Jaime Lewis (Host): Think about your child's spine. That graceful S curve that allows them to stand tall, move freely, and grow strong. Sometimes that curve can become more pronounced, leading to a condition called scoliosis. Here to discuss caring for children with scoliosis is Dr. Julio J. Jauregui, a Spine Surgeon at the University of Maryland Medical System and Shock Trauma, and an Assistant Professor in the Departments of Orthopedics and Neurosurgery at the University of Maryland School of Medicine.

 Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. I'm your host, Jaime Lewis. Hello, Dr. Jauregui. Welcome to the podcast.

Julio J. Jauregui, MD: Hey Jaime, how are you? Thank you for having me here.

Host: Yes. Happy to see you. Well, let's start with some of the basics here. What exactly is scoliosis and what are the different types that can affect children?

Julio J. Jauregui, MD: Scoliosis, by definition, we all want to have, when you look at the spine from the front back, we all want to have a spine that's straight like an arrow. The reality is that most humans are not straight like an arrow. A little bit of a curvature here or there doesn't really matter and truly it's inconsequential. Now, once this curvature measures over 10 degrees, by definition, we call it scoliosis. So this is the definition of scoliosis, a curve of more than 10 degrees seeing these patients front to back.

Host: Okay, now I'm thinking about parents. What should parents be looking for? What are the early signs of scoliosis in children, and at what point should they ask for medical advice?

Julio J. Jauregui, MD: Depending on the kid's, the patient's age, there's several different types of scoliosis and the first sign that you see in these kids is some asymmetry. So you look at the patient and they're not perfectly straight. There are very subtle findings, like one shoulder is a little bit higher than the other one.

This is a good clue to look into it. There's maybe a trunk shift where the pelvis is here and the shoulders, instead of being here, shift to the side. That's another subtle clue. One of the best clues that we have, and then just circling back on the previous question, scoliosis is not a two dimensional problem.

So when you look at the spine straight and when you look at the side, it has the normal curves. When scoliosis happens, it actually rotates, so when the spine rotates, a good subtle clue that answers your question, when the patient leans forward and when the kids lean forward, you can see that their back is not straight, but actually one shoulder is higher or the low back is higher on the other side and this is one of the best ways to examine the patient clinically to determine if they have scoliosis or not.

Host: Well, you kind of touched on this already, but there's often confusion about what causes scoliosis in a child. Can you help us understand what those causes might be and any risk factors that might increase a child's likelihood of developing it?

Julio J. Jauregui, MD: There's several types of scoliosis. The most common type of scoliosis we call idiopathic scoliosis. The word idiopathic really means that we doctors, we surgeons, don't exactly know why it's caused.

And again, the most common reason for scoliosis is idiopathic. And depending on the patient's, the kid's age, if they are very, very little, under three, very, very little, we call it infantile scoliosis. When they are under 10, we call it juvenile. And the most common type is called adolescent idiopathic scoliosis.

So it's adolescent. We call it adolescence, the reality is that probably the scoliosis started earlier in their life, but the most common time when we diagnose it is when they're in their adolescence. So that's why we call it adolescent scoliosis. We have looked into different reasons why the scoliosis happens. We pinpoint some genes here and there. We're not to the point where we can modify the genes to stop it, but we are looking into that and that would be great. We would stop operating and treating patients with scoliosis, which would be great. This is the idiopathic, the most common type, and this is the great majority of patients with scoliosis.

Now, other types of scoliosis, one is called narrow muscular scoliosis. The reality is that our spine is very small compared to the amount of work it does. So, we heavily rely on the muscles doing what the muscles need to do, so the spine functions as it should. When the muscles are not doing this, the spine quote unquote falls apart.

And that's why when it starts falling apart, we start seeing these curves. One of the most common reasons for neuromuscular scoliosis is cerebral palsy. So little kids at birth or close to birth that did not have good oxygen to their brain can develop these things. And then secondarily, they develop scoliosis.

So this is another reason for scoliosis. Some syndromes are also related to scoliosis and not worth talking to them about them right now. But another type of scoliosis is a congenital scoliosis. When the spine forms in utero, it forms in a very specific way where we end up having vertebra over vertebra over vertebra, and that's how it should be.

Now, if the vertebras are fused together in one side and not the other, that is called a congenital scoliosis. And then, we got to do some more investigation to make sure that there's nothing else going on and potentially treat it with or without surgery. This is the biggest bulk of the types of scoliosis.

Host: Well, when a parent comes into you and brings their child with concerns about scoliosis, what's the diagnostic process for you? What tests or evaluations do you typically use?

Julio J. Jauregui, MD: We heavily rely on a physical examination. So by seeing these patients, I personally like to have all these little kids and teenagers running in my clinic. It's very important for me to see them run. If they can run in a symmetric, reciprocal fashion, no deficits, no issues, I am comfortable neurologically and I know they're working okay.

I told you bending forward and all these other things. Now the bread and bulk of what we do to diagnose is called scoliosis radiographs. So they're standing x-rays that includes the base of the cervical spine, thoracic spine and lumbar spine. I do like seeing the femoral heads, like the pelvis and the hip joints, to understand and see the entirety of the spine, both in an AP meaning front to back x-ray. Technically, we get a PA and then a lateral x-ray where you get an x-ray from the side. This is the basic thing we need for the diagnosis of scoliosis. To your question, and, as a parent, it's terrifying to have a kid with a crooked spine. The words of advice I tell my parents of my patients is that don't worry.

The first thing, don't worry. It's a lot more common than you think. So when patients come with scoliosis, the parents, as well as the kids, they feel that they're the only person in the world with scoliosis. It's a lot more common than you can imagine. Now, of the scoliosis, the ones that need something done, something like a brace or something like that, is a small subset. And of those, the patients that actually need surgery is an even smaller subset.

So I would encourage parents not to worry too much. We'll have a good conversation, we'll come up with a plan, and we'll execute the plan.

Host: Good. Well, let's talk about treatment options then. What approaches are available for pediatric scoliosis and how do you determine which path is best for each individual child?

Julio J. Jauregui, MD: This question, I'm going to answer it focusing on idiopathic scoliosis. The reason why I'm focusing on idiopathic scoliosis is because by far it's the most common type of scoliosis. We will tailor different strategies to different patients, but we just don't have time right now. In for patients with idiopathic scoliosis, the two important factors that matter in terms of how to treat it is, number one, how much growth these patients have left.

And I'll explain why in a second. The second factor is how bad the curve is. Summarizing, in patients that still have the ability to grow; if your curve is less than 10 degrees, there's no scoliosis. We don't worry. We move on. When the curve is over 10, that's when it's scoliosis. From 10 to 20, 10 to 25, the first thing I do is just observe.

No real treatment is needed. Nothing needs to be done more than watch it to make sure it doesn't get worse. Once the curves are over 20, 25, we know that these curves will keep on getting worse. The curves get worse substantially when we grow. So as long as there's growth left, the idea is to hopefully keep it where it is, sometimes improve it.

So we use something called a brace. The technical name is called a TLSO, Thoracolumbar Spine Orthosis. There's several different types of orthosis and one of the most commonly ones is called the Boston brace, but there's several different braces that would fit and will be tailored to each specific patient.

 But when they use this brace, the idea is help keep it in the right spot so that when the patient grows, it does not get worse. 60 percent of the time it works and it stays there. 20 percent of the time I'm actually very happy and it gets better. And this is great news for parents, for me, for everybody.

There's a small subset of patients that still progresses and then we may have to do different things. Once the patient is done growing, there's really no role for bracing because the role for bracing is guide the growth. So once the kids are done growing, really there's no role for bracing and then it's either observation or surgery.

Now, once the curve reaches a magnitude of around 50 degrees, it's not a strict number. I've done surgeries at 48 degrees. And I've done it for other reasons, but once a curve reaches 50 degrees, especially the one in the thorax, the thoracic curve, the lumbar curves tend to progress easier, so therefore the number is sometimes less, but once the curve reaches 50 degrees, I know it will keep on progressing through life.

It doesn't progress catastrophically, it progresses give or take a degree to three degrees a year until it reaches 90 degrees, 80 degrees, and then it progresses fast. So technically, and for the parents need to understand this, there's no urgency in doing anything surgical. We have time. We have time to optimize

the patients we have time to schedule and find a time where it will not disrupt school life too much, it will not disrupt family life too much, and we were able to do the surgery and get these kids back to life, get back to school and get to doing what they want to do. That's the criteria where.

So treatment options really are observation, bracing, there is a small role for physical therapy and I do send my patients to physical therapy when they can benefit from it, and then the last resource is surgery. This is the bread and bulk, most of the scoliosis.

Host: Well you mentioned surgery. Can you explain how recovery goes for a child? What can parents and children expect after surgery?

Julio J. Jauregui, MD: So the surgery, we have to get a couple things done before surgery and we'll work on that once you come and see me. Now the day of surgery, the important part is for the patients to come into the hospital with nothing to eat or drink. Typically I do my scoliosis surgeries on the first surgery of the day so they won't be too hungry.

Now the day of surgery, I finish the surgery, most of my pediatric patients having surgery go to the Pediatric Intensive Care Unit. I do this to make sure that there's no issues, to make sure that there's no problems, to make sure that they have everything they need under their care. Typically, the next day after surgery, they go to the floor and stay in the hospital for around 3-4 days.

I've had patients leave on day 2, I've had patients leave on day 6, but most of the patients leave on day 3 or 4. It does hurt, it's real surgery, real incisions. Most of the pain, the quote unquote terrible pain is in the first 3 days. The pain keeps on subsiding from day three to week two, it's real pain, but very manageable.

And then by week six, almost all of the pain is gone. And then most of the recovery is me slowing these patients down because they want to go back to their life and doing all these crazy things. And I need them to wait a little bit longer for the spine to be fully fused and then we will let them do everything they want.

So, it is a process. It will involve seeing me several times after surgery. I want to make sure that there's no issues, no problems. True with the incision early on, then with the screws and rods and the alignment later in life. And then we keep on, I tell these patients that we negotiate what they can and can't do.

And there's no one rule or rule for everybody. And I tailor it to each specific patient depending on their goals and activities and personalities.

Host: Wonderful. I bet it's wonderful to see them itching to go and do something when that's exactly what we want. Right.

Julio J. Jauregui, MD: For me, it's game changer. You see these patients that we do and they're like, am I ever going to get better? And when you see them in month three, they're like, can I go do this? I'm like, not yet, but soon.

Host: Not yet, but you will. Yeah. That's wonderful.

Julio J. Jauregui, MD: Happy. It's great.

Host: Well, this can be an emotional journey for both children and parents. How can parents best support their child through the whole process? You know, uh, getting diagnosed, getting it treated or surgery and recovery. How can a parent best be there for their child?

Julio J. Jauregui, MD: I mentioned this before, but it's important for these patients to understand that they're not the only ones in the world with this problem. t ne thing I do need parents to do is be there for them.

There isn't much they need to do. So after surgery, my patients stand and walk and they're able to do the basic things on their own. They don't need to be carried, they don't need to be anything, but they need to be there with them. It's just being with them is the best thing that I would recommend. I'm obviously part of the whole process and very easy to reach out to, and there's questions or problems I'm always happy to answer, but just being with them is the biggest thing.

And understand that yes, it's painful and it hurts early on, then the pain subsides and then they may need help. To the previous question, I typically keep my patients out of school for around two weeks. Week two, they go to school again, but they go to school and that's when I need the parents help. I tell them they go to school half time, which just means they do whatever they want. I want them to go to school, but I want patients to feel that if they're hurting, they're uncomfortable. They're really not ready. They go three hours, four hours, and they can go back home. And for parents, it's very disruptive.

All the parents work. We're all busy. And having a two week post op scoliosis son or daughter in school, in home, it's complicated. So, just being for them. That's the biggest thing.

Host: Wonderful. Well, thank you so much for all of your time, your expertise, your insight. Is there anything that you want to share as a final thought on this subject?

Julio J. Jauregui, MD: It's a fun thought. I said before, if your son, your daughter, more commonly daughter, because it's more common in women, have scoliosis, don't worry. Let's go through the steps. It's less scary once all the information is there and we'll take good care of them. That's the biggest advice and the great majority, overwhelming great majority of patients do great after the surgery and after scoliosis and it should not affect them what they do down, down the road in life.

Host: Well, I'm sure you've reassured a lot of people. Thank you so much, Dr. Jauregui, for being on the podcast.

Julio J. Jauregui, MD: Jamie it's been my pleasure talking with you. Thank you for setting this up and it's been awesome talking to you.

Host: That was Dr. Julio J. Jauregui, a spine surgeon at the University of Maryland Medical System and Shock Trauma. Find more shows just like this one at umms.org/podcast and on YouTube. I'm Jamie Lewis. Thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System.