Deborah Howell (Host): With the diagnosis of scoliosis in a child, life can change pretty quickly for the family. In this episode, Dr. Torin Cunningham, a Board Certified Orthopedic Surgeon and Medical Director of the Orthopedic Center at Miller Children's and Women's Hospital will help us learn about early detection of scoliosis and talk about some advanced treatment options for our children.

Welcome, Dr. Cunningham.

Torin Cunningham, MD: Thank you so much, Deborah.

Host: Right off the bat, what is scoliosis and how does it affect children?

Torin Cunningham, MD: So scoliosis is a sideways curvature of the spine, but more complex. It's a three dimensional rotation of the spine that over time may can slowly progress, especially with growth in children leading to visible deformity of the spine and ribcage and in very severe cases start to impact heart and lung function, and potentially cause back pain issues in older kids with worsening curve sizes as well.

Host: Sure. So you want to catch it early. So what early signs should parents and pediatricians watch for?

Torin Cunningham, MD: Oftentimes it may be something very subtle where their child is getting ready to go for a bath or they're at the pool and they bend forward and they see asymmetry in their shoulder heights or their ribs are more prominent on one side or the other. Sometimes it may seem like one side of their waistline is indented relative to the other.

And so this can be a couple very subtle early indicators of it. But certainly the best way is to do what's called a forward bending test. And this is part of what's ultimately recommended in terms of screening evaluations to detect asymmetry in the rib cage that would suggest this kind of rotation and curvature of the spine that's developing.

Host: And I know there's more than one type of scoliosis. What are the most common types of scoliosis for kids?

Torin Cunningham, MD: Correct. So the most common type is the, I don't know, type or we don't know type, which is idiopathic scoliosis. And there's really been a lot of work trying to evaluate potential genetic, hormonal causes. And seems that's really so many different variables involved that, there's probably a very complex interplay of these, but ultimately that's the most common type and the, within that we look at infantile, kids under the age of three, juvenile between about three to 10 and then adolescent 10 and up. And within those three age groups, adolescent is the most typically involved within the idiopathic group. And then there are a lot of other various types, congenital, which are deformities of how the vertebrae either develop or segment from one another, during basically embryogenesis. These can be some very complex and severe curves. There are also a lot of different genetic or neuromuscular conditions that can also lead to scoliosis. And these are all different conditions that we treat at Miller's.

Host: And when and how often should children be screened for scoliosis?

Torin Cunningham, MD: So a lot of the time the screening evaluations do take place when the children are seen during their well-check examinations with their pediatrician, but especially focusing on the adolescent idiopathic group. Really the recommendations, especially through our Scoliosis Research Society, is between the ages of 10 to 14 on a yearly basis.

These curves can progress relatively quickly. So what could be a seemingly small curve, at a younger age, can progress, a degree to a degree and a half per month. So if we don't screen on a regular basis, all of a sudden they can come in with a severe curve that was just simply unnoticed because nobody was looking for it.

Host: And why is early detection so important and how can it affect a child's future health?

Torin Cunningham, MD: Well, the benefit of early detection is that it gives us at least the option of looking at conservative treatment. And really within that we're looking at brace treatment to try to halt the progression of that curve as the child is getting older. There's been a lot of research efforts looking at things like physical therapy as well.

Chiropractic treatment and many of these modalities really don't seem to have benefit. There are some physical therapy treatments that, in addition to bracing, may add a little benefit, but bracing is really the gold standard in about 80% of cases where children are actually, using the brace, the prescribed amount of time, they have a well-fitted brace and we do that up until the time that they're getting relatively close to being done growing.

Then we can prevent change in their curve within plus minus about five degrees from where they started and obviate the need for any type of surgery in the future.

Host: Well, that's wonderful. And I know each child is different, so you're talking about a number of years they're wearing these

Torin Cunningham, MD: Potentially, and that's the hard part with the bracing, is it really is a dedication by the patient, the family, to go through the whole process of getting fitted for this brace, wearing it, and really dedicating the time because for a full-time brace wearer, we're looking at about 18 to 20 hours per day in the brace so they can have it off for things like sports and activities.

And we really encourage them to be out of the brace to do those things so that they don't get excessive just core and kind of trunk muscle deconditioning, and they can just enjoy being a kid. But there's still this commitment to having that brace on the remainder of the time for it to really, truly be effective.

Host: Right. And that's what we want. What can parents ask their child's pediatrician to help with early diagnosis and referrals?

Torin Cunningham, MD: Well, I think the, certainly if they're seeing anything that they're concerned about in terms of asymmetry and the, the appearance of their child's back or their shoulder heights or the waistline appearance, then they can have the pediatrician at, a regular evaluation or even a separate evaluation do at least a simple forward bending test screening assessment to say, does this look like it's enough of a concern to maybe warrant an X-ray evaluation or referral to see myself or one of our colleagues as a pediatric orthopedist to do a more rigorous assessment and x-rays, and then determine if based on the curve size, it's a big enough curve to warrant treatment, or at least maybe continue monitoring it as that child is getting older.

Host: Sure. And that's on the physician. But, are there any steps families can take to help slow scoliosis progression?

Torin Cunningham, MD: Unfortunately there's really not, outside of the brace treatment. Again, having done there's numerous research studies looking at other types of treatments such as chiropractic therapy, physical therapy, different types of exercise, and again, none of them have been shown to halt the progression of scoliosis.

So really the gold standard is brace treatment. And in those exceptions where these curves do continue to progress, then we're really looking at operative types of treatments.

Host: And how has new technology, like 70 surgical system and the EOS imaging system changed the way scoliosis is diagnosed and treated?

Torin Cunningham, MD: So the first one, the EOS is actually a relatively new, within the last say 10 years, x-ray technology that allows us to obtain basically two directional x-ray imaging. So from the front and the side simultaneously, with a much lower overall radiation exposure, about 60% less than standard x-rays.

And because we're seeing many of these patients for years, the cumulative radiation exposure dose is always a concern. And so the EOS was a great advance in not just the diagnostics of getting full length head to toe x-rays if we need them, but also minimizing that dose exposure to our patients. Once it comes to things like surgery, there's been a tremendous advances in terms of the technology available compared to even 30 years ago for the actual implants, techniques that we use. And now in the last five years, there's really been an explosion into the realm of really three dimensional imaging and navigation techniques so that we can safely put basically screw instrumentation into the spine into what's called the pedicles, which is a channel of bone on either side of where the spinal cord passes, which allows us to really get tremendous three dimensional control of each individual vertebrae as we do these corrections. It really helps us to maximize the safety and efficiency of doing these procedures.

There are other things we do with what's called neuromonitoring. We have a separate technician, who is electrodes basically from head to toe, checking all of the pathways of the spinal cord during the operations to alert us if there's any change in those evaluations as a real time indicator, are we doing something that might be stretching the spinal cord, has the blood pressure gotten too low and affecting the spinal cord. And so it allows us to just take a pause and assess and see what can we do to kind of correct this problem before we finish doing what we're doing, rather than waking up and finding that somebody has an actual neurologic deficit.

Host: Okay. Is there anything else you'd like to add to our conversation, Dr. Cunningham?

Torin Cunningham, MD: No, I think, we've really been increasing the capability we have at Miller's over the past 20 years in terms of treating scoliosis with things like the EOS, the 70 navigation. We have four individuals that are all Spine Deformity Surgeons, but also very comfortable in brace management for patients with scoliosis.

We have a very close working relationship with our orthotists in the, in the area. That allows us to have real time communication and feedback if our patients are having difficulties with their braces so that we can try to really help our families manage this difficult kind of treatment modality, knowing that it does take years to try to achieve this outcome that we're all hoping for, which is avoiding surgery.

But at the same time, if we have to go into that realm of doing surgery, we have great teams, both our surgeons and our operative teams that are very experienced in doing these surgeries to provide the best outcomes for our patients.

Host: That is so wonderful, and we thank you so much Dr. Cunningham, for your time and your expertise today. We really enjoyed having you on the podcast.

Torin Cunningham, MD: Absolutely. Thank you so much.

Host: Families can learn more about the Orthopedic Center at Miller Children's and Women's by visiting millerchildren's.org/orthopedics. That's all for this time.

I'm Deborah Howell. Have yourself a terrific day.