brother and see what's happening, but it's really a patient education tool. And so oftentimes when kids come back to see me after they started bracing, they come with a little compliance report card, which basically shows me, how many hours have they been wearing the brace And it allows us to identify points in the day or points in the week that are really troublesome for them and why they are not able to worry there brace. So we're really trying to boost compliance. It allows me to be to provide more directed counseling to the family and to focus my time and effort on those particular periods of the day of your period of the week where we can improve compliance and have actually been studies that have shown that by just telling that a child that your compliance is being monitored, compliance gets better and that I think speaks to, you know, what many of us know is the hawthorne effect. Right actions change when people are being studied. So there are multiple benefits benefits to that. Now, what about surgery? Um, surgery is generally considered when curves get above 45 and 50°. And again, I've alluded to the reasons for that. And the reasons are because those are the ones that progress even after skeletal maturity. So generally, you know, it's a growing child and increasing curb over 45-50°. And the goal of surgery is to stop progression and to achieve a balanced spine. Again, the goal is not to make the X ray look fantastic and to make the curve go from 60 degrees zero degrees. For me, the goals are to balance the spine to do it safely. Um and to get the spine to fuse in that position. So what do I mean by balance? Balance basically means making sure the head is centered over the pelvis because sure enough, this child has a long life ahead of them and and they need to be optimized from biomechanical point of view so that we're not creating a problem for them, things like disc disease, back pain later in life. The conventional surgical management that we recommend is poster spinal fusion and that's kind of the workhorse for what we do in terms of correcting spinal deformity in patients. But there are some other techniques um There are some anterior approaches to spinal fusion as well. Um Now there's a lot of them are becoming less and less common because of better instrumentation that we can do procedurally, but we still consider that in some patients, um there are some other more emerging techniques like spinal tethering, in which we're, what we're trying to do is really harness the growth potential is fine. Now the gathering is still, I would say, relatively experimental um and the indications are somewhat unclear and the outcomes are definitely mixed. Um So one of my colleagues here does do that UCSF but again, I think the jury is out on who's the right patient for that condition for that procedure rather. Um But in general, poster spinal fusion patients do very well. And we have a long track record with this, not only at our institution, but throughout the world with poster spinal fusion patients generally have good functional outcomes and the corrections maintained. And in fact if you look at things like back pain, the rates of back pain patients have had a spinal fusion are pretty comparable to the general population. So let's bring the discussion back to the primary care setting. So when is a referral warranted for these patients? This is a nice algorithm from a paper that was published in Jama a couple of years ago, which really shows that obviously we have screen protocols that have been put together by the Ap and the Pdf with peak society and the scoliosis racial society which really talk about the times and you should be screening the school. The Ammeter is an important tool in screening and figuring out which patients would be referred and then definitely if there is a concern. Um you know I think having a low threshold is reasonable in these cases because I you know I do understand that it caused a lot of anxiety on behalf of the families and the patient when they're told that they have scoliosis, I would say the other patients to refer are ones that have particular syndromes and conditions associated with scoliosis. For example insurance through a policy. Um Insurance with Children with our fans for example as well. Um are probably reasonable candidates who refer for evaluation as well. I also understand that it sometimes takes time to get a referral. And so what are things that can be done? Well an X ray. So again, doing an X ray of high quality X ray at an institution that does X rays or at a facility that does a scoliosis x rays is probably a good first step making sure that families come with the cd of their X ray so that we're not having to repeat imaging for these Children and then um offering some patient education. Um I totally understand that everyone has a very busy practicing a lot to do. Um and so some of the resources that I use are the scoliosis Future Society, the American Academy of Orthopedic Surgeons in the Pediatric Orthopedic Society of North America. And I can send out these websites to you and all three of them have resources for families um in which there who may have a concern for scoliosis just to kind of talk about some basic questions and provide them with some more information. So before we kind of moved to uh some other topics, just a few other uh, you know, important points to discuss here as a surgeon. You know, I definitely think that surgery is a team sport and it is a partnership between not only me but also other providers who take care of this child, including the primary care doctor, the hospitalist, the intensity of the anesthesiologist. And so again, I feel very fortunate to work at Insurance Hospital where we do this often and we often tend to meet as a multidisciplinary team to talk about issues surrounding a particular case. Um and then post operatively is having pathways and goal directed care. Um you know, there is very subjective that we want to fulfill for these families. There's a lot of confusion and a lot of mixed messages, mixed messaging about pain and what to expect after surgery. So I think again, this is uh it really helps to to communicate directly as a team in order to set expectations for patients and families so that we can successfully get them through surgery now. Um, surgery spine surgery in general is major surgery and I think it's very scary to um practitioners, but also scary to families and patients. And so one of things I'd like to also expresses that. I would say generally it is a very safe surgery, especially in a place that does high volume spying. And so this is a paper that was published which looked at over 3000 posters spinal fusions that we're done. And you can look and see that the rates of, you know, kind of, you know, big major complications. The rates of those are very low. Yes, infections happen. Um, yes, hard work and break. But if you look at neurological risks, risk of death, things like that are very low. And so again, I would say that generally surgery is safe in these patients, but again it is important surgery surgery so it is important to convey that to families as well. So in the next kind of five or 10 minutes just kind of move through a couple of other types of scoliosis. And I wanted to vote most of my talk to idiopathic scoliosis since that's the most common type and that's you know what we, all of us collectively see the most of. But let's just talk a little bit about the other types of scoliosis. So congenital scoliosis, this is an important one. Um Now congenital scoliosis by definition results from abnormal growth or development of the vertebral column. This usually is the result of an interview or an event early on in gestation. So kind of around the sixth week of gestation when the spinal column is being formed. Generally it's either a failure of formation or segmentation. Now what that basically means is formation as formation of the vertebra. And segmentation is separation of the vertebra and um sometimes you can have one or the other or you can have a mixed type. The most important thing to recognize about congenital scoliosis um both in the primary care setting and even for me um in orthopedics is that it is very important to rule out associated conditions specifically cardiac and uh and guiyu conditions. So for example just maybe over a month ago I saw a 15 year old kid who had a congenital scoliosis. And sure enough we got an echocardiogram, we've got a G. U. Ultrasound and subsequently an M. R. I. And it showed that the child had a solid retro peritoneal tumor. And so you know these are things that people write about but I think it is definitely common in practice too. So it's having you know uh having a low threshold to get those imaging, especially for the cardiac and G. U. Systems um is a very important point for treatment generally for congenital scoliosis. We don't treat those embracing because they're usually pretty rigid deformities because they're structural. Um And oftentimes surgery is what we will do for them. However, the indications for surgery are very different and often times we will differ surgical management until the child develops some kind of imbalance. Um So whether that's, you know, they're setting balance or they're standing balance or their casual playing whether they tend to tip forward to backwards. Those are things I guide our decision making for surgery for congenital scoliosis patients. The next type to just recognizes neuromuscular syndrome. X. Scoliosis. So these are common in patients with conditions such as fury palsy muscular dystrophy and certain syndromes such as Marfan and Ehlers Danlos. This is a little bit different from congenital scholars in the sense that this is more due to weakness of muscles or muscle imbalance or even spasticity. This results in an imbalance. Oftentimes difficulty with care and implications to their pulmonary function. So this image on the upper right, there is actually one of my patients Um who has read syndrome and her curve measures about 95°. Sure enough, she's had multiple bouts of pneumonia has been admitted to the hospital. Um and so, you know, this can have significant implications to the patient's general health. Talking about going back to a discussion of what are typical and atypical curves typically curves. And neuromuscular scoliosis are these long C shaped curves and you can probably appreciate by looking at this X ray. This looks different from the first extra I showed you for scoliosis. And so oftentimes when I see a C shaped curve um in a kid that doesn't have one of these conditions that raises my antenna and it's a that's an atypical curve in a patient without neuromuscular condition. But in a neuro muscular patient, these are the more typical type of curves we see. Now treatment for them bracing is oftentimes tried because we think that because it's a muscular imbalance, maybe that has some flexibility, but our level of evidence is nowhere as close as it is for the idiopathic scoliosis patients. Remember I showed you that that curve where we see compliance and efficacy of bracing and idiopathic patients. Unfortunately, we don't have such robust data in this population. But hopefully one day we will Um for curves that got about 50°, those are those are those are the ones where we start to consider surgery. But surgery in this population is very different from surgery in the idiopathic population. So I just spent a minute or so talking about surgery is generally safe in the idiopathic population. Surgery in this population is fraught with complications. So there could be many road bumps along the way. And so this is a big part of my counseling with families that I'm doing a spinal fusion for from normal conditions is that you know there is a high risk of complications. Again it's a reason why we do this at a specialist center like a Children's hospital is because oftentimes they go to the ICU intubated um there can be infections, pneumonias, G. I. Issues alias. And so it's really important to make sure that their care is optimized before surgery but also that we're in a setting where we can provide safe postoperative care of the family. So in the last couple of minutes here we'll talk about hypothesis. So if you remember emphasis again, we're looking at the lateral x ray here, we're looking at the trial from the side. And so the first type is what we call postural infosys. And this is something that we all see, right. This is where families come in and they're just concerned that, you know, their son or daughter is just hunched over and oftentimes it's a cosmetic concern that can be voluntarily correct as if you have a child, you inspect them, you look at them from the side and they're Yeah, sure enough there hunched over. But if you ask them to stand straight, stand perfectly straight, that is postural hypothesis because it's flexible. It's not generally associated with any pain or progression. And oftentimes it can be managed with reassurance and in particular cases where families are really concerned. Uh We can sometimes recommend a hypertension hyper extension exercise program, which can be just a short course of physical therapy. Um so that the family can can practice some some good postural habits. Now, the more significant type of typhus is to know about the structural psychosis. So this is kind of what the diagnosis is, the most commonly associated structural hypothesis as Sherman's disease. Um And what we're talking about here is a rigid deformity. And so oftentimes in an X ray, what you'll be looking at, as you can see wedging of the three consecutive vertebrae. So what what I mean by wedging is the answer. Part of the vertebra is narrower than the poster part of the vertebra. And so this is one of my patients whose got Sherman's disease. Um and um you can see that there's some wedging in the mid thoracic spine there on those X rays, the disk space look unhealthy in the sense that they are a little irregular. They seem squished. They're not as healthy as the ones lower down in the lumbar spine. And oftentimes these are the ones that we do have to intervene in some way. Now treatment for structural purposes depends on the magnitude of the emphasis. So all of us obviously have some ketosis, but typhus is greater than I would say 50-60° of the ones where we tend to recommend some physical therapy to see if we can we can help with some dynamic exercises to correct that Psychosis above 60, maybe 75, of ones where we tend to consider embrace and again, the level of evidence for embracing. It's not as great and this is not as well studied in this population, but we still do it. And oftentimes it's what we call a hyperextension brace to help correct the spine. And the point there is to hold the spine in a position So that as growth happens, that the child's natural growth can help them grow out of the hypothesis and encourage that uh sorry, hypothesis that gets above 75 and 80°, the ones where we tend to consider surgery, because again, there could be implications to cardiopulmonary function and some patients can even have pain. Um and so those are kind of in general the algorithm we follow for hypnosis. So I believe we just have about five minutes left for the formal talk part of this, but I'll just show you a couple of examples here of treatment for scoliosis. So we'll go back and forth between the different types of scoliosis. This is a patient um that I saw actually my first month of practice here at UCSF. Um is there is a kid who is I think maybe a month postman article Came in with this about 30° lumbar curve. Had skeletons of skeletal maturity and so I put her in a brace for the extra on the very left of the initial X ray, the extra in the middle of the extra and embrace again. The purpose of the brace is not to make the curve go away but it's to help control the curve. And then just last week um you know she is now kind of plateau in her growth. I see signs of skeletal maturity. So we just discontinue the brace and I would consider this to be embracing success. We kept that curve, that 30 degree curve at 30 degrees. And so to me that's that's a win now it doesn't mean that we're done. I continue to watch this child because again scale the scale of growth is something that you know, we can make our best guess at, but we cannot predict exactly. But again, from a breaking point of view, this is a success. This is a kid with uh with adolescent idiopathic scoliosis and you can see she had about a 65 degree, threw us a curve that underwent a spinal fusion. And so this is what a spinal fusion looks like. Again, the purpose of the surgery is to get the spine if you, so if you look really carefully, you can see at the bottom of the screws, you see some fuzziness around the screws and that's bone that's fusion bone to the bone is starting to fuse. Her balance looks good. Um And so if we continue along this road, um I'd be very happy with the outcome for for this child, this is a younger child. This is a kid who's got a syndrome IQ condition with scoliosis, her curves about 100 degrees. And because she is still growing, she was about 10 years old and she saw me pre monarchical and the most important thing about her is her stature. I mean, she was about four ft tall. And so if I were to fuse her spying, then she would have many issues later in life, including having a short trunk, having um you know, her pulmonary function would be compromised because her one wouldn't develop. And so we did hear what we call a growing rod construct. So screws above, screws below and every six months or so I take her back to the operating room and lengthen that rod so it helps to correct her deformity, meaning it makes her balance better, um but allows her to grow and then eventually once he's read skeletal maturity, then I'll go through and use her definitively. Yeah. So in conclusion here, um I would like to say that, you know, spinal deformity is something, so it's something that we commonly see in Children of all ages. Um It is important to value for scoliosis and key focus as per the guidelines of our professional societies, but also based on your clinical judgment if in doubt obtaining X ray and refer for further evaluation. I think all of us would rather know than not know and I think families would appreciate that too. Um Consider associated conditions, especially for patients that have certain diagnosis of things such as congenital scoliosis, patients with syndromes. Um Those are all important populations to think about associated conditions, observation, embracing our successful strategies for the right patients. And so again, um it's selective. But you know, our treatment algorithm is again based on how bad is the curve and how much growth the child has left and then spine surgery is major surgery, but it is becoming safer and it's generally associated with good outcomes for most patients. However, again, peri operative management is critical to patient outcomes and satisfaction. So I think that's where working together in terms of understanding and setting patient expectations is critical to the work that we all do in taking care of Children. Um In summary, here's a referral slide for our institution. We offer clinical services in both sides of the bay, um The East Bay and the West Bay. My clinical practice is mostly focused out of Oakland. However, I do operate sometimes at Mission Bay. Our clinical outreach in the East Bay spreads all the way from san Ramon walnut Creek in Oakland in the West Bay. Um It's all the way obviously in the city but also to some locations in the North Bay as well. And these are my colleagues in pediatric orthopedics. We have a rapidly growing division um in pediatric orthopedics. I joined the staff here last year after doing all my training on the East Coast. Um But we have three or four of my colleagues helped take care of spine patients as well. And we do offer services for all other pediatric subspecialty care, including sports and limb deformity um and neuromuscular patients as well. Mm. Mm. Yeah.