Transcription:
Straightening the Curve

Prakash Chandran (Host): You are listening to Pediatric Insights, Advances and Innovations with Children's Health. Today, we're talking about scoliosis treatment methods at Children's Health. And joining us is our expert, Dr. Christopher Redman, a Pediatric Orthopedic Surgeon at the Children's Health Andrews Institute for Orthopedics and Sports Medicine.

Dr. Redman, it is really great to have you here today. I wanted to start by asking what scoliosis treatment methods do you offer at Children's Health that you really think set you apart?

Christopher Redman, MD (Guest): Wonderful. So at the Children's Health Andrews Institute, we do offer a wide range of treatment methods. Luckily, most spinal curvatures do not require any treatment other than observation. So, in order to make observation a little bit safer, we do have the EOS machine, which has an ultra low dose radiation machine for scanning of scoliosis.

And that can be used for monitoring in the clinic. Studies that demonstrated up to 50 times less radiation doing this compared to standard x-rays depending on the technique used. And if you look at the average patient that gets diagnosed with scoliosis, even if they don't undergo any true treatment and are just observed, they're going to undergo multiple x-rays during that adolescent period.

So, if we can decrease that exposure to radiation over that, it's really paramount to the patient's safety. You know, if the patient does require treatment, there are methods that can range from bracing to surgical procedures. The Andrews Institute, one of the things that sets us apart is the treatment of early onset scoliosis and early onset scoliosis is basically a curvature in a child less than five years of age.

And so it's relatively uncommon. And most of the time it can be just observed and it will actually improve on its own. However, about 20% of those kids will not improve on their own. And that can become a very large problem because they're very young and they have significant growth remaining. So, we can't, we can't perform a standard fusion like we normally would in other children.

One of the things that we do here is medicasting and medicasting is a body cast basically that is put on under anesthesia. And it's a set of serial casts that ultimately, you know, if initiated at an early age, can actually lead to complete resolution of the curvature. There's not many other times in the treatment of scoliosis that we can ever say that something is going to resolve in complete resolution of the curvature.

So that's a really cool thing that we can do with young kids. It's definitely much more efficient or works much better if they're under age four, but it is something that they will spend anywhere from six months to even a year, year and a half in casts, just trying to get this curvature to improve. Now with that though, we also have vast knowledge and experience with growing constructs that can be used in early onset scoliosis. So at a young age, some children will require surgical intervention. However, it can be very difficult as we don't want to stop that growth, like we talked about at the spine. Typically with the most common form of scoliosis treatment, like a fusion, we're going to stop the growth in that area. So, if you have a very small child, that's not going to work because that's going to stop the growth of their lungs and all those things. So, typically or classically growing constructs would allow us to control the curve without stopping the growth.

And that was something that we'd have to take the patient back to the operating room every six months or so. We're going to have to make a small incision there in the middle of their back. And we would expand the rods mechanically or directly under visualization in the operating room. And then they would go back and they would live their life and every six months or so, we'd have to go back and we'd have to expand those.

Well, a while back, there was a product called Magic Rods that came out and it's a magnetically lengthening rod. And so it's something that we can place into the spine to control the curvature and we'll fix it at the top of the spine and the bottom of the spine, and then the rods go in between those areas. And so those rods then we can magnetically lengthen in our clinics.

So, basically the child just comes into the clinic. We put a little machine on their back and it actually makes that rod grow as they grow. Which ultimately is really cool technology because typically we can get those rods to last about two years, which decreases at least three surgeries that, that child would have otherwise been exposed to.

So pretty cool things. I mean, there's always complications with any of these things, but we've got to look at what's the best treatment for the patient. What's the best options. What has the lowest risks based on their age and the size of the curvature and all those things? When it comes to other forms of surgical intervention for scoliosis, we have multiple different forms of cutting edge technology to improve the safety of the patient.

One example of this is using custom made guides for assisting in placement of pedicle screws during surgery. This is something that has been used in total joint replacement. So, like total knees, things like that for several decades. And basically they're guides that are made to tell us where to put a drill hole or where to put a saw cut, things like that.

And so we get a CT scan of the patient's back prior to surgery. And then I plan the placement of all the screws ahead of time before we ever go to the operating room, I send that off and we make 3D custom molds for each vertebrae that during surgery, I can literally put onto the vertebrae and it will tell me, this is where you wanted that screw to go.

And it'll give me a cannula basically. It'll give me a hole that I can actually drill right down into. And so that's really cool because the document accuracy is less than two millimeters, which when you're working around the spinal canal, well it's pretty crucial to be as accurate as we can be. It also decreases radiation exposure to myself and to all my staff while we're in the operating room, because we literally will take about four x-rays at most the entire surgery when we're using that product.

If we don't use something like that, a lot of people will just use plain x-rays and they'll take a lot of x-rays during surgery to try and put that in, but there's documented articles that have shown the lack of accuracy when you're doing that and how misplaced screws can be. So just something that can really help with.

Host: Yeah, that really makes sense. And it really seems like there are so many innovations that are available to you for treating pediatric scoliosis. What are other ones that you might want to mention that are just really exciting for the future of treating the scoliosis?

Dr. Redman: Other things that are really advanced that we're doing is a new technology called vertebral band tethering. This is something that's really exciting to me. I think that it's the future of spinal surgery, it's fusionless surgery. So the typical treatment for scoliosis would be performing a posterior spinal fusion with instrumentation.

And that's where we go in, we basically make the body think that all the bones in the back, or the small bones in the curvature of the back are broken. And then we get those bones to all heal together and we use rods and screws to hold the bone straight while they heal together. Now, ultimately that does decrease some motion.

Now, most of our studies tell us that it doesn't take away significant motion, but it does decrease some. Especially in people that are high level competitive athletes, they are not real excited about a fusion of their spine. So, this is one option that allows us to avoid an actual fusion. That being said, it's still pretty new technology. There are roughly 150 surgeons in the world right now that are trained on this technology. And it's only been performed on about 600 cases in the world as of now. So it's still relatively new technology, but we're seeing really great results with it.

And it does have specific indications. So, it's not meant for every patient, but if we have a growing patient with a flexible spine, vertebral band tethering could be a very good option for them. It is done through a much more cosmetic incision. So it has typically about five small incisions along the flank and axilla, rather than one big incision down the middle of the back for a posterior spinal fusions.

It's all done thoracoscopically so it's all done with a camera, through the chest wall and we basically, we have to lower one of the lungs to place screws onto the side of the vertebrae on the convex side. And we place the screws on that side. And then we put a tether on that side and then that allows the inside part of the curvature to grow, which then ultimately allows that curve to straighten as we grow.

We've seen some failures within vertebral band tethering. It's not a perfect science yet, but we're getting better and better at it. And we figured out better strategies to do it, things like that and ultimately as long as we can avoid that patient, when they're done growing from having that curvature greater than 50 degrees in the thoracic spine, then we avoid a fusion. We avoid any further surgery or something that potentially is going to limit them the rest of their life.

Host: Absolutely. One of the questions that I had is what advice do you have for other providers when it comes to determining whether a patient actually needs surgery or not?

Dr. Redman: First of all, I'm happy to see any patient in my clinic for evaluation of scoliosis. I know how anxiety provoking it can be for family and even for providers potentially taking care of this, because a lot of providers aren't taught musculoskeletal systems, to the level that we probably should be given that we see so many musculoskeletal complaints in primary care visits and things like that.

But ultimately any curve, less than 10 degrees, we don't even call scoliosis. We just call it spinal asymmetry and spinal asymmetry is nothing to worry about. There's nothing to do for it. No matter what age it is, if it's less than 10 degrees, there's really no treatment we're going to offer other than the observation. When we start talking about, when do we want to really see patients from an orthopedic standpoint, well, any curvature over 20 degrees, I should definitely see and evaluate just so I can make sure that they don't have too much growth remaining, that we're worried that, that curve's going to get worse.

We don't typically initiate bracing until 25 to 30 degrees with curvatures. So really prior to that, it's mostly observation, potentially referral to Schroth physical therapy, things like that, which is a specialized form of therapy that can be used to improve curvatures. there's limited research on Schroth, but we have noticed, curvature improvement of about 10 to . 15 degrees, in patients that are compliant with the home exercise programs and the therapy itself.

Host: I'm sure that you have people that come in that want their spine corrected for cosmetic reasons. Let's say someone comes in maybe with a 12 degree curvature. It may not be something that warrants surgery per se. But let's say for themselves or for their children, they want it perfect for, just athletic reasons and just for the future of their life and how people will perceive them.

Do you ever have patients who want surgery for cosmetic reasons? And if so, how do you respond to them?

Dr. Redman: Absolutely we do. I mean, especially as curves, get larger, when you have a, thin adolescent female, and she has a 35 degree, 40 degree curvature, it may not be the level of surgery, but it's definitely recognizable. And you can definitely see when you bend forward that that rib prominence will show up on one side.

I often demonstrate it to families, myself. I mean, I personally have a curvature and I personally have a rib pumping and you can see it when I bend forward. But it does bother some people from a cosmetic standpoint, It comes down to education for me, I'm talking to the families about why do we do scoliosis surgery, when we do it and what levels really cause problems for us.

I mean, when we talk about even that 50 degree curvature that we typically recommend surgery for in the thoracic spine, well, 50 degree curvature, it doesn't really cause you problems. It, shouldn't cause problems with your heart, your lungs, things like that. We typically don't see problems with the heart and lungs until curves are up over 70, 80, 90 degrees, and they have to be really large curvatures.

The only reason we even operate at 50 degrees is just because we know that curve will continue to progress the rest of your life. And it's much easier to go through a surgery when you're young, flexible, you can heal better. All those things.

So I have that conversation with families once they have 35 degree curvature and it is cosmetic deformity, but is it worth taking the risk of undergoing surgery for that?

Because the vast majority of idiopathic scoliosis does fantastic with surgery. Very rare do we have complications, very, very low infection rates, all those things. That's different when you start talking about neuromuscular scoliosis and things, those have much higher risks. Idiopathic, most kids do very, very well, but there's still reported literature rates of neurologic injury up to one in a thousand.

I would hate for a child to be somebody who had a neurologic injury for a surgery that was done strictly for cosmesis. So I don't typically recommend that.

Host: Okay, got it. All right. That's helpful. Dr. Redman, I really appreciate your time today. Just before we close, is there anything else that you think is worthwhile sharing to our providers when it comes to scoliosis treatment methods or things that they should be aware of or be inspired by?

Dr. Redman: Well it comes to outside referring physicians the first thing that I would want everybody to know is that we are here to help them in any way possible. And there, again, like we've spoken about, there's so much anxiety that happens when families learn that they have a curvature and families want answers quick. And so if they have to wait months to get in to be seen, it's not good for anybody. It just increases stress levels, things like that. Our goal is to try and get patients in as quickly as possible for evaluations so that we can educate them, and potentially start treatment if needed early on.

From our standpoint, at the Andrews Institute, we're trying to stay above the new technologies. We're trying to make sure that we're following all of the guidelines that are out there and provide the best care possible to all of the patients. We have an organized group or a dedicated group, a team of members within our clinic space and within the hospital that are really dedicated to the spine service and really making sure that patients get the best treatment that they can. We're constantly advancing from a imaging standpoint, like we talked about with the ultra low dose radiation to our surgical technique standpoint, like we talked about with those custom molds.

And ultimately I think that any patient that comes here will be very happy with the care that they have and we're always open for communication and your providers are more than welcome to reach out to me anytime via email or phone and I'm happy to discuss further care.

Host: Dr. Redman really appreciate your time today. Thank you so much.

Dr. Redman: No problem. Thank you. I appreciate it.

Host: That's Dr. Christopher Redman, a Pediatric Orthopedic Surgeon at the Children's Health Andrews Institute for Orthopedics and Sports Medicine. And thank you to the audience for listening to Pediatric Insights. You can find more information at children's.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. My name is Prakash Chandran, and we'll talk next time.