Thursday, June 23, 2016

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.

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