This presentation from pediatric orthopedic surgeon Ishaan Swarup, MD, shines a light on the developing spine. Focusing on scoliosis and kyphosis, he offers definitions, classifications, physical exam and testing pointers, treatment options and associated outcomes, and tips on when to refer.
today, we'll try to specifically focus on evaluation and management of this condition, focusing both on scoliosis and ketosis. I do have a few disclosures, none of which are relevant to the stock. I do servants, um, professional committees for pediatric orthopedic society in the American Academy, and I do some consulting work. But again, none of this is relevant to the talk today. So obviously PDS founder for me is a huge topic, even though, you know, it might be kind of ah, very focused area in the care of Children. For me, there's a lot that that I see in a lot that I treat in this realm. Um, for the purposes of today's talk, we will first go into the definitions of what really is scoliosis and ketosis. What are the technical definitions? Um, what are things that you know we should be way should all know and and use when we communicate with each other? Well, specifically, talk about conditions that are the most commonly seen, and these would include things such as idiopathic scoliosis, a swell as congenital scoliosis and Euro Moscow scoliosis. And then we'll talk about ketosis on. Really, there's two major ones to know when it comes Thio psychosis. And then And for the last couple of minutes, I'll just briefly talk about pediatric orthopedics here at UCSF as well as spine surgery at UCSF, so that everybody has a bit more familiar with what we do here at this university. So let's jump right in. So what exactly is scoliosis? Well, even though we often times when you use the word scoliosis, you think of a two dimensional deformity. It's usually a lateral curvature of the spine and the frontal plane. But what I'd like to kind of have you kinda understand that this is a three dimensional deformity. And the way I really explain this to families is that I say that if you take a wet towel and you ring out the towel and you have a twist, that's essentially what's happening to the spine. It's actually curling upon itself because our imaging modalities air limited. We see this as a two dimensional deformity, but again, this is a three dimensional deformity, and it's important to understand that because that has implications to your physical exam. And for me, as a surgeon has implications to what I do surgically now idiopathic scoliosis. Um, it's sorry. Excuse me. Scoliosis can be broken down into various different types. And so the big buckets of scoliosis are idiopathic scoliosis, congenital scoliosis, which is essentially a failure of formation or segmentation of the spine during development. Neuromuscular scoliosis. So this is patients that may have cerebral palsy, Rhett syndrome, some other neuro muscular condition that is attributing that is contributing to their scoliosis. Myopathy is like Russians syndromes like Maher fans and Ehlers Danlos and in compensatory scoliosis, which could be scoliosis. Do a luckily discrepancy, which really isn't scoliosis, but it comes off as an apparent scoliosis. Now, on the other hand, what is ketosis while ketosis is looking at the sagittal planes at a lateral X ray, And in general, all of us have normal parameters of cervical lord doses, thoracic, Infosys and Lumbar Lord doses. But thoracic hyper kit focuses can be seen in patients, and they're really too big, too. Big types of that one is postural, which is essentially flexible, and the other is structural in the most common condition. That falls into the structural categorias Sherman's disease, and we'll talk about that as well. So let's talk um, for the briefly about idiopathic scoliosis, since that's a topic that you know most of us have seen. And it's definitely something that is commonly seen in the primary care setting. So generally idiopathic scoliosis. What is the ideology of the well, it's really unknown. Um, there have been various studies that have been done, um, looking at the genetics. And there are some studies that have shown that there are some auto zonal, dominant traits to idiopathic scoliosis. However, there is incomplete penetrates. So even though as a surgeon, when I see patients with idiopathic scoliosis, I often all I mean, I always ask about family history, but it's clear that it does not go from generation to generation. Overall, we classify, we sub classify idiopathic scoliosis into three types juvenile, infantile, juvenile and adolescent, and this is purely based off of the age of time of diagnosis. So the infantile group is essentially Children between the ages of zero and three that are diagnosed with idiopathic scoliosis, juvenile between three and 10 and an adolescent, which the most common, um, is essentially Children that are over the age of 10. Diagnosis scoliosis. What is the epidemiology? Well, UM scoliosis in general is quite common. It is seen in about 2 to 3% of Children. However, more severe curves are less common, so you can see there. The prevalence dropped significantly for curves greater than 20 degrees. It is important to note that, by definition, in order for a child have scoliosis, the curve must measure greater than 10 degrees. If it's less than 10 degrees, it is not scoliosis. It is what we consider spinal asymmetry, and in fact, the prevalence of spinal symmetries is probably much, much larger than even 3% of the population. This is a nice table here, which shows that if you look at the distribution of boys and girls with scoliosis for smaller curves occurs between 10 and 20 degrees. The ratio is relatively similar for boys and girls. However, the more severe curves, um, tend to happen more commonly in girls. And that's the reason why when we think of patients scoliosis, you know it is oftentimes more commonly seen more severe curves more commonly seen in girls than than they are in boys. The clinical evaluation. I think this is probably one of the most important slides that I'll be sharing with you today. I think in general, when we see these Children for scoliosis, oftentimes patients come in with a concern for families come in with a concern of cosmetic appearance and oftentimes that the story is that it's a summer holiday. You go to the beach and you notice that you know something looks different. Shoulder height looks different, the pelvis looks different. There's waste crease asymmetry. And oftentimes there was the things that families perceive first, which oftentimes prompt a referral for evaluation. It is important to note that back pain is not commonly seen in idiopathic scoliosis, and actually, the back pain is a typical and so oftentimes, When I see a patient that has scoliosis and back pain, I'm really scratching my head and thinking about other reasons why a kid may have back pain. And oftentimes I'm thinking about more advanced imaging for that patient, because again, that is not a very common finding idiopathic scoliosis, So the history and physical exam are very important. Since this is a diagnosis of exclusion, the word has idiopathic in it, and so as a result we have to do our due diligence and rule out every other potential cost for scoliosis on physical exam. I'll kind of walk you through what I do in my physical exam in we can talk about. You know how much of that is applicable to the primary care setting. So generally, ah, large part of my exam is inspection. And so what I'm doing is I'm looking at the child from the back. I start from the top and go to the bottom. So I look at shoulder heights. I look at their waste crease. I look at their pelvis. Those are all giving me some subtle ideas of How bad is the deformity? It first of all, is there a deformity? And how bad is the deformity? Then what I'll do is I'll do in Adam's for bending tests. As many of you know, that is just having a child bent forward. And this is where I'm looking for thoracic and lumbar prominence. This is exactly where that three dimensional aspect of scoliosis comes into play because it's a rotate. It's a road, a Tory condition. That is why you see one side of the ribs being higher than the other. And so that is what I'm looking at to see what side is higher, which one is more significant. And that's where you would also do your Schooley ometer measurement, which we'll talk about on the next slide on inspection. I'm also looking at their skin. So what am I looking for? What I'm looking for? Cafe Ole spots, you know, thinking about neurofibromatosis, a possible condition for that's associated scoliosis. I'm looking for, um, Harry patches my things about my woman into seals Andi as a surgeon. If it's a surgical candidate, I'm also looking at their skin for things like acne. You know, there are some studies that air have been published that do show that risk of infection may potentially be higher. And so I'm often times looking at those things a swell when I'm when I'm inspecting a child's back. And then I really focused on a neurological exam. Now again in the primary care setting, it's probably more limited than it is in my world. However, um, it is critical to neurological exam in certain patients specifically, for example, patients that have juvenile idiopathic scoliosis, the patient between the ages of three and 10 studies have shown that about a 25% of them have an interest final abnormality in addition to their scoliosis. So those are the patients that specifically do need a neurological exam. In the things that have been known to be found in those patients are things like a chiari or ceramics, And so it's important to do reflexes on do a gross motor and sensory examine those patients. Additionally, it is important to do a neurological exams on patients that have rapid progression of scoliosis. Scoliosis generally doesn't progress very quickly, but when it does, that is another sign under the reason that we should do a thorough neurological exam to make sure there's no abnormality in the neural access that is driving their scoliosis. Eso that maybe another population that would deserve a more thorough neurological exam. So moving on Thio Scully ometer a little bit more So this is something that we use commonly in clinical practice. Um, it's essentially a measure of a symmetry, and so it's all done on Adams for bending test, and with the patient leaning forward, we measure up and down the spine at different parts of the spine to see how much of a rotational asymmetry there is, and generally, if there is more than 5 to 7 degrees of asymmetry, those of the patients that should be referred, they're happened. Correlation studies because again, this is looking at rotation, and so 5 to 7 degrees tends to correlate about a 15 to 20 degree curve. And so those patients that have truly have a definite diagnosis of scoliosis and they're definitely the ones that should be followed by an orthopedic surgeon so that we could determine whether they need any kind of treatment. Now, if admittedly a lot of us don't have a Scully ometer and actually I don't carry Scully ometer around anymore, and so there are other ways to do this. And so there's a kind of a whole bunch of smartphone app that have been developed. Um, that also do the same thing as a Scully ometer. And in fact, if you have just a regular cell phone, you can use your level app, which is used in carpentry to kind of do the same thing, which is essentially showing you whether things are level or not. So if there is a suspicion for scoliosis, what do we do next? Well, our first step is to get imaging and image ing for patients. Scoliosis is an X ray, so generally it's a standing high quality p a X ray, a swell as a lateral luxury of the entire spine. Now the reason we do p a X rays, there's a couple of different reasons. But in general, as a spine surgeon, were oftentimes looking at patients from the back. And so by convention, as you've probably seen in the extra up, showing already in a couple of X rays that I'll show you all of the extra they're looking from the back left is the left and the right is the right. Um, in addition, we do get lateral X rays as well, just to kind of see what? How is the deformity? How is the scoliosis affecting their sagittal profile on? There are some abnormalities that you can see on a satchel profile, which could be a typical which again, qu in tow. Could this be something other than idiopathic scoliosis and some funds that are typical which go with the diagnosis itself? Now, the measurements that we do, and oftentimes these were done by a radiologist is what we call a Cobb angle, and this is looking at the most severe curve that you can find in the spine. Oftentimes, residents and fellows will ask me, You know, how do you determine where one curve stops and the other one begins? And I tell them, You know, the easiest way to tell is to look at the disk spaces between the vertebra, and so you could tell that if there is a right the massacre, for example, in that image on the upper upper right there, you can see all the vertebra are wedged so that the smaller part of the disc spaces towards the contaminant of the curve. Also for imaging, I would say that it's probably best to have imaging done at a facility that that routinely does scoliosis measurements, and that's for a couple of reasons. One is it is very technique dependent. Oftentimes, these extras have to be stitched together by the radiology tech. And so a place that does this more often, um, is more fast. All of doing that and the other is the measurements. So you wanna have a radiologist who does these more than just a handful of a handful of times a year so that we get reliable measurements for these patients. There are some or emerging technologies that are coming out, and a lot of these have to do with the fact that we want to minimize the radiation that Children receive, especially for spinal imaging. On DSO, There are some things that have been written about are being done surface topography, which is actually a relatively it's been around for a long time, but it's actually has some renewed interest in order to see. Is there any any topographic measures any, um, and the inspection measures that we could correlate with spinal deformity? And so we are starting to do that a bit at UCSF, and there's gonna be more to come on that as we start to validate that and use that for clinical decision making. But still, I think that's a couple of years down the road for us now. What about more advanced imaging memories? Well, in general, I would say that in the primary care setting, it's pretty rare that you would be ordering this, but things that you know conditions that where I consider an Emory our patient, that certain diagnoses. So, for example, the juvenile idiopathic scoliosis patient. You know, if they're old enough to be able to tolerate a memory without sedation, and if I have a heavy, high enough concern for a neural access abnormality, I will definitely ordered that, um, patients that have any abnormal findings on exam. So a typical you know, asymmetric reflexes, asymmetric abdominal reflexes or a typical curve patterns. Um, if you know, for those of us that look at scoliosis enough, you know, we know that our right Jurassic Curve is very common. Whenever you see a left Jurassic Curve, then that's a typical and oftentimes those of the patients that need to have a memory and and then the last cohort that I usually get a memory on other patients that that we're gonna be doing surgery. And there's a couple of reasons for that. One of them is again, even though the diagnosis idiopathic scoliosis, you know, they're undergoing surgery. They're gonna be undergoing. You're monitoring. So if there is an abnormality, you would rather know than not no and the other is it also gives me an idea of their anatomy, especially from a surgical planning point of view. Now, you know, we wrote a paper about this, and we found that actually, the rates of neural axis abnormalities, even in patients that have idiopathic scoliosis, is quite high. But it's important to recognize that a lot of those patients do not need any intervention for their neurological abnormality. It could be a small cyst. It could be a very small Cyrix again, none of which may need treatment. But it is again important to recognize those findings. So why do we treat scoliosis? You know, why does this matter so much? And this Ah, lot of this information comes from natural history studies that were done in Iowa many years ago. And so these studies were done in Iowa because they had a relatively, um, stable population that they followed for multiple years. So it was a landmark paper. I'm sorry this may not project so well, but it was a landmark paper by Stewart Weinstein, in which she followed patients for over 40 years with idiopathic scoliosis and generally scoliosis. The way I think about it, there's a couple of implications. The biggest and the kind of the most scary implication is the cardiopulmonary implication of cardio pulmonary function. Now it is important to note that those implications that changes in Pft s restrictive lung disease, things like that oftentimes happen when the curve gets above 80 and 90 degrees. And thankfully, in North America, we oftentimes intervene before Children get to that severe of a deformity. Now there are some other implications, too, including pain later in life. And there was actually a really good study that showed that patients that had or Children that had idiopathic scoliosis or patients identify scoliosis. Children oftentimes have a higher rate of back pain later in life, and the way that works is because it is simply because you're buying. Mechanics are different when you have scoliosis. Your discs are being loaded a different, uh, in a different way than they are. If you don't have scoliosis, and as a result, you're probably more prone to developing degenerative changes. And so they may have more back pain later in life and then the most obvious. And I think the one that is probably, you know, really the elephant in the room is the CAA's missus and self image. Part of this I do, you know, seeing patients with scoliosis. There's a huge part of this, which is psychological and kind of implications to self image, and I think that's an important part of the discussion with families and patients. The have scoliosis Generally, the options for treatment depends on I'm sorry are threefold. One is observation, the other is bracing and the last one of surgical management. I'll talk a little bit more about those indeed in detail in the subsequent slides. The decision for treatment to depends all upon the risk. The magnitude of the curve and the risk for progression so generally curves that are between 10 and 25 degrees or the ones we're observing. And the reason we're observing those is because, as you can see from this natural history study by Weinstein, those are the curves that have the lowest risk of progression on DSO. It's fair to watch those and see what happens. Some get worse, but the majority of them don't now. The larger the magnitude of the curves, the curves that get above 25 30 degrees have a higher likelihood of progressing. And so those are the ones that we start to think a little bit more critically about intervening. The other thing that determines risk of her progression. That kind of the most significant driver. But is growth so generally scoliosis gets worse as you grow. And so that is something else that I plays a huge role in my decision making of what treatment I'm offering to the family. And so what are some factors? I or was some things I look at, So one is skeletal growth remaining. So oftentimes on that X ray that that we've obtained, we can look at their pelvic hypothesis on that reliably closes from lateral to medial. And so there's this thing called the reserve stage, which you've probably seen it in a lot of notes that we all right, and that helps me figure out how much growth the child has left. If it's a female, I'm looking at their menstrual history and agent monarchy because we know that peak with velocity happens right before monarchy. And then generally, growth happens for about a year and a half to two years after monarchy and girls. So that's helping me figure that out. And thirdly, it's actually the growth chart, Um, and so I often times, you know, look at the growth charts. If It's a patient that's been in our system here at UCSF. I could go and look at the pediatrician's note and look at the growth chart that they have generated and see What are they doing? It's That kind of helps me a lot to figure out treatment as well. So generally observation is recommended for most Skelly immature patients with curves less than 20 to 25 degrees. Now the frequency of observation, whether I'm seeing them every four months or six months or nine months or a year or two years all depends on the patient's age and growth potential. So if it's a child who's 10 whose pre monarchical has a 20 degree curve, I'm probably seeing that child back every six months just to make sure that curve is not getting worse because they have a significant amount of growth left. Whereas on the other end of the spectrum of it's an 18 year old postman Arkle female with a 20 degree curve, I might I might, you know, make the follow up there from a year to two years just because their risk of progression is so much lower because their growth potential is so much lower now. Curves that get much larger are the ones that I start to watch more closely on DSO 50 to 70 degree curves. For example, if a curve gets up to 50 degrees, we know those are the ones. Those are the Those are the bad actors and the reason why they're bad actors. Because even after scaled maturity, those can progress a degree a year for the rest of your life. And so this goes into a little bit of decision making for when we intervene with surgery. So the reason why you know, oftentimes I get asked what's so magical about 45 or 50 degrees? And and the reason is is because again, natural history studies have shown us because that's the critical number where, even after you've rescheduled maturity, those crops could get can progress about a degree a year for the rest of your life. So if you have a 50 degree curve when you're 18 years old, that could end up being a 75 or 80 degree curve by the time you're 50 which again could have implications to cardiopulmonary function, which again is something that we want to avoid in this in this in these patients, so bracing, who's a good candidate? So we talked about observation, and who's a good candidate for bracing? Bracing is generally considered for curves that between 25 45 degrees in patients that have growth remaining. And so the goal of bracing. And again, this is a very important point on, but something I tried to express the patients and families. Is that the goal of bracing us not to make the scoliosis go away? There's nothing that that we could do todo to make it go away. But the goal is to stop it from progressing. And if so, if it's a 30 degree occurred when we started, it would be fantastic if we could keep it at 30 degrees. Once the child is re skeletal, maturity racing is not a walk in the park. It is a commitment, and it's a real commitment. On behalf of the child is a real commitment on behalf of the family and so often times. This is a pretty serious conversation that I'm having with families and often times you know, these their families I spend extra time with, and, um, it's one of the perks of being at a place like UCSF, where I have support staff who can help me. Um, council families put them in touch with other kids who have done bracing because we know that bracing will only work if the family and the child buys into it. So compliance is really key. There have been good studies which have looked at how many hours should be should be bracing Children. And so this graph that you could see on the upper right it really shows that you need to have a child and embrace for over 18 hours a day in order to really get the maximum benefit of the brace. And so that's generally what I recommend. And if you can think about your average day, 18 hours, a big chunk of the day. And so again, that's the reason why I think this is a real commitment, but that's the general. That's the reason why we make the journal recommendations for 16 18 hours a day. Minimum for bracing is toe, because that's where we know it's the most efficacious now on the topic of compliance. The other thing that I've recently started do my practice and do this as a fellow when I was a fellow in Philadelphia is that we would put in compliance monitors and this isn't, you know, trying to be big brother and see what's happening. But it's really a patient education tool. And so, oftentimes, when kids come back to see me after they started bracing, they come with a little compliance report card, which basically shows me how many hours have they been wearing the brace, And it allows us to identify points in the day or points in the week that are really troublesome for them and why they're not able to worry their breaks. So we're really trying to boost compliance. It allows me to be to provide more directed counseling to the family and to focus my time and effort on those particular periods of the day of periods the week where we could improve compliance. And they've actually been studies that have shown that by just telling that a child that your compliance to be monitored compliance gets better and that I think speaks toe. You know what many of us know is the Hawthorne Effect, right? Actions change when people are being studied, so they're multiple benefits benefits to that Now. What about surgery? Um, surgery is generally considered when curves get above 45 50 degrees. And again, I've alluded to the reasons for that. And the reasons are because those the ones that progress even after skilled maturity, so generally you know it's a growing child and increasing curb over 45 to 50 degrees. And the goal of surgery is to stop progression and to achieve a balance fine. Again. The goal is not to make the X ray look fantastic, and to make the curve go from 60 degrees zero degrees for me, the goals are to balance the spine to do it safely on GTO. Get the spine to fuse in that position. So what do I mean by balance? Balance basically means making sure the head is centered over the pelvis because, sure enough, this child has a long life ahead of them, and they need to be optimized from biomechanical point of view so that we're not creating a problem for them. Things like, you know, disc disease, back pain later in life. The conventional surgical management that we recommend is poster spinal fusion, and that's kind of the workhorse for what we do in terms of correcting spinal deformity in patients. But there are some other techniques. There are some anterior approaches, um, to spinal fusion as well. Now there are a lot of them are becoming less and less common because of better instrumentation that we could do push generally. But we still consider that in some patients, um, there are some other more emerging techniques, like spinal tethering in which we're what we're trying to do is really harness. The growth potential was fine. Now tethering is still, I would say, relatively experimental on. The indications are somewhat unclear, and the outcomes are definitely mixed. Eso one of my colleagues here, does do that. UCSF. But again, I think the jury is out on who's the right patient for that condition for that procedure. Rather. But in general poster spinal fusion patients do very well, and we have a long track record with this, not only in our institution but throughout the world. With poster spinal fusion. Patients generally have good functional outcomes and the corrections maintained, and in fact, if you look at things like back pain, the rates of back pain and patients have had a spinal fusion are pretty comparable to the general population. So let's bring the discussion back to the primary care setting. So when is a referral warranted for these patients? This is a nice algorithm from a paper that was published in JAMA a couple of years ago, which really shows that obviously, we have screen protocols that have been put together by the AP and the Pediatric Orthopedic Society and the Scoliosis Research Society, which really talk about the times and you should be screening the school. The OMETER is an important tool in screening and figuring out which patients would be referred and then definitely if there is a concern. Um, you know, I think having a low threshold is reasonable in these cases because I, you know, I do understand that it caused a lot of anxiety on behalf of the families and the patient. When they're told that they have scoliosis, I would say the other patients to refer are ones that have particular syndromes and conditions associated with scoliosis. For example, ensuring with cerebral palsy, um, insurance with Children with Marfan, for example, is well are probably reasonable candidates to refer for evaluation as well. I also understand that it sometimes takes time to get a referral. And so what are things that could be done well in X rays again? Doing an X ray of high quality X ray, an institution that does X rays or in a facility that does a scoliosis X rays is probably a good first step, making sure the families come with the C d of their X rays so that we're not having to repeat imaging for these Children and then offering some patient education. I totally understand that everyone has a very busy practice and a lot to do on DSO. Some of the resource is that I use or the scoliosis Future Society three American Academy of Orthopedic Surgeons in the Pediatric Orthopedic Society of North America and I can send out these websites to you, and all three of them have. Resource is for families, um, in which there who may have a concern for scoliosis just to kind of talk about some basic questions and provide them with some more information. So before we kind of moved thio some other topics, just a few other, uh, you know, important points to discuss here as a surgeon. You know, I definitely think that surgery is a team sport. And it is a partnership between not only me but also other providers who take care of this child, including the primary care doctor, the hospitalists, the intensive, this the anesthesiologist. And so, um, again, I feel very fortunate to work at Insurance Hospital where we do this often and we oftentimes meat is the most disciplinary team to talk about issues surrounding a particular case on Ben Post Operatively is having pathways and goal directed care. You know, there is very subjective that we want to fulfill. For these families, there's, ah, lot of confusion and a lot of mixed messages, I think mixed messaging about pain and what to expect after surgery. So I think again, this is, uh it really helps Thio communicate directly as a team in order to set expectations for patients, their families, so that we can successfully get them through surgery. Now, um, surgery. Spine surgery in general is major surgery, and I think it's very scary Thio practitioners, but also scary toe families and patients. And so one of things I'd like to also expresses that I would say generally it is a very safe surgery, especially in a place that does high volume spine. And so this is a paper that was published, which looked at over 3000 posters, spinal fusions that were done and you could look and see that the rates of, you know, kind of, you know, big major complications. The rates of those are very low. Yes, infections happen. Yes, hardworking break. But if you look at neurological risk, risk of death, things I got are very low. And so again, I would say that generally surgery, it's safe in these patients. Um, but again, it is important surgery, surgery, eso It is important to convey that to families as well. So the next kind of five or 10 minutes just kind of move through a couple of other types of scoliosis, and I wanted to vote most of my talk to idiopathic scoliosis, since that's the most common type. And that's you know what we all of us collectively see the most of. But let's just talk a little bit about the other taxes scoliosis, so congenital scoliosis. This is an important one. Um, now congenital scoliosis by definition results from abnormal growth or development of the vertebral column. This usually is the result of an injury or an event early on in gestation, so kind of around the sixth week of gestation, when the spinal column is being formed. Generally, it's either a failure of formation or segmentation. Now, what that basically means is formation, as formation of the vertebra and segmentation is separation of the vertebra, and sometimes you can have one or the other, or you can have a mixed type. The most important thing to recognize about congenital scoliosis, both in the primary care setting and even for me, um, in orthopedics is that it is very important to rule out associated conditions, specifically cardiac and on, and g you conditions. So, for example, just maybe over a month ago I saw a 15 year old kid who had a congenital scoliosis, and sure enough, we got a echocardiogram. We've got a G ultrasound and subsequently memory, and and it showed that the child had a solid retro pharyngeal tumor. And so, you know, these are things that people write about, but I think it is definitely common in practice, too. So it's having you know, uh, having ah, low threshold to get those images, especially for the cardiac and G you systems, um, is a very important point for treatment generate for congenital scoliosis. We don't treat those embracing because they're usually pretty rigid deformities because their structural, um and oftentimes surgery is what we will do for them. However surge. The indications for surgery are very different. And oftentimes we will differ surgical management until the child developed some kind of imbalance. Eso whether that's, you know, they're sitting balance or they're standing balance or their satchel playing, whether they kind of look forward to backwards. Those are things that guide our decision making for surgery for congenital scoliosis patients. The next type two just recognizes neuro muscular and syndrome X scoliosis eso. These are common in patients with conditions such as through re palsy, muscular dystrophy and certain syndromes such as more fans and Ehlers Danlos. This is a little bit different from general scholars in the sense that this is more due to weakness of muscles or muscle imbalance or even spasticity. This results in an imbalance, oftentimes difficulty with care and implications. Thio there pulmonary function. So this image on the upper right There is actually one of my patients who has read syndrome and her curve measures about 95 degrees. Sure enough, she's had multiple bouts of pneumonia, has been admitted to the hospital on DSO. You know that this could have significant implications to the patients. General health Talking about going back to our discussion of what are typical and atypical curves. Typically, curves and neuromuscular scoliosis are these long C shaped curves, and you can probably appreciate by looking at this extra. This looks different from the first extra I showed you for scoliosis. And so, oftentimes, when I see a C shaped curve Onda kid that doesn't have one of these conditions that raises my antenna and it zone atypical curve in a patient without neuro muscle condition. But in in your Moscow patient, these are the more typical type of curves we see now treatment. For them, bracing is oftentimes tried because we think that because it's a muscular imbalance, maybe that has some flexibility but are at level of evidence is nowhere as close as it is for the idiopathic scoliosis patients. Remember, I showed you that that curve where we see compliance and efficacy of bracing an idiopathic patients. Unfortunately, we don't have such robust data in this population, but hopefully one day we will, um, for curbs that got above 50 degrees those those Those are the ones where we start to consider surgery. But surgery in this population is very different from surgery in the idiopathic population. So I just spent a minute or so talking about surgery is generally safe in the idiopathic population. Surgery in this population is fraught with complications, so there could be many road bumps along the way. And so this is a big part of my counseling with families that I'm doing Spinal fusion for from normal conditions is that you know there is a high risk of complications again. It's a reason why we do this at a specialized center like a Children's hospital. It's because oftentimes they go to the i C u intubated. There could be infections pneumonias, G. I issues Alias, and so it's really important to make sure that their care is optimized before surgery, but also that we're in a setting where we can provide safe, post operative care to the family. So in the last couple of minutes here, we'll talk about ketosis. So if you remember psychosis again, we're looking at the lateral X right here. We're looking at the child from the side, and so the first type is what we call postural ketosis. And this is something that we all see right? This is where families come in, and they're just concerned that you know their son or daughter is just hunched over. And oftentimes it's a cosmetic concern that could be voluntarily correct is if you have a child and you inspect them. You're looking from the side and there Yeah, sure enough there, hunched over. But if you ask them to stand straight, they stand perfectly straight. That is postural kit posts because it's flexible. It's not generally associated with any pain or progression, and oftentimes it can be managed with reassurance and in particular cases where families were really concerned. Uh, we can sometimes recommend ah hypertension hyper extension exercise program, which could be just a short course of physical therapy eso that the family can practice, um, some good postural habits. Now, the more significant type of kite folks just to know about a structural ketosis. So this is kind of what you know, The diagnosis that's most commonly associate structural hypothesis is Sherman's disease. Um, and what we're talking about here is a rigid deformity. And so, oftentimes, in an X ray, what you'll be looking at is you can see wedging of the three consecutive vertebrae. So what I mean by wedging is the answer. Part of the vertebra is narrower than the poster part of the vertebra. And so this is one of my patients whose got Sherman's disease. Andi, Um, you can see that there's some wedging in the mid thoracic spine there on those x rays. The disc space look unhealthy in the sense that they were irregular. It seems squished. They're not as healthy as the ones lower down in the lumbar spine. And oftentimes these the ones that we do have to intervene in some way now. Treatment for structural kit focuses depends on the magnitude of the ketosis, so all of us obviously have some ketosis. But typhus is greater than I would say, 50 to 60 degrees of the ones where we tend to recommend some physical therapy to see if we can. We can help with some dynamic exercises to correct that hypothesis above 60 maybe 75. 80 degrees of ones where we sent tend to consider a brace. And again, the level of evidence for bracing is not as great in this is not as well studied in this population, but we still do it, and often times it's what we call a hyper extension brace, um, to help correct the spine and the point there is toe hold the spine in a position so that has growth happens that the child's natural growth can help them grow out of the psychosis and encourage that. Sorry, Typo says. That gets above 75 80 degrees, the ones we tend to consider surgery because again there could be implications to cardiopulmonary function. And some patients can even have pain on DSO. Those were kind of, in general, the algorithm we follow for psychosis. So I believe we just have about five minutes left for the formal talk part of this. But I'll just show you a couple of examples here of treatment for scoliosis. It will go back and forth between the different types of scoliosis. This is a patient that I saw actually my first month of practice here at UCSF Eyes there is a kid who is, I think maybe a month postman Arkle came in with this about 30 degree lumbar curve had skeletons of schedule in maturity. And so I put her in a brace of the extra on the very left of the initial X ray, the extra in the middle of the extra and embrace again the purpose of the braces not to make the curve go away, but it's to help control the curve. And then just last week, um, you know, she is now kind of plateau in her growth. I see signs of skeletal maturity, so we just discontinue the brace. And I would consider this to be embracing success. We kept that curve, that 30 degree curve at 30 degrees. And so to me, that's that's a win. Now it doesn't mean that we're done. I continue to watch this child because again skeletal scale, the growth is something that you know we can make our best guess at. But we cannot predict exactly. But again, from a bracing point of view, this is a success. This is a kid with with adolescent idiopathic scoliosis, and you can see. She had about a 65 degree throughout the curve that underwent a spinal fusion. And so this is what a spinal fusion looks like again. The purpose of the surgery is to get the spine, if you so. If you look really carefully, you can see at the bottom of the screws. You see some fuzziness around the screws, and that's bone. That's fusion Bone to the bone Started, refused Her balance looks good on DSO If we continue along this road, Um, I'll be very happy with the outcome. For for this child, this is a younger child. This is a kid who's got a syndrome IQ condition with scoliosis, her curves about 100 degrees and because she is still growing. She was about 10 years old when she saw me Prima Markle. And the most important thing about her is her stature. I mean, she was about 4 ft tall, and so if I were to fused her spine, then she would have many issues later in life, including having a short trunk having a Z. You know, her pulmonary function would be compromised because her one wouldn't develop. And so we did hear what we call a growing rod construct. So screws above screws below. And every six months or so, I take her back to the operating room in a lengthen that rod. So it helps to correct her deformity, meaning it makes her balance better, Um, but allows her to grow. And then eventually, once she's reached skeletal maturity, then I'll go through and Fuser definitively. Okay, so in conclusion here, um, I would like to say that you know, spinal deformity of something. So it's something that we commonly see in Children of all ages. It is important to value for scoliosis and key focuses per the guidelines of our professional societies, but also based on your clinical judgment. If in doubt obtaining X ray and refer for further evaluation, I think all of us would rather know than not know Andi. I think families would appreciate that, too. Um, consider associated conditions, especially for patients that have certain diagnoses of things such as congenital scoliosis, patients with syndromes. Um, those are all important populations to think about associated conditions observation, embracing our successful strategies for the right patients. And so again, it's selective. But you know our treatment algorithm is again based on how bad is the curve and how much growth the child has left and then spine surgery is major surgery, but it is becoming safer and is generally associated with good outcomes for most patients. However, again, peri operative management is critical to patient outcomes and satisfaction. So I think that's where working together in terms of understanding and setting patient expectation is critical to the work that we all do in taking care of Children. Um, in summary, here's ah, referral slide for our institution. We offer clinical services in both sides of the bay in the East Bay and the West Bay. My clinical practice is mostly focused out of Oakland. However I do operate, sometimes in Mission Bay are clinical outreach in the East Bay spreads all the way from San Ramon, Walnut Creek in Oakland in the West Bay. Um, it's all the way, obviously, in the city, but also to some locations in the North Bay as well. And these air my colleagues in pediatric orthopedics. We have ah rapidly growing division in pediatric orthopedics. I joined the staff here last year after doing all my training on the East Coast but we have three or four of my colleagues helped take care of spying patients as well, and we do offer services for all other pediatric subspecialty care, including sports and limb deformity, um, in your Moscow patients as well.