intro: Welcome to Pediatric Voices, Duke Children's podcast about kids healthcare. Now here's our host, Dr. Angelo Milazzo.

Angelo Milazzo, MD: Hello and welcome to Pediatric Voices, a conversation with the people who make up the healthcare team at Duke Children's Hospital. I'm Dr. Angelo Milazzo, a Pediatric Cardiologist and a Professor of Pediatrics at Duke Children's and one of the hosts of the show. I'm here to bring you insights about children's health from my expert friends and colleagues.

On this episode of Pediatric Voices, let's look at the world of Pediatric Orthopedics and Orthopedic Surgery. Orthopedics is the medical specialty that deals with correcting deformities and injuries of the bones, the joints, the ligaments, tendons, muscles. Pediatric Orthopedic Surgeons treat issues related to growth and development, as well as deal with trauma, injuries, sports, and things that arise from other physical activities as well.

Today, we're going to look at this world of Pediatric Orthopedics with a focus on spine health, which is a very important issue in the overall care of children. And of course, we're going to talk about the very important topic of scoliosis. Luckily, I have the ideal expert to help us explore this subject.

Today I'll be talking with Dr. Robert Lark. Dr. Lark is a Professor of Orthopedic Surgery and a Professor of Pediatrics here at Duke Children's in sunny Durham, North Carolina. He's an expert in the care of spine disorders in children, including scoliosis, as I mentioned before, and also an expert in growth abnormalities in children.

Dr. Lark graduated from the Citadel and from the North Carolina State University, and he attended medical school at the University of North Carolina. So he has divided sports loyalties, I'm sure. He completed his postgraduate training at Rady Children's Hospital in San Diego, as well as here, at Duke. He serves as the Section Chief of Pediatric Orthopedics and also as the Fellowship Program Director for Pediatric Orthopedics.

He's the author of numerous publications. He's been deeply involved in research and teaching. He's spoken at numerous conferences, and he's an active member of several professional societies focused on pediatric orthopedics and orthopedic surgery. Welcome, Rob. It's a great pleasure to have you on the Pediatric Voices Podcast today.

Robert Lark, MD, MS: Thanks so much, Dr. Milazzo, especially for that elegant introduction. I've been looking forward to this for a long time. This will be fun.

Host: Well, Rob, I'm very excited to have you here. And there's a lot that I'd like to cover with you today. I want to start with the general subject of pediatric orthopedics and pediatric spine health. What are the major diagnostic and treatment issues that you're dealing with in your day to day work?

Robert Lark, MD, MS: Boy, that's actually a really hard question to because it's incredibly broad. If you think about my adult colleagues in orthopedics, we can almost dwindle everything they do down into one word, and that's pain. Many of the reasons for a referral to orthopedics as an adult regard shoulder pain, knee pain, back pain, etc.

Here in the world of children's orthopedics, is, as you mentioned, much broader. There may be a growth or developmental anomaly that needs evaluation. Pain is still in the picture for sure, but we have children that have rotational abnormalities at their lower limbs. You mentioned scoliosis. Some children have a leg length inequality.

So it's quite a broad topic and it's part of the reason I'm so passionate about children's orthopedics so that I can help take care of all these issues. I think one of the biggest things we wrestle with is having such a broad spectrum to know. We also get referrals from a broad spectrum of people, from children's primary care providers, from athletic trainers, from chiropractors, from all kinds of folks.

So, trying to boil down all of that referral knowledge into what's the actual point of the visit and what we can do to help your child can sometimes be difficult.

Host: Rob, let's look at that issue from the perspective of the patient. So if you think about the kinds of patients that are typically coming into your practice, what can you tell us about their ages? What can you tell us about their general health? Is there anything else that's interesting about the kinds of patients that are coming to you for care?

Robert Lark, MD, MS: Oh, for sure. We treat patients from newborn, from day of life to even sometimes all the way into late adolescence. Unfortunately some children are born with congenital anomalies that need early attention, such as a club foot or a hip dysplasia. And those get diagnosed by our pediatric colleagues quite rapidly and referred to our clinics appropiately so, at a very, very young age, and then we can go on to the opposite end of the spectrum where we're dealing with rapidly growing adolescents and their puberal growth spurt that are having issues with back pain, knee pain, onset of scoliosis, et cetera. So we kind of see the broad spectrum from birth and to early college years.

Host: And that must be really challenging. I can imagine it must be very different performing an operation on an infant or a newborn than performing an operation on an older child or a teen or an adolescent. What are some of those technical challenges that are, you know, specific to these various age groups that you're dealing with?

Robert Lark, MD, MS: Oh, for sure. The very young ones can be quite challenging for size reasons. Some of the premature babies, these 23 to 25 weekers, if they have an infection in their hips, we're using surgical magnification loops just to be able to see into a very small child's hip joint, and they also have a lot of anesthetic considerations and other medical conditions, which makes being at a fabulous facility such as Duke University Medical Center so special because I have so much support from folks like yourself and our other colleagues here at Duke.

And then as we move into to the older adolescents, it's they're behaving more like adults. I'm, I'm surrounded by adult colleagues here too. So we have such a fantastic team approach here at Duke. It really helps me tremendously.

Host: Rob, I want to ask a bit about how patients are reaching you. You mentioned referrals from different sources, but can a patient or a family just come to you directly? How does it look from the perspective of actually accessing your services?

Robert Lark, MD, MS: Yeah, that's a great question as well. I think we have to be a little bit careful because there aren't too many of, of folks like myself just like in your field, Dr. Milazzo. So we really want to see the patients that need to see us most. And we definitely prefer referrals via primary care physicians.

But you can definitely reach out to our orthopedic scheduling hub. We have an 800 number. It's 800-851-5811, and actually schedule and actually scheduled directly us. They will have a, a screening protocol to make sure you get routed to the correct type of provider. And then we'll do our best to get you in in a timely fashion.

Host: So it sounds like some patients are reaching you directly. Some patients, if not most patients are reaching you through primary care or through a referral. Do you get referrals from other health care professionals? Like, I mean, you mentioned chiropractors before. Do you get referrals from chiropractic or from physical therapists, you know, those types of health professionals as well?

Robert Lark, MD, MS: We definitely do. For children that are experiencing a sports injury, for example sometimes after they've seen their pediatrician, the pediatrician refers them to a physical therapist, appropriately so, and maybe in the physical therapist's eyes there's something a little more going on there, something that maybe needs some further imaging studies, etc. So our therapist will reach out to us through the multiple channels we have via our electronic medical records or phone numbers, and same thing with other types of providers such as chiropractors, especially for scoliosis, because if they do have the capability to get imaging, some radiographs, and if they see something abnormal on those radiographs, then they're usually kind enough to route them our way.

Host: Well, I'm glad you mentioned scoliosis because I want to dive into that in some specific depth with you here now. From a family, from a parental perspective; scoliosis is one of those issues that I know comes up a lot in general pediatrics. General pediatricians may do sort of a rough screening for scoliosis at a routine care visit.

But from the perspective of the caretaker, the parent, the guardian, what should they be looking for? Are there warning signs? Are there things that there's, that they might be seeing as the child grows and develops that could lead them to think, you know what, it's time to ask my pediatrician or ask a pediatric orthopedic specialist about scoliosis.

Robert Lark, MD, MS: Oh, for sure. Believe it or not, scoliosis spans the gamut of age. We see it in newborns, we see it in seven year olds, but most commonly we see it in early adolescence, right as children are going through their pubertal growth spurt. Because scoliosis typically happens during the rapid phases of growth.

So anytime your child's having a growth spurt, there are some physical signs that you may be able to pick up on, such as a shoulder imbalance or the pelvis is not standing exactly level, and those would be things for sure to bring up to your pediatrician or reach out to us so that we can help you under, understand better, and I'm glad you mentioned about that early detection because I think for a lot of reasons we don't do school screening for scoliosis anymore, and I think historically that's based on our lack of having an early treatment that would actually help.

And now that we've found that bracing and physical therapy and all these other things can be beneficial and actually really decrease your chances of needing a surgical intervention for scoliosis, the early detection becomes that much more important.

Host: So you talked about the rapid phase of growth during adolescence and the teenage years being sort of a hot spot for detecting developing scoliosis. So that could be something the parent or the guardian observes. Are there symptoms the teen or the adolescent might experience related to scoliosis that could also be warning signs.

Robert Lark, MD, MS: There can.

Back pain occurs in about one third of patients with scoliosis. Unfortunately, back pain in general happens to a large number of the population. So literally millions of Americans seek the opinion of a medical professional for back pain. So trying to differentiate between back pain that's non-scoliosis related and back pain that is scoliosis related, can be hard.

We definitely don't want to ignore anyone's pain, especially our children. So that definitely warrants evaluation by a healthcare professional. And then that person can look, they're very simple physical exam findings that can tip us off to, Hey, this child needs to be evaluated by a pediatric orthopedist.

Host: So let's say you get to that point where either through the evaluation of a pediatrician or another health professional, a determination is made that this child needs to see an orthopedic surgeon. That patient comes to your office, you do your evaluation. How do you begin to distinguish between those kids that are going to need, for example, bracing versus kids that are going to need a surgical intervention?

Robert Lark, MD, MS: Oh, for sure. So this is the crux of a lot of our decision making, and if I had to try to simplify it as best I could; it relates mostly to how large the curve at presentation and how much growth the child has remaining. So, for example, if I see a small to moderate curve in someone who is skeletally mature, say an 18 year old female, for example, that patient may just need some reassurance, that this is not going to progress, and hopefully you won't need any treatment at all. Take that same curve, back it up to a 10 year old and now we're looking at, okay, I've okay, I've got a curve that has the potential to get worse. This child has not even hit their pubertal growth spurt yet, so this may be a child that I want to intervene early with some physical therapy modalities or bracing to try to prevent that curve from continuing to worsen to the point that it does need a surgery.

Unfortunately, are there are some patients that do reach us that already have a curve that's that's large enough that no matter if they're still growing, if they're done growing, that curve's going to progress throughout their adult life. And those are the children that we need to talk to about having a surgical correction at a young age while they're healthy, they don't have a lot of the comorbidities that some of our adults friends experience, they can be in the hospital for just a couple of days and recover quite quickly. And that tends to be at a curve magnitude of around 50 degrees. So we, measure these curves as the arc of a circle and Professor Cobb gave us his Cobb angle, and if that Cobb angle hits 50 degrees, then it's very common that those curves will progress into adulthood, and those are the children that we actually talk to about having a surgical intervention.

Host: Can you talk a little bit about the innovations that you and your team here at Duke Children's have brought to bear on the surgical treatment of these patients?

Robert Lark, MD, MS: Oh, absolutely. I think one of the greatest things, as I mentioned before, is the team approach that we use here at Duke. When you come to see me in my clinic, we also have non-operative physician extenders that help us with our patients. We have Physical Therapists that are specifically trained in Spine Physical Therapy, Schroth Physical Therapy if you will.

And all of that has really promoted this environment of teamwork and learning and providing the best care for the patient. From a surgical standpoint, I think Duke's always been at the forefront of surgical innovation. When I came back from fellowship, probably the most important new technology that was coming around the corner is a concept of trying to growth modulate the spine. Most people will see that in their home research as vertebral body tethering. So historically the spinal surgeries for scoliosis have involved a spinal fusion whether that's coming from the front, meaning an anterior fusion or more commonly coming from the back called a posterior fusion.

And fusion. we've been doing that surgery since the 1950s and it's very reproducible and works well, but we're taking a bunch of motion segments of your spine and making them into one solid block of bone. And for long term health of your spine, maybe that's not the greatest thing. So now we've developed a way to growth modulate your spine so that if we, as you mentioned before, Dr. Milazzo, catch this early, initiate a program early, we can do a little bit smaller operation where we come from the front, apply some fixation to the convex side of these curves. And instead of getting them to fuse together, just kind of tighten down on that convexity, so the concave side of the curve will continue to grow. And over time the child can literally grow themselves out of scoliosis, which is pretty remarkable if you think about it.

Host: That's amazing. And it sounds like it's a world different from what I remember the older treatment options for scoliosis were back when I was in medical school or even early in my training after medical school. So it sounds like we've come quite a long way.

Robert Lark, MD, MS: Oh, for sure. The technology is amazing. We've got a lot of great partners out there helping us innovate and I really hope by the time I finish my career, fusion's a thing of the past, but that remains to seen.

Host: So if we think about the patient who gets referred for evaluation, who you ultimately determine needs surgery, and you go ahead and schedule that operation and then eventually perform the operation, what should parents, families expect in terms of recovery, both in and out of the hospital and then beyond in terms of therapy or rehabilitation and what should be the expectation about returning to normal function.

Robert Lark, MD, MS: Great questions, if I could highlight one thing, I would say this is not your grandparent's back surgery. This is very, very different than adult spine surgery. You'll hear horror stories from any family member that's had that and I'm sure you can find plenty online as well. But in young, healthy healthy adolescents and children, this surgery is actually tolerated quite well.

The surgeries typically take anywhere from two to four or five hours and most often result in only a two to three hospital day stay. Whereas many of my adult colleagues, if they do the exact same operation on someone my age or older that you're looking at a couple of weeks, maybe in the hospital.

And as far as returning to function, I'm glad you mentioned that because that's a very active area of research of mine, and we don't really know the, the appropriate answer to it, so we're doing some great studies here at Duke looking to see how far see how post-operative patients return to that kind of baseline functional motion that they had prior to surgery.

Obviously, the part of their spine that's been included in the surgery is not going to move. That's a no brainer. We know that. But how does everything around that compensate? How do we get back to going to gymnastics, going to play soccer, going to play baseball? So we're doing some great work with our pediatric physical therapists here to understand that better.

And it turns out in some areas, our early data is suggesting for example, balance may actually improve after you've had a spine fusion surgery, which is a little easy to see when I'm looking back on things, but going forward, we worry so much that patients are going to lose motion, lose function.

If you think about it, if you take a spine that's not in its proper plane and bring it back to the midline, get your head centered over your pelvis, your balance, actually, sometimes gets better. So those are all great questions that we're, we're working on currently. And I think the future is ripe for us to understand that timing a little bit better.

Host: I really appreciate the comparison you made between adult spine surgery and pediatric spine surgery. It reminds me of the comparison that in my field we make all the time, the difference between adult cardiac surgery and pediatric cardiac surgery; in terms of outcomes, in terms of expectation to return to normal function. It's just vastly different. I think that's something that perhaps families may not appreciate. But it's really nice to hear you lay it out like that because that's very, very important information. It probably sounds very daunting to most patients and families when they hear that they have to have a spine operation.

Robert Lark, MD, MS: Oh, 100 percent. And, I never wish this on anyone. Don't get me wrong. I'm not trying to say every kid with scoliosis should have surgery for sure. They, if they're not a candidate for it they should not. But I do want people to understand that in young life, the surgery is tolerated quite well and children bounce back so quickly and get back to their day to day activities. It makes my job a lot of fun.

Host: For most patients, Rob, is it the expectation that you'll do one operation and that'll be it? Or are there patients where you have to eventually reoperate or treat with some other modality in the future?

Robert Lark, MD, MS: We like to think this is, at least for the fusions, we're pretty certain it's going to be one and done. If you look across your lifetime, if you've had scoliosis surgery from, say, the mid 1990s forward, we expect your lifetime risk of having another surgery is under 10%. Within five years, it's under 2%. So that's a very reproducible operation. Now with our newer studies on tethering and things like that, we're still learning a little bit about that. So I'm incredibly selective with the patients I choose to growth modulate because there are a lot of factors involved there. And, as well as I do being a pediatric provider, growth is something we see, but it's not something we can always predict down to the last little degree of correction. So we do a lot of work to try to ensure that a patient is the proper candidate for some of these newer surgeries.

Host: Rob, to shift gears just a little bit and pick up on something you mentioned before, you listed a few sports activities, gymnastics, baseball, sports, obviously important to most children and to most adults. And, you know, we always think about a child's participation in sports in cardiology because it's often a relevant issue.

So thinking a bit now beyond scoliosis, since so many young people participate in sports, either in school or out of school, what are some of the other sports related issues that come up in your day to day practice? What should parents and families take away from this conversation when they're thinking about the orthopedic impact of some of the common sports that kids are involved in today?

Robert Lark, MD, MS: Well, that's great question and it's something that we really, really try to focus on when patients come to see us because children grow through a structure in their bones called a growth plate. And that growth plate, or physis as the medical term would be, is made of cartilage, it's not of bone.

 There are injuries that children can get that actually injure that growth plate. And we see it in gymnastics. We see it in baseball. We see it in a lot of sports where you have to do a lot of repetitive activities. So I definitely try to encourage children to mix it up a little bit and and try to avoid being this one sport athlete.

 You know, In baseball, we have pitch counts now, we have other things to try to minimize repetitive stress across certain parts of your body. For gymnasts, it's very common to get stress fractures in their lower back called a spondylolisis from the hyperextension maneuvers that they do. So we definitely try to encourage people to be multi sport athletes.

Try not to get into these overuse injury categories because the physis is, can be the weak, structure. That growth plate can be the weak structure. And, once that's damaged, it can be difficult to treat.

Host: Do you in your work as an Orthopedic Surgeon, when thinking about kids who are playing sports, do you serve as an advisor to any sports teams, whether it's at the the high school level or the college level? I know a lot of Orthopedic Surgeons are involved in that work, and I think all of us are used to watching a professional football game or professional basketball game and seeing an Orthopedic Surgeon or a trainer courtside or on the sideline. Have you been involved in any of that type of work?

Robert Lark, MD, MS: I definitely did while I was doing my training, but as the medical field continues to grow, children's orthopedics is no different than anyone else. And we've become subspecialists within our own subspecialty. So we have people that do a fellowship in sports medicine and children's orthopedics.

We have people that do training in spine and children's orthopedics. So a lot of the court side and field side surgeons are people that have really been trained in sports medicine uh, as much as children's orthopedics. And we have several great people on our faculty here at Duke that do reach out and we cover all of the the Durham football games for example. We have orthopedic surgeons on the sideline at every Durham Public School football game, et cetera, But those are more of our, of my sports colleagues several of which have actually done subspecialty training in pediatrics as well.

Host: Again, I can relate to what I think you and I have seen in our careers, increasing sub specialization in our fields, which has been good. It's sort of mirrored the way these fields are exploding in terms of new knowledge, in terms of research and innovation. I think it makes it a little bit confusing for patients and families sometimes when they may not know exactly to which specialist they, they need to be referred. But from our perspective, it's nice to work with a team where we have all these different levels of expertise.

Robert Lark, MD, MS: I couldn't agree more and I think if patients can give us the benefit of the doubt and be a little bit patient with our scheduling process, that's what's going on in our head. We want each patient to go to the doctor they need to see so that they're not getting bounced around to various providers. We want you to get to the sub specialist that most suit your needs.

Host: Rob, with most of my guests, I've explored the reality that we're all facing today as medical providers, the reality of social media. We know that our patients, our families are exposed to it every day. We're exposed to it every day, of course, as well, and we know that they're getting a lot of their information about their health from social media. Some of it is quite good. Some of it is not. What has been the impact of that in your practice as an orthopedic surgeon?

Robert Lark, MD, MS: Oh, I think I'm feeling the same disinformation overload that many of my colleagues are. I think it's very easy for one person who may not have had a favorable outcome from a treatment to go to a social media site and blast a way that hey, I had X, Y, or Z done and it didn't work for me.

And when their followers receive this information, they take that N of 1 opinion and think it's gospel. Whereas, us as physician scientists look at groups of thousands and thousands who have had that same procedure and try to average out, the good and the bad and be able to give you proper percentages of rates of success, et cetera.

But I feel that pain daily. And unfortunately, there are a lot of people that have motives other than, just the good health of your child, whether it's financial or otherwise that want to promote things that may not be scientifically proven or scientifically backed and trying to dispel that disinformation is, it can be really challenging.

Host: I can absolutely relate to that because it comes up in my practice. And I know all of us, all of our colleagues are up against this in one way, shape, or form. One specific example I wanted to ask you about, and it may or may not be relevant, but I'd love your perspective on it. We've heard a lot in the popular press about leg lengthening and other orthopedic procedures that seem to be purely cosmetic, that, probably don't have any functional benefit and may actually be harmful to patients. Is that a good example or are there other examples in your work of things that parents should be really wary of as their children are seeing these procedures talked about?

Robert Lark, MD, MS: That's a great example, Dr. Milazzo. I'm glad you brought that one up. It's very popular right now and I think for cosmetic reasons, you're reasons right. You really need to understand the risks of doing a limb lengthening and all the things that can go wrong because trust me, there are a lot of things that can go wrong.

And as long as your provider is adequately providing the pros and the cons of these procedures; it's something to think about. But, there are a lot of good things that happen with limb lengthening. And, unfortunately, not a small percentage of the population have unequal leg lengths. So, if your leg lengths are more than 5 centimeters, which is roughly 2 inches different that has been shown to cause some issues later down the road with lower back pain, hip pain, and maybe that is a scenario where you want to consider lengthening that shorter limb just to get your pelvis balanced.

But if you're five foot six and you want to be five foot eight, and the only reason you want to be five foot eight is so you can say that you're five foot eight, to break both of your legs and insert a magnetically driven device into the canal of your femur bone is a pretty big operation.

I think you need to be wary of that a little bit. That said, there are some people with extreme short stature that have difficulties in public life. If they want to go to a Duke men's basketball game and try to use the restroom, for example, that sometimes they can't reach the counter, sometimes they have difficulty getting to the toilet.

And for those patients, I think that's a different conversation. I mean, that can really be a life changing event for them. But to be doing these operations purely for cosmesis is hard for me to justify.

Host: Well, I think your answer really speaks to the thoughtful approach that is necessary in your field. And maybe we can take this to a close by having you give whatever you feel is reasonable general advice for patients and families out there, who again may have a concern about their child, whether it's about scoliosis, whether it's about height, whether it's about a developmental abnormality, what would be your take home message for folks who are listening, if they have concerns or if they want to get additional information?

Robert Lark, MD, MS: As I mentioned before, we are a super sub specialized field, which means there aren't enough of us. So a great place to start is, is with your pediatrician. And I think at least in my experience around here, our pediatricians are phenomenal. And they really try to do a good job of it and do a great job of explaining a lot of things that relate to maybe torsional abnormalities. Maybe your child walks their toes in or out or uh, very subtle limb length inequalities of under a centimeter and how the natural history of those boad quite well and don't usually require any treatment. But then to look for the concerning things, the, the things that you didn't see last month or three months ago with your child as they've gone through a growth spurt, for example, with their spine, or maybe you're noticing a subtle change in their gait pattern, et cetera, that may warrant more investigation by a more sub specialized approach like we have here in Children's Orthopedics and I definitely, one conversation I'll have almost every time with families uh, regards things we can do and things we should do.

And I really, really try to drive home the point of the things we should do, because I can do all kinds of things that aren't necessarily in the best interest of your child. And I'm not going to do those things. So I really want to focus on the pros and the cons and the things that we should do.

Host: Well, that is a great way to summarize the conversation. Again, it speaks to the thoughtful approach that's so typical of my surgical colleagues here at Duke Children's. This has been a fascinating look at Pediatric Orthopedics and the care of the spine and related issues.

You know, Dr. Lark, I want to thank you so much for being a guest on the show. This is such a large and important part of pediatric care, and there's so much more we could discuss. So I hope you'd be willing to come back and talk with me again.

Robert Lark, MD, MS: Oh, can't wait. This was a lot of fun. I really appreciate the invitation I hope we've sent some good information out to your listeners.

Host: Absolutely. Thank you again so much. Pediatric Voices is brought to you by Duke Children's Hospital and the Department of Pediatrics at the Duke University Medical Center here in sunny Durham, North Carolina. The show was created by my friend, Dr. Richard Chung, and by me, Dr. Angelo Milazzo. Courtney Sparrow keeps us on track and organizes our work.

And I want to give a special shout out to Debbie Taylor and to Dr. Anne Reed and all of the great people at Dr. Podcasting. You can find our show and hit the subscribe button, please, wherever you find your favorite podcasts. You can also connect with us online at our website, pediatrics.duke.edu/podcasts.

You can connect with us on all of the usual social media channels and at dukechildren'sorg. We'd love to hear from you. So leave us a review at Apple Podcasts or your favorite podcast app. Thanks for being a part of the show. We'll see you next time.