Decision Making

Treatment Decision-making: Age and Magnitude

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.
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.
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
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.
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.
Blogpost: Scoliosis in Sports

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