Dr. Bob Underwood (Host): Welcome to Pediatrics in Practice, a CME Podcast. I'm your host, Dr. Bob Underwood. As we get underway, I'd like to remind you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/cme podcast, and then click on the Claim CME button.

Today, we are breaking down scoliosis management, what pediatricians need to recognize, when to act, and how decisions are made across the spectrum of scoliosis care. And to do that, we have the distinct privilege of talking to Children's Mercy doctors Aaron Shaw and Michael Benvenuti, both pediatric orthopedic surgeons and experts in scoliosis care. Doctors, welcome to Pediatrics in Practice.

Dr. Michael Benvenuti: Thank you for having us.

Dr. Aaron Shaw: Thanks for having us.

Host: Absolutely. And so, Dr. Benvenuti, let's start with some general questions. When a pediatrician suspects scoliosis during a well-child visit, what are the most important elements of the initial assessment and what findings should be raising concerns for that pediatrician?

Dr. Michael Benvenuti: The best way to evaluate for scoliosis just with an examination is looking at truncal rotation, and we do that with the Adams Forward Bend Test. We have the patient bend over and try to touch their toes. And you look for asymmetry from one side to the other with a rib or flank prominence, marking that there is some rotation of their spine or ribcage.

Other things that you want to look for on the examination would be any kind of neurological findings. So in rare cases, scoliosis is associated with spinal pathology that can lead to neurologic deficits or reflex asymmetry. So, checking reflexes can be helpful and making sure that this is not a secondary cause of scoliosis, but rather just an idiopathic scoliosis.

Host: Understood. And we're going to get into a little bit of the neuromuscular or syndromic questions here in a minute. So, Dr. Shaw, there's ongoing debate about scoliosis screening and what role pediatricians play today in early identification. What ages should they be most vigilant? And what is the pediatrician's role in this?

Dr. Aaron Shaw: Yeah. Great, great question, Bob. And you're absolutely right, there is a fair bit of disagreement out in the professional worlds on what universal screening should be done, or if at all. For us, as pediatric orthopedic spine surgeons, we really rely on the pediatricians as our first line of defense when it comes to identifying these pathologies.

So, the most common type of scoliosis that we see is what we would refer to as the adolescent age group. So, that's most commonly a curve that's going to have its onset after the age of 10. Usually, it corresponds with the adolescent growth spurt. And so, like Dr. Benvenuti was mentioning, in that age group, identifying these patients early can help us make sure they can have the most optimal treatment outcome with non-surgical intervention, such as with bracing, which is very effective at preventing these curves from getting worse when identified early and treated with a good compliant treatment protocol.

There are also younger age groups as well where this deformity arises: kids under the age of 10, both infants as well as kind of what we would call a juvenile age group, so anywhere from birth to nine, much less common to have scoliosis arise in those age groups. But much more important to identify those patients. And I think this is where the annual physical exam with the pediatrician is very important to help identify these cases.

Host: Yeah. I think, treatment timing is really kind of key in scoliosis depending on what kind it is. And so, that kind of brings us back to Dr. Benvenuti. And one of the questions we were talking about before is: what are the signs or symptoms that suggest a scoliosis case may actually be atypical or more serious? We mentioned neuromuscular or syndromic scoliosis. Does this warrant a more urgent referral?

Dr. Michael Benvenuti: Usually, the answer is thankfully no scoliosis is very rarely an urgently necessary treated condition. In patients that have a neurologic deficit, which is likely not related to their scoliosis, in fact, but perhaps their positional deformity is related to some other underlying thing, then, obviously, urgent referral would be necessary.

But even in this syndromic or neuromuscular cases of scoliosis, we still treat them in a similar fashion for the most part to the idiopathic scoliosis patients. So, urgent referral is not necessary, but we would definitely like to see these patients when their curves are still small and could potentially be treated with bracing instead of surgery.

Host: Absolutely. If we could avoid the interventional part, then that's beneficial. Dr. Shaw, when is imaging appropriate in the primary care setting?

Dr. Aaron Shaw: Yeah, great question. So, imaging for us, I think, is a prerequisite whenever you have a concern for scoliosis. It's the only way to truly quantify it from an objective standpoint. There are different items such as a scoliometer, which has been used maybe more so historically to measure the truncal rotation, which Dr. Benvenuti was mentioning earlier. But the radiograph is really the only objective way that we have right now to truly evaluate this. And I think it really helps guide what the treatment is going to be if it is at all needed.

Host: Right. And I'm assuming we're just talking plain films in the primary care setting.

Dr. Aaron Shaw: Yes, absolutely. Yeah, plain x-rays, we ideally like to get one x-ray. These are usually taken looking from the front in a posterior-to-anterior direction to kind of minimize radiation exposure. And then, also, a lateral radiograph so we can truly identify the three-dimensional aspect of the deformity.

Host: Sure. Sure. That makes total sense. And Dr. Benvenuti, what information is most helpful for the orthopedic providers when that patient is being referred from the pediatrician?

Dr. Michael Benvenuti: Probably the most important thing for us would just be knowing what their deformity looks like with a radiograph. We can obviously get radiographs here in clinic also, but it helps us and the patients if they get radiographs ahead of time, if possible. We also like to know a little bit of what their other medical problems are. So, we treat patients differently if their scoliosis is caused by neuromuscular conditions such as cerebral palsy or spina bifida compared to the idiopathic or syndromic kids. But really, we can figure out a lot of that information when we see the patient in clinic.

The best thing that we would like to see is just patients that are known to have rotational deformity or a concern for spinal deformity, seeing us at an early stage so that we can hopefully avoid surgery for them.

Host: You bet. You bet. And Dr. Shaw, can you walk us through how treatment decisions are made? Okay, so from observation, bracing or surgical intervention and how growth curve progression factors into those decision-making points.

Dr. Aaron Shaw: Yes. So, growth progression is really one of the key factors in helping us differentiate treatment modalities. So, from a clinical practice standpoint, we will frequently ask the families, especially for our female patients, have they started menses, because an 11-year-old, who is premenarcheal, is going to behave a whole lot different if they have a 20-degree curve compared to a 13-year-old who's two years premenarcheal, because that growth differential is going to be very different.

So in addition to that, we also will use x-rays of the hand, traditionally, people have used the Greulich and Pyle atlas to kind of give a bone age. We have a different skeletal maturity system that we use to quantify what their maturity level is. And that helps us guide treatment decision-making. But it's a combination of how big the curve is and I tell patients, how big the curve is, and how much growth they have remaining. So if someone is, in general, with a curve under 25 degrees, we typically we will keep an eye on that. So, observational management, getting repeat x-rays in six months to determine if that is progressing. So in general, historical treatment threshold for scoliosis, bracing is a 25-degree curve in a child who is still growing. And the amount of daily brace wear is really driven by how much growth they have left. So if they're very skeletally immature, a girl who's premenarcheal, and they have a 25-degree curve, they're. Ideally going to be recommended to wear the brace 18 plus hours a day; whereas if they are later stages of growth based off of our skeletal maturity assessments, then we can use a lower bracing duration threshold.

However, we have recently started using kind of an accelerated bracing protocol where children who are very skeletally immature, who according to our natural history studies, they have an 18-degree curve, but if we follow it a long, long-term, it's going to eventually get to 25-degree threshold. And that can be a hard pill to swallow from going from not doing anything when you know it's going to get worse, and then telling them they have to wear a brace all day, every day. We've started using an early bracing protocol where we start the brace before it hits that threshold and just have them wear it at night to try to help avoid the progression at that faster rate if we were doing nothing. And some of the early studies on this have shown that it helps get kids to skeletal maturity with smaller curves, and it prolongs how long we can wait before implementing a more full-time bracing protocol.

And then, the surgery for this, largely for children with idiopathic scoliosis, is reserved for patients who have a curve of 50 degrees or more, because those curves tend to continue to progress long-term, even after skeletal maturity.

Host: Wow. So, we kind of hinted on this, so we will ask Dr. Benvenuti, you know, what do pediatricians need to know about modern bracing options, physical therapy? And then, the key that Dr. Shaw kind of hinted at is the adherence challenges. You know, when you're telling the kid they've got to wear a brace for 18 hours a day, and they're teenagers. Teenagers are trying to be independent. So, adherence is kind of an issue too. How can pediatricians best support families navigating these various forms of treatment, like bracing, physical therapy, things like that?

Dr. Michael Benvenuti: That's a great question. And unfortunately, you're right, wearing the brace for 18 hours a day can be a pretty big challenge both for patients and their families. We have pretty good studies, as Dr. Shaw mentioned, showing that increased time in the brace does result in better outcomes and decreased progression of curves. So, we use that to help counsel families.

In regards to physical therapy, there have been a few recent studies done that show that potentially the addition of some forms of physical therapy to bracing can help mitigate curve progression by a degree or two as well. These physical therapy studies usually involve pretty intensive physical therapy, and it's not readily available for all patients.

So in many cases, the sole treatment non-operatively for scoliosis is bracing alone. But for families that really want to try everything possible, then physical therapy could be on option two. I tend to tell my families that, while bracing is a great tool and helps us avoid surgery, we also don't want their families to fall apart over bracing for scoliosis. Surgery is a big deal and something that we try to avoid, but it's also not the end of the world, And we know that the mental health for these children is important too. We also know that even when we prescribe bracing for 18 hours a day, they're most likely only going to wear the brace for 12 or 13 hours of that 18 hours prescribed. So, as the prescribers of the brace, we understand that most patients aren't going to be hitting the targets that we provide.

Host: And so, this is a question really kind of for both of you. And we'll start with, Dr. Shaw, emerging technologies, surgical techniques, research development, there's always progress in medicine, which is probably why we like doing it so much. What are the newer things that are out there for pediatric scoliosis that pediatricians should be aware of when they're talking to the families? And what are the new things that you're interested in?

Dr. Aaron Shaw: Yes. So, I already kind of alluded to one of the big things, which is the early bracing protocols. I think that has a lot of potential to help try to institute treatment earlier to give us the best chance to prevent these curves from progressing a lot. And the early research studies are pretty supportive of that.

Along the idea of bracing, there's been a lot of progress in the bracing types. I think a lot of people still think of that brace from the movie 16 Candles when we talk about scoliosis bracing with the cervical extension. But the reality is that the braces today are very, very low profile. They're three-dimensionally shaped to kind of give us the best optimal correction of the deformity. And I think that that technology is only getting better and better as we gain better understanding of scoliosis in general.

Additional advances, the historical treatment for scoliosis has largely been with a posterior spinal fusion in a child who's in the adolescent growth or the adolescent age group. There has been. The introduction of newer surgical techniques, both in the younger age group as well as, in that adolescent age group to try to mitigate some of the concerns that families have with a fusion surgery in particular. One of those being vertebral body tethering, which I can let Mike talk a little bit about.

But there's also been advances within the management of early onset scoliosis as well, that has potential to really help change our management. Early-onset scoliosis is a very challenging condition because it's very differently treated compared to our adolescent growth, adolescent age group. Because we have this very small child who has a enormous growth potential with very significant implications on their pulmonary development. Because if we did an early fusion, their thorax is going to be stuck the same position. It is not going to be able to go through the normal maturation process. So, there's newer surgical techniques and implants that, unfortunately, are not quite available in the states, but are very promising with the early studies that we're seeing and hopefully something that we'll be able to provide for our families in the future.

Host: Yeah, I think that that's fascinating. And since you brought it up, we'll go over to Dr. Benvenuti to talk about the tethering, something we were talking about right at the beginning. Actually, before we started recording, we were talking about this newer technique.

Dr. Michael Benvenuti: Sure. This is a somewhat newer technique. It's been around for about 10 years, so we still don't really know the natural history of what happens to these patients postoperatively long-term. But the idea is that it preserves motion in the spine while still enabling correction of the curve. It's really indicated for patients that have growth remaining so that their continued growth can allow the spine to grow straighter.

So, there's only really a small select portion of patients that are probably good candidates for this surgery and that proportion of patients seems to be getting a little bit smaller as we understand better the longer term outcomes of this procedure. So, it seems like it might be a good option for some of these patients with idiopathic scoliosis that are within a pretty strict skeletal maturity and size of the curve and location of the curve domain. However, it's not for everybody.

Host: Yeah. Yeah, absolutely. As we conclude, anything that either of you would like to add, advice for pediatricians, the primary care doctors taking care of these kids either through diagnosis or through treatment?

Dr. Aaron Shaw: I think from my perspective, if a pediatrician has a patient, they're just not sure what to do about, just go ahead and reach out to our team. We have a great team here at Children's Mercy with three pediatric orthopedic spine surgeons and three nurse practitioners who help manage these patients. And this is what we love to do and we'd be happy to help you guys out along the way.

Dr. Michael Benvenuti: I'd like to second Aaron on that too. We're happy to see any patient that there's a concern for. And we definitely like to see patients when their curves are smaller and more amenable to bracing compared to once they're a little older and a little bit more challenging to take care of.

Host: Yeah. Yep. You bet. Dr. Shaw, Dr. Benvenuti, thank you so much for being with us today.

Dr. Michael Benvenuti: Thank you very much for having us.

Dr. Aaron Shaw: Thanks for having us.

Host: Yeah, absolutely. And to our listeners, as a reminder, claim your CME credits after listening to this great episode today. And you can do so by visiting cmkc.link/cmepodcast, and click the Claim CME button. For more information for other important topics, you can visit the same site, cmkc.link/cmepodcast.

And if you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics that are of interest to you. I'm Dr. Bob Underwood. And this has been Pediatrics in Practice, a CME podcast.