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Evaluating and Treating Pediatric Scoliosis · Pediatrics in Practice: A CME Podcast

• 0:01
  Dr Bob Underwood (Host): Welcome to Pediatrics in Practice, the CME Podcast.
• 0:04
  I'm your host, Dr.
• 0:05
  Baba Underwood.
• 0:07
  As we get underway, I'd like to remind you to claim your CME credits
• 0:10
  after listening to today's episode.
• 0:12
  You can do so by visiting CM kc.link/cme
• 0:18
  podcast, And then click on the claim CME button.
• 0:22
  Today we are breaking down scoliosis management, what pediatricians
• 0:26
  need to recognize when to act, and how decisions are made across
• 0:30
  the spectrum of scoliosis care.
• 0:33
  And to do that, we have the distinct privilege of talking to Children's
• 0:38
  Mercy Doctors Aaron Shaw and Michael Ben Vanti, both pediatric orthopedic
• 0:44
  surgeons and experts in scoliosis care.
• 0:47
  Doctors.
• 0:48
  Welcome to Pediatrics in Practice.
• 0:51
  Dr Michael Benvenuti: Thank you for having
• 0:52
  Dr Aaron Shaw: us.
• 0:52
  Dr Bob Underwood (Host): Absolutely.
• 0:53
  And so, Dr.
• 0:55
  Ben Vandi, let's start with some general questions.
• 0:58
  When a pediatrician suspects scoliosis during a well-child visit, what are the
• 1:04
  most important elements of the initial assessment And what findings should be
• 1:10
  raising concerns for that pediatrician?
• 1:13
  Dr Michael Benvenuti: The best way to evaluate for scoliosis just
• 1:16
  with a examination is looking at truncal rotation, And we do that
• 1:20
  with the atoms forward bend test.
• 1:22
  We have the patient bend over and try to touch their toes, and you
• 1:26
  look for asymmetry from one side to the other with a rib or flank
• 1:31
  prominence, marking that there is some rotation of their spine or ribcage.
• 1:36
  Other things that you wanna look for on the examination would be any
• 1:39
  kind of neurological findings, so.
• 1:42
  In rare cases, scoliosis is associated with spinal pathology that can lead to
• 1:47
  neurologic deficits or reflex asymmetry.
• 1:50
  So checking reflexes can be helpful and making sure that This is not
• 1:53
  a secondary cause of scoliosis, but rather just apathic scoliosis.
• 1:58
  Dr Bob Underwood (Host): Understood, And that we're gonna get into a
• 2:01
  little bit of the neuromuscular or syndromic questions here in a minute.
• 2:05
  So, Dr.
• 2:06
  Shaw, there's ongoing debate about scoliosis screening And
• 2:11
  what role pediatricians play today in early identification.
• 2:17
  What ages should they be most vigilant And what is the pediatrician's role in this?
• 2:23
  Dr Aaron Shaw: Yeah.
• 2:24
  Great.
• 2:24
  Great question Bob.
• 2:26
  And you're absolutely right.
• 2:26
  There is a, fair bit of, disagreement out in the professional worlds
• 2:30
  on what, universal screening, should be done or if at all, for.
• 2:35
  Us as, pediatric orthopedic spine surgeons.
• 2:38
  we really rely on the pediatricians as our first-line of, defense when it
• 2:41
  comes to identifying these pathologies.
• 2:44
  So, the most common type of scoliosis that, that we see is what we would
• 2:49
  refer to as the adolescent, age group.
• 2:51
  So that's most commonly a curve that's going to have
• 2:54
  its onset after the age of 10.
• 2:58
  Usually it corresponds with the adolescent growth spurt.
• 3:02
  And so, like Dr.
• 3:04
  Ben Vandi was mentioning like in the age group, identifying
• 3:08
  these patient's early can help.
• 3:10
  Us, make sure they, can have the most optimal treatment outcome
• 3:15
  with non-surgical intervention.
• 3:17
  such as with bracing, which is, very effective at preventing these
• 3:20
  curves from getting worse when, identified early and, treated with,
• 3:24
  a good compliant, treatment protocol.
• 3:26
  there are also younger age groups as well where this, deformity.
• 3:32
  Arises, kids under the age of 10, both infants, as well as, kind of the, what
• 3:37
  we would call a juvenile age group.
• 3:39
  so anywhere from birth to nine, much less common to have scoliosis
• 3:44
  arise in those age groups.
• 3:45
  But, much more important to identify those patient's.
• 3:48
  And this, I think This is where the annual, physical exam with
• 3:52
  the pediatrician is very important to help identify these cases.
• 3:56
  Dr Bob Underwood (Host): Yeah, I think, treatment timing is really kind of key in
• 4:00
  scoliosis depending on what kind it is.
• 4:03
  And so that kind of brings us back to Dr.
• 4:06
  Ben Vanti.
• 4:06
  And one of the questions we were talking about before is what are the signs or
• 4:10
  symptoms that suggest a scoliosis case?
• 4:13
  May actually be atypical or more serious.
• 4:17
  We mentioned neuromuscular or syndromic scoliosis.
• 4:21
  Does this warrant a more urgent referral?
• 4:24
  Dr Michael Benvenuti: usually the answer is thankfully no scoliosis is very rarely
• 4:29
  an urgently necessary treated condition.
• 4:32
  In patient's that have a neurologic deficit, which is likely not
• 4:37
  related to their scoliosis, in fact, but perhaps their, positional
• 4:40
  deformity is related to some other underlying thing, then obviously,
• 4:45
  urgent referral would be necessary.
• 4:47
  But even in this syndromic or neuromuscular cases
• 4:50
  of scoliosis, we still.
• 4:52
  treat them in a similar fashion for the most part to the
• 4:56
  idiopathic scoliosis patient's.
• 4:58
  So, urgent referral is not necessary, but we would definitely like to see
• 5:03
  these patient's when their curves are still small and could potentially be
• 5:07
  treated with bracing instead of surgery.
• 5:09
  Dr Bob Underwood (Host): Absolutely.
• 5:10
  if we could avoid the interventional part, then that's beneficial.
• 5:14
  Dr.
• 5:15
  Shaw, when is imaging appropriate in the primary care setting?
• 5:20
  Dr Aaron Shaw: Yeah, great question.
• 5:21
  so imaging for us, I think is a prerequisite.
• 5:26
  Whenever you have a concern for scoliosis, it's the only way to
• 5:29
  truly quantify it, from a objective standpoint, there are, different items
• 5:34
  such as a scoliometer, which has been used maybe more so historically to
• 5:38
  measure the truncal rotation, which Dr.
• 5:41
  Ben Nui was mentioning earlier.
• 5:43
  But the radiograph is really the only objective way, that we have right now
• 5:48
  to truly evaluate this and, I think it really helps guide what the treatment,
• 5:53
  is going to be if it is at all needed.
• 5:56
  Dr Bob Underwood (Host): Right, and I'm assuming we're just talking plain
• 5:59
  films in the primary care setting.
• 6:01
  Dr Aaron Shaw: Yes, absolutely.
• 6:02
  Yeah.
• 6:02
  Plain x-rays.
• 6:03
  we ideally like to get a one x-ray.
• 6:06
  these are usually taken looking from the front, in a posterior
• 6:10
  to anterior direction to kind of minimize radiation exposure.
• 6:13
  And then also a lateral radiograph so we can truly identify the three
• 6:17
  dimensional aspect of, the deformity.
• 6:19
  Dr Bob Underwood (Host): Sure.
• 6:20
  Sure.
• 6:20
  That makes total sense.
• 6:21
  And Dr.
• 6:22
  Ben Vandi, what information is most helpful for the orthopedic
• 6:26
  providers when that patient is being referred from the pediatrician,
• 6:31
  Dr Michael Benvenuti: The, probably the most important thing for us
• 6:34
  would just be knowing what their deformity looks like with a radiograph.
• 6:38
  We can obviously get radiographs here in clinic also, but it helps
• 6:42
  us And the patient's if they get radiographs ahead of time, if possible.
• 6:47
  We also like to know, A little bit of what their other medical problems are.
• 6:51
  So we treat patient's differently if their scoliosis is caused by,
• 6:56
  neuromuscular conditions such as cerebral palsy or spina bifida compared
• 7:00
  to the idiopathic or syndromic kids.
• 7:03
  but really we can figure out a lot of that information when
• 7:06
  we see the patient in clinic.
• 7:07
  Um.
• 7:08
  The best thing that we would like to see is just patient's that are known
• 7:12
  to have, rotational deformity or a concern for spinal deformity, seeing
• 7:16
  us at an early stage so that we can hopefully avoid surgery for them.
• 7:21
  Dr Bob Underwood (Host): You bet.
• 7:21
  You bet.
• 7:22
  And Dr.
• 7:22
  Shaw, Kenya, walk us through how treatment decisions are made.
• 7:27
  Okay, so from observation bracing or surgical intervention and how
• 7:33
  growth curve progression factors into those decision-making points.
• 7:39
  Dr Aaron Shaw: Yes.
• 7:39
  So growth progression is really the, one of the key factors in helping us
• 7:44
  differentiate treatment modalities.
• 7:46
  So, a.
• 7:48
  clinical practice standpoint, we will frequently ask the families,
• 7:52
  especially for our female patient's, have they started, menes, cause a.
• 7:57
  11-year-old who is pre monarchal is going to behave a whole lot different if they
• 8:01
  have a 20 degree curve compared to a 13-year-old who's two years post-menarche.
• 8:07
  because that growth differential is gonna be very different.
• 8:10
  so in addition to that, we also will use, x-rays of the hand, Traditionally,
• 8:15
  people have used the relic and pile atlas to kind of give a bone age.
• 8:19
  we have a different skeletal maturity, system that we use to, quantify
• 8:23
  what their maturity level is.
• 8:26
  And that helps us guide, treatment decision-making.
• 8:29
  But it's a combination of how big the curve is And I tell patient's,
• 8:34
  how big the curve is, and how much growth they have remaining.
• 8:36
  so if someone is, in general with a curve under 25 degrees, we.
• 8:41
  Typically we will keep, an eye on that.
• 8:43
  So observational management, getting repeat x-rays in six months to
• 8:47
  determine if That is progressing.
• 8:49
  So in general, histotripsy treatment threshold for scoliosis,
• 8:52
  bracing is a 25 degree curve in a child who is still growing.
• 8:56
  and, the amount of, daily brace wear is really driven by how
• 9:02
  much growth they have left.
• 9:04
  So if they're very skeletally immature, a girl who's, pre monarchal, and
• 9:08
  they have a 25 degree curve, they're.
• 9:10
  ideally gonna be recommended to wear the brace 18 plus hours a day.
• 9:15
  whereas if there are later stages of growth based off of our skeletal
• 9:20
  maturity assessments, then we can use a lower, bracing, duration threshold.
• 9:25
  however, we have recently started using, Kind of accelerated bracing
• 9:29
  protocol where children who are very skeletally immature, who according to
• 9:34
  our natural history studies are, they have a 18 degree curve, but if we follow
• 9:39
  it a long, long-term, it's going to eventually get to, 25 degree threshold.
• 9:44
  And, that can be a hard pill to swallow from going from not doing anything
• 9:49
  when you know it's going to get worse.
• 9:50
  And then.
• 9:51
  Telling 'em they have to wear a brace all day, every day.
• 9:54
  we've started using a, early bracing protocol where we start the brace before
• 9:59
  it hits that threshold and just have them wear it at night to try to help.
• 10:03
  Avoid the progression at that faster rate if we were doing nothing.
• 10:08
  And some of the early studies on this have shown that it's helps get kids
• 10:12
  to skeletal maturity with smaller curves, and it prolongs how long,
• 10:17
  we can wait before, implementing a more full-time bracing protocol.
• 10:21
  And then the.
• 10:22
  Surgery for This is largely, for children with idiopathic scoliosis is,
• 10:28
  reserved for patient's who have a curve of 50 degrees or more, because those
• 10:31
  curves tend to continue to progress long-term, even after skeletal maturity.
• 10:37
  Dr Bob Underwood (Host): Wow.
• 10:38
  So we kind of hinted on this, so we will ask Dr.
• 10:41
  Ben Vanti, you know, what do pediatricians need to know about modern
• 10:45
  bracing options, physical therapy?
• 10:48
  And then the key that Dr.
• 10:51
  Sha kind of hinted at is the adherence challenges.
• 10:53
  You know, when you're telling the kid they've gotta wear a brace for 18
• 10:56
  hours a day, and they're teenagers.
• 10:58
  Teenagers are.
• 11:00
  Trying to be independent.
• 11:01
  So adherence is kind of an issue too.
• 11:04
  How can pediatricians best support families navigating these various
• 11:10
  forms of treatment, like bracing, physical therapy, things like that?
• 11:15
  Dr Michael Benvenuti: That's a great question, and unfortunately you're right.
• 11:18
  Wearing the brace for 18 hours a day can be a pretty big challenge both
• 11:21
  for patient's and their families.
• 11:24
  we have pretty good studies, as Dr.
• 11:26
  Shaw mentioned, showing that increased time in the brace does
• 11:29
  result in better outcomes and decreased progression of curves.
• 11:33
  So we use that to help counsel families.
• 11:36
  in regards to physical therapy, there have been a few recent studies done
• 11:40
  that show that potentially the addition of some forms of physical therapy
• 11:45
  to bracing can help mitigate curve progression by a degree or two as well.
• 11:50
  These.
• 11:51
  Physical therapy studies usually involve pretty intensive physical
• 11:54
  therapy, and it's not readily available for all patient's.
• 11:58
  So in many cases, the sole treatment, not operatively for scoliosis is bracing
• 12:05
  alone, but for families that really want to try everything possible, then
• 12:10
  physical therapy could be on option two.
• 12:13
  I tend to tell my families that while bracing is a great tool and helps us avoid
• 12:18
  surgery, we also don't want their families to fall apart over bracing for scoliosis.
• 12:24
  surgery is a big deal and something that we try to avoid, but it's also
• 12:29
  not the end of the world, And we know that the mental health for
• 12:32
  these children is important too.
• 12:34
  We also know that even when we prescribe bracing for 18 hours a day, they're most
• 12:38
  likely only gonna wear the brace for 12 or 13 hours, of that 18 hours prescribed.
• 12:43
  So, as the prescribers of the brace, we understand that most
• 12:48
  patient's aren't going to be hitting the targets that we provide.
• 12:52
  Dr Bob Underwood (Host): And so This is a question really kind of for both of you.
• 12:54
  and we'll start with, Dr.
• 12:56
  Shaw, emerging Technologies, surgical techniques, research development.
• 13:02
  there's always progress in medicine, which is probably why we like doing it so much.
• 13:07
  What are the newer things that are out there for pediatric scoliosis
• 13:11
  that pediatricians should be aware of when they're talking to
• 13:15
  the families And what are the new things that you're interested in?
• 13:18
  Dr Aaron Shaw: Yes.
• 13:18
  so I already kind of alluded to one of the, big things, which
• 13:21
  is the early bracing protocols.
• 13:24
  I think that has a lot of potential to help, try to.
• 13:27
  Institute treatment earlier to, give us the best chance to prevent these
• 13:31
  curves from, progressing a lot.
• 13:33
  And the, early research studies are pretty supportive of that.
• 13:37
  along the idea of bracing, there's been a lot of progress in the, bracing types.
• 13:43
  I think a lot of people still think of that, brace from the movie 16
• 13:47
  Candles when we talk about scoliosis bracing with the cervical extension.
• 13:51
  But the reality is that the braces today are very, very low profile.
• 13:56
  They're, three dimensionally shaped to kind of give us the best optimal,
• 14:00
  correction of, the deformity.
• 14:02
  and, I think that.
• 14:03
  That technology is only getting better and, better as we, gain better
• 14:07
  understanding of scoliosis in general.
• 14:10
  additional advances, The Histotripsy treatment for scoliosis has largely
• 14:16
  been, with, a posterior spinal fusion in a child who's in the, a adolescent
• 14:21
  growth, or the adolescent age group.
• 14:24
  there has been.
• 14:25
  The introduction of newer, surgical techniques, both in the younger age group
• 14:30
  as well as, in that adolescent age group to try to, mitigate some of the, concerns
• 14:35
  that, families have with a fusion surgery.
• 14:38
  in particular, A one of those being vertebral body tethering, which I
• 14:42
  can let Mike talk a little bit about.
• 14:44
  but, there's also been, advances within the, management of, early onset
• 14:49
  scoliosis as well, that, has, Potential to, really help change, our management.
• 14:54
  early onset Scalia is a very challenging condition 'cause it's very differently
• 14:58
  treated compared to our adolescent growth, adolescent age group.
• 15:02
  because we have this very small child who has a enormous growth potential,
• 15:07
  with very significant implications on their, pulmonary, development.
• 15:11
  'cause if we did a early fusion.
• 15:14
  Their thorax is going to be stuck the same position.
• 15:16
  It is not gonna be able to go through the normal maturation process.
• 15:20
  So there's newer, surgical techniques and implants that, unfortunately are
• 15:24
  not quite available in the states, but are, very promising, with the early
• 15:28
  studies that we're seeing in, hopefully something that we'll be able to,
• 15:31
  provide for our families in the future.
• 15:33
  Dr Bob Underwood (Host): Yeah, I think that that's fascinating.
• 15:35
  And, since you brought it up, we'll go over to Dr.
• 15:39
  Ben Vanti, to talk about the tethering, something we were talking
• 15:43
  about right at the beginning.
• 15:44
  Actually, before we started recording, we were talking about this newer technique.
• 15:48
  Dr Michael Benvenuti: Sure.
• 15:48
  This is somewhat newer technique.
• 15:50
  It's been around for about 10 years, so we still don't really know the.
• 15:54
  Natural history of what happens to these patient's postoperatively long-term.
• 15:59
  But the idea is that it preserves motion in the spine while still
• 16:03
  enabling correction of the curve.
• 16:06
  It's really indicated for patient's that have growth remaining so that
• 16:10
  their continued growth can allow the spine to grow straighter.
• 16:13
  So there's only really a small select portion of patient's.
• 16:17
  Are probably good candidates for this surgery And that proportion of
• 16:22
  patient's seems to be getting a little bit smaller as we understand better the
• 16:27
  longer term outcomes of this procedure.
• 16:29
  So, it seems like it might be a good option for some of these patient's
• 16:33
  with idiopathic scoliosis that are within a pretty strict, skeletal
• 16:38
  maturity and size of the curve and location of the curve, domain.
• 16:43
  However, It's not for everybody.
• 16:46
  Dr Bob Underwood (Host): Yeah.
• 16:47
  Yeah, absolutely.
• 16:49
  As we conclude, anything that either of you would like to add, advice for
• 16:53
  pediatricians, the primary care doctors taking care of these kids either
• 16:58
  through diagnosis or through treatment.
• 17:01
  Dr Aaron Shaw: I think from my perspective, If a pediatrician
• 17:04
  has a patient, they're just not sure what to do about, just go
• 17:07
  ahead and reach out to our team.
• 17:08
  we have a, great team here at Children's Mercy with three,
• 17:12
  pediatric orthopedic spine surgeons and, three nurse practitioners
• 17:16
  who help manage, these patient's.
• 17:18
  And, This is what we love to do and we'd be happy to, help
• 17:21
  you guys out along the way.
• 17:22
  Dr Michael Benvenuti: I had like to second Aaron on that too.
• 17:25
  we're happy to see.
• 17:26
  Any patient that there's a concern for, And we definitely like to see patient's
• 17:31
  when their curves are smaller and more amenable to bracing compared to once
• 17:35
  they're a little older and a little bit more challenging to take care of.
• 17:40
  Dr Bob Underwood (Host): Yeah.
• 17:40
  Yep.
• 17:41
  You bet.
• 17:42
  Dr.
• 17:42
  Shaw, Dr.
• 17:43
  Bi Vandi, thank you so much for being with us today.
• 17:47
  Dr Michael Benvenuti: Thank you very
• 17:47
  much for
• 17:48
  Dr Aaron Shaw: us.
• 17:49
  Dr Bob Underwood (Host): Yeah, absolutely.
• 17:50
  And to our listeners, as a reminder, claim your CME credits after listening to this
• 17:54
  great episode today, and you can do so.
• 17:56
  And.
• 17:57
  By visiting CM KC link slash CME podcast, and click the claim CME button.
• 18:04
  For more information for other important topics, you can visit the
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  same site, CM KC link slash CME podcast.
• 18:13
  And if you enjoyed this podcast, please share it on your social channels and
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  check out the entire podcast library for topics that are of interest to you.
• 18:22
  I'm Dr.
• 18:23
  Bob Underwood, And this has been Pediatrics in Practice, A CME podcast.