What organ systems are affected by Early-Onset Scoliosis (EOS)?

Scoliosis, at any age, causes distortion of the body from the neck to the waistline.  Though on the x-rays (or radiographs) that are obtained to evaluate for scoliosis the spine only appears to curve in a lateral direction, however it actually has become deformed in three dimensions (front, side and axial).  The front view is shown below in the first x-ray or radiograph.  It is easy to see the severe curve, causing the right shoulder to be higher than the left, but also it is easy to appreciate the shift of the body to the right relative to the pelvis and hips.

As the spine starts to curve to the side it also twists on itself, and it is this twisting which causes the ribs to be differently oriented between the left and right sides of the body.  In the x-ray below one can also appreciate the difference in the ribs, both in their position, shape and spacing.  The ribs on the left side are more horizontal, while those on the right are more vertical, especially at the middle of this severe curve.  Also the ribs on the left are very close together, and those on the right more spaced apart.  This is because the spine on the concave side of the deformity is relatively shorter than the convex side, so the ribs are more close together.  Also as the spine curves to the side the distance of the spine, from the neck to the hips, shortens which can cause the body to look uneven, with the leg looking longer than they should be.

In Early-onset scoliosis (<10 years of age at detection) the main organ system of concern in the lungs.  The two main issues impacting the child’s lungs are the shortening of the spine (neck to pelvis) and the twisting of the spine.  In general as the spine shortens the abdominal contents (liver, spleen, stomach, intestines, etc…) relatively move upward into the chest.  Since the lungs are very compliant or soft, compared to the abdominal contents, this effectively creates less room for the lungs.  In other words the lungs become squished. 

 

3-d Computed Tomography (CT) scan of the lungs in a patient with EOS

 

 

The graph above is from a study by Emery and Mithal in 1960 which is looking at the alveoli in the young child’s lung.  The alveoli are the air sacs which permit us to get oxygen into our blood stream and get rid of carbon dioxide.  It is important that the development of the lungs is optimized early in life as the alveoli multiply in number up to approximately 8-10 years of age.  Thereafter it is mainly the alveoli mainly increase in size, not in numbers.  So it is important to maximize the growth, or length of the spine, during the first 10 years of life as this impacts how well the lungs develop.

The other organ systems (heart, gastrointestinal) are impacted to a lesser degree.  These two systems are impacted only in severe (>100 degrees) of scoliosis.  However, unlike the lungs, the impact of scoliosis on theses two systems is much more reversible.  When the scoliosis is treated these systems will return close to normal status. 

Pediatric spine deformity surgeons focus much of their attention on maximizing the development of the lungs in children unde 10 years of age.  This is why performing definitive, long spine fusions in this age group is rarely performed.  A long, multi-level spine fuison will permanently shorten the spine, and secondarily decrease the volume of the lungs.  To treat spine deformity in children <10 year pediatric spine deformity surgeons use “growth-friendly” techniques, which corrects/manages the scoliosis but permits growth of the spine.  Bracing and casting are nonsurgical techniques which are “growth-friendly” have already been posted on this blog earlier.  In subsequent blogs surgical techniques which are “growth-friendly” will be explained. 

Chiropractic treatment in scoliosis

If one searches the web for information on chiropractic care and scoliosis, the American Chiropractic (ACA) Association would be a logical place.  According to the ACA, “chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health. Chiropractic services are used most often to treat neuromusculoskeletal complaints, including but not limited to back pain, neck pain, pain in the joints of the arms or legs, and headaches.” So scoliosis is not a diagnosis directly referred to, but the “not limited to” part of this statement does not eliminate scoliosis from the conditions they may advocate to treat.

Further digging around on the ACA website one finds very little information about scoliosis or chiropractic treatment of scoliosis.  One item that is posted is a patient information handout produced by the ACA which states “Spinal manipulation, therapeutic exercise, and electrical muscle stimulation have also been advocated in the treatment of scoliosis. None of these therapies alone has been shown to consistently reduce scoliosis or to make the curvatures worse. For patients with back pain along with the scoliosis, manipulation and exercise may be of help.”  Let’s break down and analyze these three sentences.  Sentence one is factually correct, these therapies along with many others have been advocated in the treatment of scoliosis, with most therapies eventually being shown to be ineffective.  The second sentence of this quote one can essentially boil this down to this revised statement: we (the ACA) can’t come right out and say it, but there really isn’t any evidence spinal manipulation, therapeutic exercise and electrical stimulation really prevents scoliosis from getting worse.  The third sentence is partially accurate, short-term back pain may be helped with manipulation and exercise may be of help.  Long-term back pain related to scoliosis has not proven responsive to chiropractic treatment.

Another website to search on this topic is from the Scoliosis Research Society (SRS).  This is the most authoritative website, produced by medical doctors and doctors of osteopathy who specialized in spinal deformity in children and adults.  This website has a section of FAQs on scoliosis, and it is here one can find the following information:

Will chiropractic treatment help my scoliosis? 

Chiropractic is a controversial method of treatment that seems most effective in treating acute, short-term pain. Chronic conditions do not seem effectively managed by long-term chiropractic care. Patients who have scoliosis and choose chiropractic treatment should be referred to a spinal orthopaedist or neurosurgeon if their curves keep increasing. Insurance may or may not cover chiropractic treatment.

Thee two large organization can obviously be biased in their position on this subject, and one would expect both organization to support their mission and members.  So let’s look at the science behind this topic.  In this era of evidence-based medicine we should constantly strive for the highest level of evidence to support our treatments.  By searching Pubmed, the U.S. National Library of Medicine and National Institute of Health’s online search engine, one can search over 26 million citations for biomedical literature from MEDLINE, life science journals and online books.  This is a good place to search for information on “scoliosis and chiropractic treatment”.  If one does this the results of the search will demonstrate a lack of scientific evidence supporting the position that chiropractic treatment/manipulation alters the natural history of scoliosis (prevents progression or worsening of the deformity).  The existing literature on this topic is replete with cases reports and small, retrospective, single center case series which lack control groups, have inadequate numbers of patients, insufficient follow-up, lack rigorous statistical analysis and are generally underpowered statistically.  Testimonial medicine advertisements, however appealing, should not be used as evidence a treatment is helpful and safe.

Hence based on the currently available data, there is no scientific evidence that chiropractic therapies alter the natural history is scoliosis.  This statement, though grounded in evidence based medicine, is often vigorously contested by some chiropractic or homeopathic practitioners. Often talking about chiropractic treatments with families is much like discussing politics and religion, individuals often have firm beliefs in either direction and will not be swayed by a five-minute conversation in the office.

When my patients ask me about my perspective of chiropractic treatment of their child/adolescent with a spinal deformity I state the following:

1.      Spinal manipulation should never be done on a spinal deformity.  Catastrophic injuries (fractures, paralysis, etc…) have occurred when the spine was “manipulated”.

2.      There is no scientific chiropractic treatments prevent progression of scoliosis.

3.      Often when chiropractic treatment is initiated the recommended plan of treatment (with multiple x-rays) to parents/caregivers is for several treatments per week for months or years.  This can be extremely expensive, and time consuming, for families and can drain Health Savings Accounts quickly.

4.      The only benefit chiropractic treatments may help is acute, short-term back pain.

5.      The most effective interventions for pediatric and adolescent back pain related to scoliosis are:

a.       Rule out more serious and non-muscular causes of back pain (such as urinary tract infection, hip pathology, and fractures).

b.      Develop a physical fitness program in which the individual is doing some type of aerobic activity (raising the heart rate and breaking into a sweat) for 20-30 minutes a time, 3 times per week.

c.       Maintain ideal body weight

d.      Do not use tobacco products.

I hope this helps. Let me know if there are any questions.  Happy Holidays.

Spine Bracing in Early-Onset Scoliosis (EOS)

Bracing in EOS is a commonly utilized nonsurgical intervention.  Braces are constructed of either rigid or semi-rigid plastic, and are designed on an individual basis. The orthotist (the person who makes the brace) analyzes each patients’ anatomy and radiographic deformity, then constructs the brace.  The brace is contoured to place pressure points on the ribs and pelvis, with padding, and that force is then transmitted to the spine, ideally straightening it. 

In EOS one of the concerns of bracing is altering the rib development and alignment.  Hence, most often brace use in EOS is not recommended to be worn full-time.  Conceptually, having time out of the brace the chest can develop more normally.  This is more of a theoretical concern, as there is little information that bracing can permanently deformed the chest in a negative way.

Though there are medical centers and providers which report, and sometimes advocate or market, for one brand of spine brace over another, there are three main types: flexible, semi-rigid and rigid.  Flexible braces, typically constructed from a highly-elastic material like neoprene (with straps), may be appropriate for children with mild to moderate deformities and have low neurologic tone.  This brace exerts less force to the spine so it cannot be used in patients with normal or increased tone or moderate to larger deformities.  In my practice these have been used occasionally in the neuromuscular patient (cerebral palsy, spina bifida, spinal muscle atrophy, etc…) who are low demand physically and have low muscle tone.  Semi-rigid braces are a step up in stiffness, and subsequently can exert more corrective force to the body and spine.  These braces are more typically used in children under 3 years of age with milder deformities.  

Rigid braces (TLSO: thoraco-lumbo-sacral orthoses) are the most commonly used brace in EOS and in spine bracing in general.  There are several subtypes of rigid braces: Boston, Wilmington, Charleston, etc…  which have different corrective forces and wear schedule.  Regardless of which brace is used a key issue to brace is simply that the brace must be appropriately worn by the patient for the recommended length of time each day.  A brace will not have the ability to help the patient if it not being worn.  The goal of a spine brace is to maintain the deformity, not to correct the deformity.  In EOS it can be used a primary treatment for milder, more flexible deformities or after a series of spine casts.  It is difficult, if not impossible, to create a long-term plan for each patient, so the length of time each patient will need to be braced is difficult to determine.

Next blog post: Chiropractic treatment of scoliosis

Surgical treatment of scoliosis in adolescents, in 2016, is most commonly a posterior spinal fusion with instrumentation (PSF/PSSI).  Though this blog is, in general, dedicated to the “growing spine” this entry will focus on adolescent idiopathic scoliosis (AIS) and the many questions that are asked by parents/caregivers about PSF/PSSI.

 

Top Frequently Asked Questions about PSF/PSSI in AIS:

How strong will the spine be after surgery? Do I need to be careful?
Your spine will not be fragile. Multiple screws and rods are used, in a linked fashion, which corrected your spine deformity and will be holding it firmly in place. Activities of Daily Living (ADLs) will not harm the outcome of surgery or your spine.

What plans need to be made at home?
1. When you go home you will sleep in your regular bed, in your regular bedroom, wear regular clothes, eat regular food, go on walks, car rides, and see your friends.
2. You can walk up and down stairs, we are not doing surgery in your legs. You will be fully mobile though you may not walk as fast as you did prior to surgery, at least temporarily.  When you do walk up and down stairs, it is recommended someone stand below you to make sure you do not fall down the stairs.
3. You can eat in the kitchen and walk to the family room. You will not be a "patient" at home.
4. No physical therapy or braces are needed after discharge from the hospital.
5. Regular clothes may be worn. Tight fitting clothes may be uncomfortable.
6. For those patients who were driving cars before surgery it is recommended to avoid driving until after the 6-week postoperative clinic visit.
7. Driving home from the hospital does not require any special vehicle. If there is a long drive home you may need to stop more frequently and take breaks.
8. You will eat regular food at home. Fatty salty, and spicy foods may not taste good after surgery for several weeks.  Don’t worry the taste of food and your appetite will return to the way it was before surgery.

How will I sleep at home? You can sleep in any position you choose. If you prefer to lie on your stomach then use a flatter pillow than normal. It is fine to sleep on your back.

When can I take a shower or bath after surgery? The first shower or bath can be taken at 2 weeks after surgery. Before then sponge baths are recommended.

How will the pain after surgery be handled? Postoperative pain will be managed by the Pain Service, an anesthesiologist driven service. They have a detailed, thoughtful plan to manage postoperative pain. You will go home with pain medications that work for you in the hospital. After discharge from the hospital you will be able to contact the Pain Service if any problems or issues occur. Most patients are off the prescription narcotic pain medication at 2 weeks after surgery.

What is the follow up after surgery? The first follow up is at 6 weeks after surgery. Routine follow up is at 6 months, 1 year, 2 years, 3 years and 5 years.

How do is the fusion assessed after surgery? Radiographic imaging of the fusion mass is difficult, even with a 3-d imaging like a CT (computerized tomography) scan. During follow-up visits plain radiographs will be obtained to evaluate the implants integrity. If the implants are intact at 5 years postoperative then the fusion is intact.

What are the activity limits after surgery? Competitive athletics is not recommended for 6 months after surgery. There is no PE or gym class for 6 months. Athletic training and fitness activities are usually acceptable but must be approved by the surgeon.

Is there any limitation of lifting?  There is a 10 pound lifting limit for the first 6 months after surgery.

What is the chance of needing a second surgery? The historical reoperation rate at our children's hospital is 3.9%. The spine implants used will stay in place permanently.  This is a one-shot surgery, one-and-done.

Will the implants need to be lengthened? No. When a fusion is done the spine growth is stopped over the length of the spine implants.

Will the fusion stop all future growth? The fusion will stop growth only over the part of the spine that has spine implants. The spine above and below will continue to grow, and your legs will continue to grow.

What type of metal is in the implants to be used in surgery? The spine implants used will be a combination of titanium and cobalt chrome.

What sports are not recommended after surgery? In general collision sports, such as American football, rugby and wrestling are not recommended. In addition tumbling and gymnastics are not recommended due the stiffening of the spine fusion and since the repetitive, excessive motion may loosen the spine implants, prevent fusion and require repeat surgery. All other contact and noncontact sports are acceptable.

How much school will be missed?
It is expected you will return to school part-time in 2 weeks and full-time 4 weeks after surgery. Contact the school to inform them of the surgery date and the time out of school. Let us know what paperwork is needed.

What are risks of surgery? In general there are two types:
1. There are some risks which are common with all surgeries. General anesthesia is necessary and though the risk of an adverse event occurring is low, it is not zero. Also an incision is made and incisions can have problems healing and get infected. Antibiotics are given before, during and after surgery to minimize the risk of a deep wound infection. There are also many other things which are done to decrease the risk of infection as close to 0% as possible.
2. There are other risks which are unique to the spine. The spine surgery will be on the spinal column, or the bone of the spine. Inside of the bone is the spinal cord, and nerves, which runs from the brain to the lower extremities. For the purpose of the surgery the spinal cord and nerves acts like a wire from the brain to the legs, enabling muscle function and sensation in the legs and controls bowel and bladder function. During surgery the spinal cord function is continuously monitored by a Neuromonitoring specialist. If the spinal cord function becomes abnormal this is usually detected quickly using motor and sensory tract monitoring. This usually, but not always, occurs during correction if the spinal deformity, typically as the deformity is maximally corrected. If this happens the surgeon is alerted quickly and several actions are taken simultaneously to get return of normal spinal cord function.  If this happens there is over a 90% chance that the neurologic condition will return to baseline. We are always prepared for neurologic problems during surgery.

What are the most likely complications after a spine fusion? As mentioned above anesthetic problems, wound infection, neurologic deficit (paralysis, bowel or bladder incontinence, nerve problem, etc...), failure of fusion, implant breakage or pullout, cerebrospinal fluid leak, need for additional surgery, and postoperative pain.

How do you choose what spine implants to use for each surgery? Most spine fusions currently are performed from the back through one midline incision. The implants used are mainly based on patient size. There are different sized system to maximize correction and fusion yet to be as low profile as possible.

Where is the incision for a fusion and how long is it? There is one incision in the middle of the back and it is as long as the planned fusion.

How is the skin closed at the end of surgery? Staples vs. sutures vs. glue? A plastic surgery-type closure is performed leaving no sutures/stitches above the skin level. All sutures are absorbable and will dissolve and disappear with time.  On the skin there will only be glue, much like the Super Glue you can buy at the store, which gradually falls off in 3-4 weeks.

Can I put vitamin E on the incision? After the skin had completely healed, and the glue falls off, can lotions be applied. It is inconclusive that vitamin E lotion improves the appearance of surgical scars.

Will I need a brace after surgery? No

Will I need physical therapy (PT) after discharge from the hospital? No.

Spine Casting of Early-Onset Scoliosis

 

Spinal casting is a time-tested intervention which was first described, in modern literature, by Cotrel and Morel in 1964.  At that time there were no other effective means to correct spinal deformities and maintain the improvement, since spine instrumentation as we now know it was not yet created. In 1963 Dr. Harrington developed the first effective, posteriorly-based spine instrumentation, using mainly two points of fixation on the spine and distraction as it main treatment force.  It was common to supplement fusions postoperatively with casts and braces for an extended period of time (years).  The technique of spine casting was advanced by Risser in 1976 with the utilization of a three-point molding technique.  It was around this time the first segmental spine instrumentation was created by Cotrel and Dubousset and made spine casting less needed for scoliosis treatment.  Since that time spine instrumentation has evolved significantly, enabling physicians to better correct the spine three-dimensionally without a need to use spine casting.  Hence casting was performed less and less for the treatment of scoliosis until in 2005 when Min Mehta reported the use of Cotrel spine casting technique in children younger than 2 years.  Her results re-invigorated interest in spine casting as a method to improve and, at times, definitively correct scoliosis.

The two main factors that occur between 0-5 years of age, which makes spine casting effective is the rapid growth of the spine and the child’s spine flexibility.  So castings will be more effective if the child is less than 18 years of age, with a highly flexible deformity which is mild to moderate in magnitude.  It is in this age group spine casts have the greatest chance of permanently “curing” the scoliosis.  In the older children, say 2-5 years, casting can be helpful but will only be a “cure” if the scoliosis is very mild.  Even if the casting doesn’t “cure” the scoliosis it may delay the need for surgical correction.

If spine casting is deemed appropriate for a child’s scoliosis, the number of casts and the length of application is individual specific.  No two children are treated exactly the same, since no two scoliosis deformities are the same.  Each doctor who using spine casting is attempting to correct the child's spine deformity optimally with the minimum number of anesthetics and surgical procedures.  Hopefully the child will never need a surgical intervention.   

One last point: it is important not to get pre-occupied with the “name” of the spine casting the surgeon is recommending.  Parents have, on occasion, come to think that only Mehta casting works and that a cast by any other name does not.  Sometimes the casts are referred to as Risser casts, but any surgeon who cares for early-onset scoliosis in 2016 will do the technique which is attributed to Mehta.  As mentioned earlier the actual technique was described by Cotrel and Morel in 1964 and can be called by many names: derotation casting, Cotrel casting, Cotrel derotation casting, Extension-derotation casting, etc…….  What is most important is the surgeon focuses the corrective maneuvers of casting to unspin the spine’s abnormal twist with scoliosis.

References:

Cotrel Y, Morel G.  The elongation-derotation-flexion technic in the correction of scoliosis.  Rev Chir Orthop Reparatrice Appar Mot 194;50:59-75.

D’Astous JL, Sanders JO.  Casting and traction treatment methods for scoliosis.  Orthop Clin N Am 2007;38:477-84.

Mehta MH.  Growth as a corrective force in the early treatment of progressive infantile scoliosis.  J Bone Joint Surg [Br] 2005;87:1237-47.

Risser JC.  Scoliosis treated by cast correction and spine fusion.  Clin Orthop Relat Res 1976;116:86-94.

 

Next Blog post topic: Spine bracing

 

The Spectrum of Treatment Options

There are many treatment options in early-onset scoliosis (EOS), but all can be lumped into 2 broad groups: nonsurgical and surgical.  The nonsurgical options include: observation, physical therapy, bracing, and casting. Surgical options include: traditional growing rods, MAGEC growing rods, vertebral body stapling, vertebral body tether, Shilla growth guidance procedure and fusions (bilateral and unilateral) +/- resection.  Often a combinations of therapies (nonsurgical and surgical) are used simultaneously during treatment, such as growing rods (surgical) with a brace (nonsurgical). 

What has not been shown to control/modify/alter the natural history of scoliosis based on a reasonable level of scientific evidence are: spine manipulation, massage, electrical stimulation, accupuncture, accupressure, and inversion treatments.

In general milder spinal deformities and moderate ones which are not progressing (getting worse) the nonsurgical methods are the first-line and, commonly, the second-line of treatment.  When the spinal deformity becomes severe or moderate (but progressive, getting worse) the surgical procedures become treatment options. 

We will discuss each type of nonsurgical and surgical options, listed above, over a series of blogposts.  The first treatment which will be presented is observation.  While observation, or as some have called “watchful waiting”, may not seem like an actual treatment option, it can be quite helpful in EOS. 

Observation is the most basic method of treatment, can be the most difficult one for physicians to recommend.  Sometimes pressure to “do something” from caregivers, family and patients makes observation challenging.  However, rarely is there a reason, or need, to urgently perform surgery (such as worsening muscle weakness or walking ability, or the loss of bowel or bladder control).  Observation permits time to pass, and allows the spine to grow, which may help to determine if the spinal deformity is static (not changing) or getting worse.  In the outpatient setting intermittent evaluations, with radiographs, are done anywhere from 3 months to 2 year intervals.  The time between evaluations depends on many factors, such as patient age, type of deformity, underling medical diagnoses, the location of the deformity, magnitude of the deformity and the recent history of the spine deformity progression.

The other benefit of observation is it gives parents/caregivers time to obtain information and learn about their child’s spine problem.  Though spinal deformity may be commonly seen by the child’s pediatric orthopaedic surgeon, it is a new, and often overwhelming, problem in which parents do not have any previous experience and are not comfortable.  It is mportant parents/caregivers are fully informed on all aspects of their child’s diagnosis and treatment options.  They, along with the physician, are the leaders of their child’s care.  In addition, parents may need to obtain a second opinion to obtain more perspectives of their child’s spine problem and feel comfortable with the decision-making process.

So remember, observation is often a reasonable option in the treatment of EOS.  Parents/caregivers should not be “rushed” into a decision about surgery in EOS.

Next blogpost: spine casting

Why does my back hurt?

Back pain in the young athlete is very common. It has been reported that up to 75% of adolescents will experience back pain by the time they reach 18 years of age.  As more youth sporting activities are performed year-round, there is a greater risk of sports-specific repetitive activities over-loading the athletes back.  Too much activity applied too quickly to the back can cause pain.  In athletes less than 10 years of age, back pain is uncommon, for many reasons. However, as the athletes grow, add more muscle mass, generate more force and speed and training more (frequency, intensity and duration) the risk of back pain increases. In general, a gradual change in sporting activities and training will minimize the risk of developing back pain. The good news is >90% of back pain in adolescence is muscle-based and due to overloading the muscles.

Like many orthopaedic injuries the commonly recommended treatment is the "RICE" treatment, which partially applies here. Rest, ice, compression (hard to do for back injuries) and elevation (also hard to do) is recommended for the first 4-6 weeks after back pain develops. This is especially true when the athlete can relate the onset of back pain to an event in their sports. Over-the-counter pain medications (acetaminophen, ibuprofen or naproxen) can be helpful for pain control. Pain which came on without a known injury or activity, fevers, numbness in legs, bowel or bladder difficulties or other neurological symptoms is more concerning and should be evaluated by a physician early.  Depending on the amount of pain, the athletes level of participation and upcoming events a course of physical therapy can be helpful.  A course of paraspinal muscle strengthening, core strengthening and stretching can speed up recovery.  Back braces are not recommended, in general, because they can cause the back muscles to become too weak.  Similarly, narcotics and muscle relaxers are not recommended, except in extreme situations.

An evaluation for back pain is appropriate if the back pain has been present for longer than 6 weeks, there is lower extremity numbness or weakness, or bowel or bladder problems develop.

What is Spondylolysis or a Pars Fracture?

If you break the word spondylolysis down to its Latin roots and then translate to English you get spondylo- which means "vertebra" and lysis which means "crack or break".  So spondylolysis is when there is a crack in the posterior, or back part, of the bony arch of a vertebra at the pars region (see figure).  This area has a relatively thin area of bone, with a poor blood supply.  Hence it has a lower-capacity to heal when it is stressed.  The most concerning repetitive motion is back hyperextension, with or without rotation. This typically occurs in the low back (or lumbar spine) in the lowest vertebra (L5 or L4), where there is maximal back motion.

The cause of this crack is likely a stress fracture due to repetitive back motion (hyperextension).  It is most common in athletes who do repetitive hyperextension of their back, such as in American football linemen and gymnasts. Why some individuals get this problem and others don't is unknown, but it is likely some individuals have a predisposition to developing a stress fracture. Interestingly there is a higher frequency of this occurring in Inuit Eskimos, hence some populations appear more at risk. Evaluation of this problem starts with plain radiographs but can include CT, MRI, and bone scans. Treatment is dependent on the previous treatments and how long the problem has been symptomatic. In general the first level of treatment is nonsurgical with rest, limitation of activities and bracing (possible).  In situations with longstanding pain, a surgical repair may be the best option. The surgical repair is aimed to simply getting the crack in the vertebra to heal, without a fusion between vertebra, so no back motion will be lost. If a spondylolysis occurs in a younger patient, <12 years of age it is important to get intermittent radiographs of the low back to watch for any potential slippage of the vertebra forward.

 

This post has been previously posted in the Young Athlete Blog

Next blogpost: Why does my back hurt?

 

Scoliosis in Sports

Scoliosis is a spine deformity in the side-to-side (or lateral) plane of more than 10 degrees of angulation.  The majority of the time this occurs spontaneously during the pubertal growth spurt in an individual with normal spine development, up until that time.  Currently this type of scoliosis is called “idiopathic”, meaning there is no known cause.  However genetic researchers are finding more and more associations between patients’ genetics and the development of scoliosis.  There is nothing the patient or caregiver did, or didn’t do, to cause the scoliosis to occur.  Most individuals with idiopathic scoliosis are involved, to some degree, in athletic endeavors whether it be recreational or high-level competition, at the time they are diagnosed with scoliosis.  Often sports are interwoven into their day-to-day activities, so a new diagnosis of scoliosis raises questions about what sporting activities, and level of participation, a person with scoliosis may participate.  Despite the lateral curvature of the spine, the bony stability of the spine is normal, without instability or weakness.  There is no increased risk of damage to the spine during athletic participation when compared to a similar individual whose spine does not have scoliosis, or is absolutely straight.  We encourage all patients with scoliosis to be as athletically active as they desire, as the benefits of an active lifestyle are well-known.  The best way to prevent back pain in scoliosis is to remain athletically active, specifically to be aerobically fit.  For those individuals who do not participate in an organized athletic activity we encourage every other day workouts.  These should be 20-30 minutes, at a minimum, in which the patient raises their heartrate and breaks into a sweat.  More elaborate methods to quantify heartrate are commercially available, but are not necessary.

Even patients whose scoliosis requires brace use we encourage sports participation.  The brace can be removed and they can participate in their sport at full capacity.  After completion of the sporting activity the brace can be re-applied.  It is not desirable to have the patients who are wearing a brace to stop their athletic activities.  There are many negative implications of being sedentary. 

So go out there and Play Ball!

Next Blogpost: What is Spondylolysis or a Pars Fracture?

 

Treatment Decision-making: Age and Magnitude

When posed with a pediatric spinal deformity in their child, parents/caregivers must decide on the optimal treatment for their child.  This can be a daunting task because each patient is unique and there are often multiple treatment possibilities.  In addition, the perspectives and beliefs of the parents/caregivers about their child and their particular problem are significant factors in the decision process. Interestingly, early in my career about half the parents said I was too surgically aggressive, while the other half said I was too surgically conservative when presented with similar treatment options for the same musculoskeletal problem.  To me, this highlighted the importance of parent/caregiver perspectives and thoughts which are often the product of their personal experience, culture, and religious backgrounds.

In general, the treatment of pediatric spinal deformity centers around two main factors: age of the patient and the magnitude of the spinal deformity.  The age is important as this gives us a rough idea of the child’s short-term and long-term spinal growth.  Spine growth is the engine that pushes spine deformity to worsen.  Hence, the faster the spinal growth the greater the risk of deformity progression.  The periods of time in which the child has the greatest spine growth is 0-5 years of age and during the pubertal growth phase.  The time between these two periods, specifically around 5 years to the start of puberty, the child and spine does grow but not as rapidly as those earlier and later time periods.  Hence, a slower progression of a spinal deformity is typically expected during this time period.

The second factor in treatment decision-making is the Cobb measure on the spine radiographs (standing or upright sitting).  This measurement, named after the surgeon which first describe it, Dr. John Robert Cobb of New York, allows physicians to quantify a spine deformity.  It is now the mainstay measure when talking about the magnitude of spine deformity.  There are other measurements physicians use in the treatment of spine deformity but, at present, these assume a secondary role. 

So when a physician describes a patient it may sound something like: A two-year-old male with idiopathic scoliosis and a 35 degree right main thoracic curve.  This child has a much greater risk of deformity progression than a 14-year-old female with idiopathic scoliosis with a 35 degree right main thoracic curve.  This is mainly due to the fact the 14-year-old female has much less spine growth remaining, as compared to the 2-year-old male who has much greater growth ahead of him.

In general lower magnitude deformity, less than 20 degrees of deformity, often does not need any treatment more than observation.  When deformities are >20 degrees, then physicians will need to consider the patient age, diagnosis, medical history, previous treatment, medical condition, and other aspects of the spine deformity when constructing possible treatment options.  Typically there are often there are at least 2 options, if not more, for children with a spinal deformity > 20 degrees.  Be sure to ask you physician to describe all the treatment options which are available for your child and why they are or are not good options.

Next Blogpost: Scoliosis in Sports

 

How do I find a physician for my child with spinal deformity?

When looking for a physician to care for pediatric spinal deformity it is recommended to seek out providers who are member of the Scoliosis Research Society (SRS) and the Pediatric Orthopaedic Society of North America (POSNA).  The SRS is an organization which requires its member surgeons to have the care of spinal deformity occupy a majority of their clinical practice, and they must contribute to the scientific advancement of spinal deformity knowledge through research.  POSNA is a professional organization centered on the musculoskeletal care of children, from head to toe.  So for both organizations, pediatric spinal deformity occupies a part of their overall focus.  By selecting a physician who is a member of both organizations you will have someone who understands the musculoskeletal system of children and possesses the technical expertise, and interest, in spine deformity surgery. 

What are some other factors should I consider?

            Does the physician work (do surgery) at a tertiary-care children’s hospital?

            Does this hospital have ALL the services my child may need?        

                        A 24-hour pediatric intensive care unit (PICU) staffed by 24-hour pediatric intensivists

Pediatric-fellowship trained anesthesiologists

Pediatric-fellowship trained general surgeons

The full spectrum of pediatric medical specialists (i.e. cardiology, neurology, etc…)

A full-service pediatric radiology department (MRI, CT, ultrasound, bone scanning, etc…)

Hospital reputation (both word-of-mouth and U.S. New and World Report ranking)

            Physician training and experience

            Physician’s annual surgical volume of spine deformity

           

Next blogpost: Treatment Decision-making: Age and Magnitude

The Internet Medical Jungle

Over the last 20 years the development of the internet and digital medical records has changed medicine dramatically.  For physicians, the rapid access and exchange, of important information about patients has enabled the delivery of faster medical care than ever before.  For patients and parents/caregivers, there is an ever-growing amount information which is accessible, about nearly every possible subject in medicine.  The difficulty is filtering the information, first in terms of topic and secondly determining the accuracy and validity of the information.  Search engines such as Google, Bing, etc… provides the ability to pull in information at lightning speed from across the globe and then list them numerically in order of how close the information matches the search words.  We commonly perceive the higher a website is listed on the search engine the more important, valid or relevant is its information to our question. However in reality, this is not always the case.  Owners of websites can pay the search engines to raise their site to a higher to increase their “visibility” to people using their search engine.

Businesses have long known the value of marketing and that the internet provides a cheap, rapidly-accessible, customizable method to reach millions of potential customers.  Healthcare providers and institutions have also realized this, albeit slower, specifically that this can be a valuable way to market themselves and their services.  The quality of any information available on the internet must be evaluated on an individual basis.  Be wary of claims made by individuals or organizations promising excellent treatment outcomes, over a short period of time, with low recurrence rates, using simple, painless, minimally-invasive or nonsurgical methods/procedures.  Many times these are marketing ploys and not scientifically-proven methods which are based in any high-level medical evidence.  If the promises seem to be too good to believe, they probably are not good options of treatment.  Often these promises play on parents/caregivers emotions, who are trying to find the best treatment for their child.

Caveat emptor.

Buyer beware.

Next blogpost: How do I find a physician for my child with spinal deformity?

Welcome to the Growing Spine Blog!

The aim of this blog is to provide parents and caregivers with clear, concise information on the problems, issues and treatment of pediatric and adolescent spine deformity topics.  We will try to demystify and focus our postings around spine deformity topics (scoliosis, kyphosis, spondylolysis, spondylolisthesis, etc…), in the cervical-thoracic-lumbosacral spine, in patients 0-21 years of age.  Our discussions may wander outside of this area at times, but we will always re-center our attention to the core area of this blog: pediatric spinal deformity. 

There is a significant amount of information available on pediatric spinal deformity topics.  Accessing this information can be easy.  However, it often leaves individuals in a state of confusion, and frustration, when attempting to find current, relevant information on a pediatric spinal deformity topic for their child’s situation.  If you are searching for the best general information available, there are a few websites which can be useful to help obtain peer-reviewed, relevant, unbiased information on pediatric spinal deformity:

                   

Scoliosis Research Society                                          http://www.srs.org/    

Pediatric Orthopaedic Society of North America      https://posna.org/

American Academy of Orthopaedic Surgeons           http://www.aaos.org/

 

These three websites are professional, physician-society websites which are without industry or marketing influence.  Their aim is to provide scientifically-based information without bias.

If you have questions, concerns, or issues in which you are searching for answers please leave a post.  We will routinely review the blog to address new inquiries, answer questions and we will continue to post new information on a variety of pediatric spinal deformity topics.  Thanks for reading!

Next blogpost: The Internet Medical Jungle