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Prakash Chandran (Host): This is Children's Health Checkup, where we answer parents most common questions about raising healthy and happy kids. Today, we're talking about scoliosis in children and joining us is our expert, Dr. Christopher Redman. He's a Pediatric Orthopedic Surgeon at the Children's Health Andrews Institute for Orthopedics and Sports Medicine.

Dr. Redman, it is great to have you here today. Let's just start with the basics. What exactly is scoliosis?

Christopher Redman, MD (Guest): Thank you for having me today. And scoliosis is a topic a dear to my heart because it's just something that I love treating and love taking care of families with this. But when we break down the definition of scoliosis, it's really just an abnormal sideways curvature of the spine greater than 10 degrees and that is the, the actual definition. This most commonly forms during the rapid growth phase of puberty, in females that's typically kind of around age 12 or so. Although we refer to scoliosis as a curvature, you know, the reality is that it's really a complex three-dimensional deformity. It involves rotation, it involves twisting of the spine, structural changes such as wedging of the vertebrae and disc space between those bones.

And because of the definition of scoliosis is based on an angular measurement called Cobb angles, patients have to have an x-ray to actually be diagnosed with scoliosis. The diagnosis can be made clinically as far as a rough estimation, but you really have to have that x-ray to really diagnose it. It can't really be made strictly on a clinical examination. If we look at kind of how often we see scoliosis, we know that about 3% of the population has 10 to 20 degree curvature within their spine. These typically do not cause problems for people in life. A small curvature typically won't cause issues.

But about 0.3% of the population has a curvature greater than 30 degrees. And that makes us a little more concerned because those curves can continue to progress later in life and cause problems with the heart and lungs and things like that. When we look at curves over 30 degrees, there's usually about a 10 to one female ratio, meaning that there are 10 females with a curve greater than 30 degrees to every one male.

But that ratio is about the same for curves that are smaller than that. So, we know that females are at higher risk of getting curves that potentially would require treatment compared to males. But at the same time, it can happen in both sexes.

Host: So just a question around diagnosis. I'm curious as to how this is initially recognized. Does a parent just notice that something is off with their child's spine and bring them in?

Well there's

Dr. Redman: several things that parents may notice that can kind of elude to a diagnosis of scoliosis. Some of the most common findings the parents will notice, it's just that the shoulder heights, the shoulder height is imbalanced or one shoulder sits a little bit higher than the other side. They also might notice that the patient or the child shifts to one side.

So, meaning that they're kind of leaning to one side and often that's what parents will say is he just leans to one side or she leans to one side. The other thing would be a rib prominence. So, school screening examinations are largely based off of the asymmetry of the shoulders and the trunk and the waist and all those things, looking at that overall.

And that's something that families can look at just looking at the back and seeing if they see anything that looks shifted or abnormal. But the most common thing really is what's called the Adam's forward bending test, and that's what they do on these school screenings. And so that having the child just bend over forward with their hands together, and we're looking for one side of the ribs sticking up versus the other side.

And that's because as we discussed before, it's a three-dimensional deformity. So that wedging, that rotation, all that stuff happens, and so as the vertebrae twist, as they curve, the ribs also become more prominent on one side versus the other. There are studies that have shown that, that prominence, what we call that Adam's forward bending prominence; if you see more than seven degrees of rotational prominence, it potentially correlates with approximately a 20 degree scoliosis curve. Now however, that's not set in stone and it cannot be diagnosed based off of that, as we said before. It still requires an x-ray because some curves will twist a lot, some won't twist much. And so sometimes curves that don't rotate a whole lot, can be easily missed on clinical examination.

Host: So, you know, Dr. Redman, you mentioned that sometimes a parent may notice that their child is leaning to one side. Maybe there's a shoulder height thing or the rib prominence. When does this usually start to express itself to where the parent can actually notice this? Is this kind of in their teen years? Is it younger? Talk a little bit about that.

Dr. Redman: You know, when we talk about how is it seen or when does it take typically seeing, well, most commonly they are diagnosed between the ages of 10 to 18 years of age when we're talking about idiopathic scoliosis. And we can talk about the different types later, if we want to. But most commonly it is around the time of the adolescent growth spurt. So, small curves typically only increase during that growth phase. And most females will hit that fast growth spurt, what we'll call their peak height velocity right around when they have menarche or the start of their menstrual cycles. And that typically is around age 12 for females, around age 14 or so for males. So, that's typically when small curves will really develop, because you're going through this fast growth phase, which then causes the curve to accelerate or to get worse. IT's also the time period where, especially females are getting more conscious about their body and they're keeping themselves covered more around family members. So, often it goes missed by family members for a long time.

Host: So you alluded to different types of scoliosis. Maybe let's unpack those right now.

Dr. Redman: Sure. There's three general forms of scoliosis. Now you can break these down into smaller forms and whatnot and different varieties of this, but the major forms are broken down into idiopathic, neuromuscular and congenital curves or scoliosis. The most common form is definitely idiopathic.

Idiopathic is a type of curvature that we really don't know what causes it. And that's what it means. They have no identified cause for their curvatures and those can also be broken down further into the type of scoliosis, based on the age of when it was diagnosed. So, we can break the idopathic scoliosis further down into infantile, juvenile or adolescent based on the age of diagnosis.

And each of those has a different overall treatment plan and risk of progression because the younger you are with a curve, the more growth you have remaining and further progression or risk of progression that you have. We know with idiopathic scoliosis, we know there is some sort of genetic component to that, but we don't really know what it is.

We haven't identified that gene. Years ago, they actually thought they figured that out. And they were selling a test for thousands of dollars to try and tell if you had progressive scoliosis. Well, they found out years later that it really didn't do anything for us. But we do know there's a genetic component with one in three patients with scoliosis will have some sort of family history of scoliosis in their history.

And then one in 10 will actually have a direct relative. So, either mom, dad, brother, or sister or something like that. But again, we just haven't identified really what causes it and therefore we call it idiopathic. Now the other forms, the other forms such as neuromuscular scoliosis, that's a curvature that develops in a child with medical conditions that actually impair the body's ability to control those muscles.

The muscles are unable to support the spine or are too tight on one side of the spine that leads to curvatures of the spine, things like that. Some of the most common medical conditions that can cause neuromuscular scoliosis include things like Marfan syndrome, muscular dystrophy, cerebral palsy, and spina bifida.

These can often lead to, you know, severe and progressive spinal curvatures, which then ultimately can lead to pulmonary and cardiac or lung and heart problems later in life for these children. The other group that we mentioned was congenital scoliosis. This is secondary to failure to properly form the spinal canal while in utero. So, actually while the child is developing, their bones just don't fully, properly form whether it's failure to do what we call fuse and segment. And so, occasionally, it can be a vertebrae that is fused or stuck together on one side of the spine, which then tethers the spine that then allows growth on the opposite side, causing the major curvature.

It can also be due to an extra piece of bone on one side of the spine, which then allows for increased growth on that spine. Or you can even have a combination of both. So a fusion and an extra vertebrae or extra piece of vertebrae. But ultimately these can lead to rapidly progressive spinal curvatures at early ages, and they can be difficult to treat and require multiple procedure

Host: Talk a little bit more about how it is diagnosed. So, let's say a parent comes to bring their child in. So, let's talk a little bit about the process of getting it diagnosed properly. And then what are the first line, I guess, treatment options that you most typically see?

Dr. Redman: Sure. So first the identification or diagnosis of it. So, we have to look at first, it has to be found somewhere. So, whether it's a parent notices it, school screenings or well-child examinations. And I will tell you, those are the three far most common ways that curves are initially recognized.

If we talk about school screenings, you know, in Texas, it's mandated that every child be screened. Scoliosis school screenings are performed in the fifth and seventh grade for females. And then in eighth grade for males, it's a little bit later in males just because that growth spurt doesn't happen until a little bit later in males.

So once a child is identified on a examination, well, then they require an x-ray and again, the only way to diagnose true scoliosis is based off of an x-ray. You have to have that Cobb angle or Cobb measurement that we talk about. In our clinic, the way that we do that is, we have an advanced, imaging machine called EOS E-O-S.

It's an ultra low dose radiation machine for scoliosis scanning. And depending on the study you look at there's some studies that show that it can be up to 50 times less radiation than a standard x-ray just depending on how it's shot and how it's used. Once we get the x-ray and we know the diagnosis, then it all depends on how big or how small the curvature is and whether we treat it or how we treat it and things like that.

Host: Got it. So, yeah, let's talk about some of these correction methods, and what's available. You know, you mentioned bracing treatment, you've mentioned sometimes surgical options, and I know that kind of depends on the different types of scoliosis, but maybe just kind of at a high level, talk about the different treatment options.

Dr. Redman: Absolutely. Well, so first luckily, and I tell all parents this, because people get very anxious about this. When they hear that their child has a spinal curvature, it can be very anxiety provoking. And so the first thing I tell people is most scoliosis curvatures don't require any treatment. They can simply be observed. We talked about how 3% of the population has a 10 to 20 degree curvature. Well, 10 to 20 degree curvatures, not going to cause any problems in your life. So, we just need to observe those. We just need to make sure they don't get significantly bigger. And very few people actually get very large curvatures. So, mostly it's observing. Now the goal of treating idiopathic scoliosis is to prevent a curvature in the upper part of the spine or what we call the thoracic spine, from progressing to greater than 50 degrees, or 40 to 45 degrees in the lower part of the spine by the end of skeletal maturity.

So, by the time that females are, typically around 14 and males typically around 16, we want that curvature in the upper part of the spine to be less than 50 degrees. And we want the lower part of the spine to be less than 40 to 45 degrees. If they're less than those numbers, that curve should not significantly progress during the rest of the person's life.

And it should not cause any major problems for them. Unfortunately, we've noticed that if you've finished growth and your growth is over or your curves over those magnitudes, we know that curve will continue to slowly worsen the rest of your life. That then can lead to further, you know, lung and heart problems, like we talked about before. So, if we look at that, bracing can be used to attempt to slow or stop progression of a curvature during growth and has demonstrated significant efficacy and preventing curve progression during growth and ultimately the need for surgery. Dr. Weinstein actually did a study on this, that was published years ago in the New England Journal of Medicine, but it showed that one in every three kids that we put into a brace for scoliosis will actually avoid having surgery that otherwise would have had surgery without the brace. So, it can work. And so we do like to use that. Bracing is typically initiated in curves with over 25 to 30 degrees and a significant skeletal growth remaining that we're afraid may reach a surgical level if they continue to progress.

If a curve is greater than 50 degrees in the thoracic spine or 45 degrees in lumbar spine at the time of skeletal maturity, well unfortunately, like we said, it's going to continue to worsen. These are typically the curves that require surgical intervention to correct the curve as much as safely possible. I always tell families with safety is the number one thing. We want to make sure that your child is going to be as safe as we can.

And we want to make sure that they're going to walk out of that room without a neurologic injury, things like that. So, I often tell families, you know, we may not be able to get the spine 100% straight. But that's okay because the child's been functioning with a bigger curve, things like that, and not having any problems and we're going to make sure it's definitely straighter than what it is then, but ultimately again, the number one goal is safety.

And so when we do require surgical intervention, the most common form surgery is, is just a posterior spinal fusion with instrumentation. And so if we break that down, posterior is going in through the back. Spinal fusion, a fusion is turning the little bones into the back into one bone and instrumentation is the rods and screws.

So with the procedure, we kind of trick the spine into thinking the small bones in the curvature are fractured or broken and broken bones like the heal together. And that's what our goal is, is to make all those little bones heal together or fuse. We place instrumentation such as rods and screws into the spine to hold the spine in a corrected manner, as much as we can, as those bones heal together. There's several other forms of surgical treatment. It just depends on the type of curve, the age of the curve, everything else that we can do. Some of these different forms include casting. We have growing constructs such as magic rods, which is a magnetically lengthening rod that can be inserted into a child's back and can be lengthened as that child grows, allowing us to control a curvature, but still allowing growth. That's used for young children with scoliosis. We also have a relatively new concept called vertebral band tethering, also known as VBT it's a fusionless technique, so it doesn't require a fusion.

It's not causing those little bones to turn into one bone and therefore it doesn't take away motion in those segments. It's a technique to correct a spinal curvature by inserting a cable on the convex side of the spinal curvature, which then creates a tether or a band on that side to where it can't grow any further.

And then that allows the concave side, to start growing. And allows that to ultimately straighten the curve without fusion. So, there's all sorts of different treatments that are out there. And we're constantly trying to stay at the front of the technology and provide the best care that we can for all of our patients.

Host: Absolutely. Well, Dr. Redman, I really appreciate your time today. Just before we close, is there anything else that you would like parents or people listening to know about scoliosis in kids?

Dr. Redman: Absolutely. Thing is I just, I highly encourage families to take their children to their primary care visit every year for a well child examination. That can often lead to early recognition of scoliosis and therefore potentially early treatments when necessary and potentially avoid surgical treatments by starting non-operative treatments earlier. If a child does develop a curvature, I mean, first, just remember not to panic. Most curves don't require any treatment other than observation. It's amazing how many families are very concerned when they find out that their child has a very small curvature and they're relieved, once I'm able to tell them that, hey, it's okay.

There's nothing that we have to do here. Right. But the Children's Health Andrews Institute, you know, we have a dedicated team of experts to provide world-class treatment for spinal deformity. We've done everything that we can for advanced treatment and advanced technologies, such as that EOS machine, we talked about with low dose radiation for monitoring curvatures in the office.

And we're also at the forefront of the latest research and technology in order just to provide the best care possible when needed.

Host: Well, Dr. Redman, thank you again so much for your time. I really appreciate it.

Dr. Redman: Not a problem. Thank you.

Host: That's Dr. Christopher Redman, a Pediatric Orthopedic Surgeon at Children's Health Andrews Institute forO rthopedics and Sports Medicine. For more information, please visit childrens.com/spine. If you found this podcast helpful, please rate and review or share the episode and please follow Children's Health on your social channels.

This has been Children's Health Checkup from Children's Health. My name is Prakash Chandran and we'll talk next time.