Scott Webb (Host): Scoliosis is defined as an abnormal curvature to your spine and you may even know someone who has scoliosis and lives with it. But did you know that scoliosis can develop in children and may require specialized treatment? I'm here again today with Dr. Brian Dial, surgeon at EvergreenHealth Spine, Back and Neck Care to discuss adolescent idiopathic scoliosis or AIS. Dr. Dial is a specialist in the Puget Sound region who treats AIS.

 Hello and welcome to Check-Up Chat with EvergreenHealth. I'm Scott Webb. Doctor, welcome back to the podcast.

Dr. Brian Dial: Yeah, thanks for having me back. I'm excited to talk about this one. So, going back to when I was training as a resident, this is the surgery that got me interested in spine surgery. And it's still probably is my favorite condition to manage and work with these kids who are dealing with scoliosis. So, happy to be here and happy to talk about it.

Host: Yeah, it's awesome to have you back. I can remember being in school, maybe middle school, where everybody was sort of checked for scoliosis. And it was a very sort of weird, kind of embarrassing thing. And I don't know how they do it anymore. I don't know how you diagnose, but that's why you're here. It's why we have experts. So, let's just start there. What is AIS, what causes it, who typically experiences it, and so forth?

Dr. Brian Dial: Absolutely. So, you're dead on, they don't do it anymore in school. They used to have everyone bend forward, touch their toes, and they put something called a scoliometer on their back. And if it was greater than seven or five degrees, they were sent to the pediatrician for an x-ray. We still do that in the office, and the pediatricians still do it when you see them. But what is scoliosis?

So, scoliosis is a deformity of the spine. It's in the coronal plane, which means if you're looking straight at someone, the curve is to their side. It's actually a little bit more complex, and as we've learned more about the condition, it's a 3D deformity, which means there's deformity in the coronal plane, the spine's rotated wrong, and it's also a little bit flatter than it should be. So, it's a more complex deformity than just that one curve, but that's the obvious one to see when you're looking at these x-rays for sure.

Host: Yeah, I'm wondering about the causes. Is it just genetics, family history? And when is it typically diagnosed?

Dr. Brian Dial: Yeah. So, there's different types of scoliosis, and it's really important to kind of say that.

Host: Okay.

Dr. Brian Dial: We're talking about AIS, which is one type, and that type is diagnosed in children 10 to 18 years old, kind of when they're going through their pubertal growth spurts, or growing, definitely before skeletal maturity. And the incidence of it is about 3% of the population will have AIS. Out of that 3% though, only about 0.3% need to be treated. So, the majority of people with scoliosis can just be observed and they never have to have anything done with it. Why they get it is still to be discovered, if you will. There's a genetic component. It definitely runs within families. So if you have it, most likely at least one other relative in your family will have it. And it's much more common in girls compared to boys. So, it's about 10:1 female to male ratio. So, especially the bigger curves, boys will have smaller curves, but the ones that continue to get bigger and bigger are much more common in females.

Host: Yeah. Wondering about the symptoms. Obviously, as you say, there's like the big curve, that's maybe the obvious sign of AIS, but do children, adolescents who have AIS, do they suffer any actual symptoms or pain or anything like that?

Dr. Brian Dial: No. And that's the funny thing. So, it's a completely, or almost completely, pain-free diagnosis. So, most kids don't describe back pain. They don't describe any sort of functional inability. They're in sports, they're in gymnastics, they're doing all the same things all the other kids are doing. The way that's normally picked up is through some physical signs. So, their shoulder heights might be different, or they might have waist asymmetry. There's something called a rib prominence, which is one side of their back is more pronounced than the other side. And those are probably the three most common ways it's picked up, other than, you know, these girls tend to be very skinny. They can be quite tall. So, you know, if they're swimming in the summer at the pool, moms will pick up these signs or the pediatrician might. But almost never pain is the presenting symptom.

Host: Right. Yeah. And I mentioned the genetics family history part of it, as you say, it's still sort of yet to be determined how kids, adolescents end up with scoliosis, but is that the strong suspicion that it really is just genetics, that it's nothing that they're doing per se?

Dr. Brian Dial: Absolutely. You're genetically predisposed to having your spine grow that way. There's nothing they did. There's nothing they ate. It's not that they were too active or underactive. It was just the way they were born.

Host: Yeah. You mentioned that the surgery for AIS is what kind of brought you into surgery, fueled your passion, you know, to be a spine surgeon. So, let's talk about what are the treatment options. I assume you try some things before surgery, but take us through that.

Dr. Brian Dial: The whole reason we treat scoliosis, right? We said it doesn't cause pain, why does matter, is if these curves continue to progress and they get too big and that number, you know, if curves get to be 80 degrees or 90 degrees in adulthood, that can cause some issues, that can cause back pain at that point. It can cause respiratory issues, some GI issues. So, there are things we try to prevent by not allowing these curves to get too big.

The whole goal is to prevent the curve progression. So if the curve isn't going to continue to progress, we don't have to do anything. And what we've learned through quite a bit of Research is that if these curves stay small once a child reaches skeletal maturity, that's 16 in boys and 14 in girls, it's unlikely that it'll continue to get bigger. So if that curve is less than 50 degrees, or maybe 40 degrees at skeletal maturity, that curve won't keep getting bigger, they'll have a 40 or 50 degree curve. But other than that, they'll be asymptomatic from it, and there won't be any issues. If the curves are bigger than that after skeletal maturity, they tend to progress about 1 to 2 degrees per year, which doesn't seem like a lot. But if you're 16, 30 years later, you're still 46, and now you have an 80-degree curve. So, we're trying to prevent that situation.

So, what we do, how we treat it is, if your curve is greater than 25 degrees and you're still growing, we'll put you in a brace. And you'll wear that brace until you're skeletally mature. Those braces, they don't correct the curve, but they prevent it from getting any worse. And as long as we can keep it pretty small, by the time you're done growing, that's all you'll ever need.

And then, if that fails, or there are some kids that just have really big curves out of the get go, greater than a 50 degree curve, you know, in those situations, that's when we start to have that discussion around surgery. But we do do observation. We do bracing. There's some different physical therapy programs out there that can help these curves not progress. So, there are non-surgical treatments as well.

Host: Yeah. Yeah. I was going to ask you about PT. So, glad you covered that. Let's just finish up here and talk about the surgery a little bit. What's involved, at least broadly speaking and, you know, outcome success rate.

Dr. Brian Dial: Yeah. So, what we're doing is it's a fusion surgery, it has to be. We're trying to prevent these curves from getting any bigger. And the way to do that is to fuse and stabilize the spine. If we do it earlier on when the curves are still really flexible, you know, when kids are in their teenage years, we can do a much shorter construct than if we wait until adulthood. It tends to be, you know, a larger surgery. It's a big surgery for these people who are undergoing it. But they're kids, they're resilient. They do quite well with it. There is a postoperative recovery period. But by six months, I would let a kid go back and play football. I would let a gymnast go back to do gymnastics. There is some very small loss of maybe flexibility with these surgeries. But kids, again, they're so resilient and they can adjust to situations so well that there are very high-level performing people in all different fields that have had scoliosis and have had these surgeries and are still competing at, you know, top levels. So, kids do quite well with these surgeries.

Host: Yeah. It's amazing. As you say, kids are so resilient. My daughter broke her wrist when she was nine. And then, she just had an x-ray for something else, and there's no signs that her wrist was ever broken. You know, it's just really amazing. Whereas if you broke your wrist when you're 30, you're probably always going to know that you broke your wrist, right?

Dr. Brian Dial: That wrist will never feel the same.

Host: Yeah, totally. Well, it's been great to have you on again. Great to learn more about AIS. As I told you, it was a fairly traumatic experience being checked for scoliosis back in school. Glad you do it in the office now. Good to hear the latest treatment options, what's involved with surgery. Thanks so much.

Dr. Brian Dial: Absolutely. Thanks for having me.

Host: If your pediatrician suspects scoliosis, they can refer your child to Dr. Dial at EvergreenHealth Spine, Back, and Neck Care. Visit neuro-spine-ortho.com to learn more and to schedule your appointment. I'm Scott Webb. And please remember to subscribe, rate, and review this podcast and all the other EvergreenHealth podcasts. For more health tips and updates, follow us on your social channels.