With a focus on the most common type of scoliosis, pediatric orthopedic surgeon Ishaan Swarup, MD, offers this guide to detecting and evaluating the vertebral deformities seen every day in the clinic. He explains how to distinguish true scoliosis from mere spinal asymmetry; risk factors for curve progression; which treatments are demonstrated to work for various kinds of scoliosis and kyphosis; and how to counsel families to understand their options, comply with therapy and have realistic expectations regarding outcomes. Learn about recommended X-ray views and modalities, indications for MRI, how often to recheck children with less significant curves, and when to refer to orthopedics.
All right. Hi, everybody. Um, good afternoon, I guess. My name is Ishaan Swaup. I am one of the pediatric orthopedic surgeons here at UCSF. Um, just I'll give a brief introduction, um, about myself and my practice, and then I'll kind of jump into our topic today, which is pediatric spine disorders. So, um, I am actually originally from this, from the Bay Area, um, I grew up in the East Bay, went to college at Cal. And then did all of my training on the East Coast. Um, I was at medical school at Dartmouth residency at Special Surgery in New York, and then fellowship was at the Children's Hospital of Philadelphia. I joined the faculty here at UCSF in 2019, and my practice is mostly on the East Bay side at Children's Oakland, um, but I also see and operate at the Mission Bay campus as well. Um. And then my kind of clinical areas that I work in are pediatric spine, pediatric hip, and trauma. So, you know, kind of relevant to today's talk, but I also take care of a lot of patients with dysplasia, you know, Perthy, skiffy, and then um I do serve as the director of trauma for our group, um, here at UCSF. So today or this afternoon, we'll be spending some time talking about pediatric spinal disorders. Um, my disclosures are listed there, but none of them are relevant to this talk. So by way of outline over the next, you know, 40, 45 minutes, um, I'd like to go over a couple of things with you. Um, one is to again review, um, kind of some of the basics of scoliosis and kyphosis, you know, what do these terms actually mean? What are the clinical definitions of them, um, how do we use them from an orthopedic perspective? And then we'll talk about some specific conditions and I think, you know, out of the ones that are listed there, the biggest one is obviously idiopathic scoliosis, which is by far the most common type of scoliosis we see. Um, we'll also talk about some of the other. More rare types, including congenital scoliosis, since it has several implications to, you know, other general medical topics, um, and conditions. We'll also talk about neuromuscular and syndromic scoliosis, and this is maybe relevant to, you know, those of you that do take care of patients with complex medical conditions. Um, we'll also talk about kyphosis because that's oftentimes, um, a major reason for referral to orthopedics. Um, and then I'll try to provide you with some updated kind of resources and patient education materials which I think are, you know, really helpful, um, to provide to families, especially as, you know, they're diagnosed with something, whether it's on X-ray or by clinical exam, they're waiting for a referral, so these might be things that might be helpful, um, in the clinical setting for you. So our objectives, um, uh, this afternoon are to describe the different types of scoliosis and kyphosis, describe physical exam and radiographic findings that go along with these conditions, explain some of the basic treatment options for these conditions and no educational resources to offer to patients. So first of all, what is scoliosis? And so scoliosis is really defined as a three dimensional deformity of the back, um, and, you know, I did this webinar similar one a couple of years ago, and, and kind of the analogy that I use and I still use, um, is the twisting of the towel analogy. So I usually tell families. You know, when you have a wet towel and you kind of wring it out to get the water out of it, that's kind of what what happens to the spine and scoliosis. It's three dimensional. That's, you know, really the reason why an Adam's forward bend test shows what it shows, right? A prominence is shown mostly because it's actually rotation um in the axial plane that's happening in the spine. Um, we oftentimes interpret it as a lateral curvature of the spine in the frontal plane. And um, by definition, scoliosis has to be greater than 10 degrees. And so there's, you know, we'll talk a little bit about the cobb angle in a second, but cobb angles that are less than 10 degrees as measured by the radiologist or orthopedic surgeon are not true scoliosis, they're more likely spinal asymmetry. And then they fall into various buckets and the most common ones we see um in in North America in our patients are idiopathic, congenital, which is basically a failure of formation or failure of segmentation, uh which goes way back to, you know, the days of embryology, and we'll talk a little bit more about that. Um, neuromuscular, so these are, you know, neuropathic diseases such as cerebral palsy, um, my my myopathies are myopathic, and these would be things like Duchaines or arthroriposis. And then uh syndromic, which would be things such as neurofibromatosis or Marfans. And then I put compensatory there as well because sometimes it can look like you have scoliosis or compensatory scoliosis or apparent scoliosis, but it may be due to something else like a leg length difference, for example. And then for kyphosis, it's really defined as a sagittal plane deformity. Um, in general, we all have some normal cervical lordosis, some thoracic kyphosis and lumbar loidosis, and then thoracic kyphosis or hyperkyphosis really falls into two buckets. One is what we call postural or flexible kyphosis, and we'll talk more about that, or rigid kyphosis. Um, there's different types of rigid kyphosis, but the most common one we see in North America is a condition called Sherman's disease, and we'll talk a little bit about that as well. Other reasons for rigid kyphosis could be infection or trauma, uh, which again not so common, uh, fortunately in our population, but, uh, but are other reasons for, um, rigid kyphosis. So let's take some time and talk about idiopathic scoliosis. So idiopathic scoliosis, the etiology of it is still in 2025 unknown, but it is likely multifactorial. We know that genetics plays a role. It is likely autosomal dominant, but it has incomplete penetrance. So oftentimes you'll see, you know, parents may have had mild scoliosis or grandparents may have had mild scoliosis. Um, it can skip siblings, so that that's why the penetrance is incomplete, but there is clearly a genetic component to it. We classify idiopathic scoliosis based off of the age at the time of onset. So if you are 0 to 3 at the age of onset, then this is called infantile scoliosis, ages 3 to 10, this is called juvenile idiopathic scoliosis, and um 11 and older is called adolescent idiopathic scoliosis, which is certainly the most common out of the different types of idiopathic scoliosis. You know this obviously um is important from a classification perspective and um you know, from a research perspective. However, it has clinical implications too. So for example, infantile idiopathic scoliosis sometimes has a tendency to improve with time so it's important to know about that. Juvenile idiopathic scoliosis, um, which by the way, is unlike juvenile idiopathic scoliosis and adolescent idiopathic scoliosis, juvenile idiopathic scoliosis is associated with neural access abnormalities on MRI. So this is a population where if I see them and they have significant curve and they in that 3 to 10 age group, then I would oftentimes get an MRI to ensure there's no syrinx, there's no curry malformation. And then adolescent ones, of course, um, these are the ones that are most common and oftentimes, you know, are quite progressive because it's right around their growth spurt. So in general, um, You know, prevalence of scoliosis is about 2 to 3% of the population, um, but a very small number of patients have curves that are kind of of of clinical significance, so curves that are maybe over 20 degrees, it's about 0.3% of the population. As I mentioned earlier, adolescent idiopathic scoliosis is by far the most common and it comprises about 70% of all types of idiopathic scoliosis. And girls tend to have it more often than boys, um, especially, um, curves of greater magnitude. So you can see there, you know, if you look at the ratio of boys to girls. It's always a little bit higher for girls than it is for boys, but it really seems to be a lot higher for curves, um, greater than 30 degrees, and so more severe curves are more common in girls. So how do we, you know, evaluate patients um with scoliosis? So oftentimes this is typically a change in cosmetic appearance or based on on your physical exam on in, you know, in their annual well child check. And so, um, this is where families will often say, hey, you know, we've noticed one shoulder may be higher than the other or a common thing you hear about is like asymmetry in the waist crease, right? So like, you know, summertime kids are at the beach or they're at the pool, and families notice some asymmetry at the waist crease and so that kind of tips you to be like, OK, let's take a look at the spine a little bit more closely. Um, so history and physical are obviously very important since idiopathic scoliosis by definition is a diagnosis of exclusion, right? So you want to rule out um, any other, um, you know, syndromes, any other atypical, um, uh, symptoms that a patient may be having, you know, of note, back pain is not typically associated with idiopathic scoliosis, so back pain is a primary complaint that is more of an atypical um complaint. And so that's where maybe, you know, a good neurological exam, potentially even advanced imaging might be helpful. Um, but you know, generally these patients don't have many complaints and generally don't have another associated condition, but may have some family history. And so, um, you know, I think um that's why the history part is important. And then on physical exam, um, you know, inspection is obviously the first thing we all start with, and the things that I generally look at are, I look at the chest wall, is there any asymmetry? I look at the trunk and the waist crease. Is there any asymmetry of the waist crease? And then I look at shoulders being level and the pelvis being level. You know, shoulders being level can be a little bit deceiving, you know, for example, if you feel the trapezius then trapezius could be asymmetric. So what I try to look at is kind of the bony aspects of the shoulders, you can kind of feel the acromion. Um, and see are the acromians asymmetric, um, is one higher than the other? And then for the pelvis, you can look at the iliac crests from behind and you can kind of put your hands and get a rough estimate of is one leg higher than the other. If one, if one side is higher than the other, that suggests maybe there's a leg length difference and that could be leading to an apparent scoliosis or not true scoliosis, but it looks like they have some scoliosis. Um, and then the other things to obviously do on physical exam are the Adams forward bend test. So as I as I mentioned, scoliosis is a three dimensional deformity. And so when you have a child bend forward, you'll obviously, you'll sometimes see um prominence in the thoracic or the lumbar spine. So the way to kind of document that is where the prominence may be. So it might be at the right side of thoracic prominence or a left sided lumbar prominence, which is oftentimes what we see in idiopathic scoliosis. And really what's happening is there's rotation happening towards the convexity of the spine. And so that's why in a right thoracic curve, they may have a right thoracic prominence on forward bend. Um, now these things that can get a bit more subtle on the inspection exam, but if you want to look at their sagittal profile for scoliosis, oftentimes what you'll see is you'll see straightening of the thoracic kyphosis. And um, the way to think about that again is twisting of the towel analogy. If you look at that twisted towel from the side, it looks straight. And so therefore, you know, because the spine is rotating, it's therefore taking away the normal kyphosis that we all have in the thoracic spine. Other things to look at on physical exam are, you know, your skin exam is important, so Kala spot, hairy patches, those obviously um can be are important to document and maybe, you know, might, you might start thinking about, oh, could this patient have some other more rare condition like neurofibromatosis, which is associated with scoliosis, um, and so um it's important to kind of, um, to look at the skin exam as well. And then a neurological exam is, uh, is important, um, especially kind of in that juvenile group, you know, so. Sensory motor reflexes, those are kind of the most common ones, um, you know, probably in the primary care setting, you know, other exam findings that I sometimes will do, especially if a kid has, you know, maybe some pain or the curve has some atypical features which we'll talk about, you know, I'll check abdominal reflexes, um, and so those are other things that um are part of the neurological exam, um, that are important for scoliosis. So a little bit more kind of on the atoms for ben test. So, you know, we talk a lot about using scoliometers and scoliometers um are obviously telling you how much, you know, thoracic rotation you have. And so in this case, you can see on forward bend there's a left lumbar, you know, left thoracical lumbar prominence, and it'll quantify that based on the scoliometer. And generally, you know, guidelines suggest that if there is more than 5 to 7 degrees um of of of rotation, then that would necessitate a referral. Um, and so it's again, you know, for the scoliometer exam, it's important to kind of look at it kind of in the thoracic spine and the lumbar spine, um, and so that allows you to kind of, you know, quantify it in in both areas. Um, there are, you know, uh, I mentioned this a while back, and, and, and some people, you know, actually wrote to me on this, which I think is really helpful, is, you know, your phone has an inclinometer built into it, you know, an inclinometer is basically what, you know, carpenters and um people in construction use to make sure things are level. And there's one built into your iPhone. So if you don't have a scoliometer available, you could use that. Um, but scoliometers are readily available, you know, um, and I think it is important to have, especially in the primary care setting. Now, um, when you do suspect scoliosis, what kind of imagings are important to order? So the imaging imaging that you want to get is a standing, you know, PA and lateral radiograph of the entire spine. So, you know, at our institution it's called a scoliosis X-ray or to view scoliosis um uh scoliosis 2 views. Um, and so, you know, it's important to, to, to write, to request that. And I think in the primary care setting, it's also OK to write in your, you know, in your request also please provide a cob angle, um, because, you know, not everyone is familiar with measuring that and you know, obviously orthopedic surgeons are and radiologists are, so it's important to kind of request that as well. Um, you know, kind of a bit more of an editorial than more so than objective, but you know, I do think it's important to get a higher quality X-ray. So oftentimes getting them at places that do. You know, scoliosis X-rays routinely or do them on children. I think that's helpful because, you know, that therefore they make sure that, you know, they stitch the films correctly, they don't miss part of the spine, um, they don't miss part of the pelvis, which is important and kind of assessing skeletal maturity. So it's important to kind of maybe send it to a place that does this more routinely. Um, on the topic of pelvis, it is important to include the pelvis as part of that X-ray, and the reason for that is, um, there's something called the riser sign, which is shown in that image on the bottom right. Um, that's how we get a rough estimate of where patients are in terms of their skeletal maturity. So when you're born, you don't have any of your iliac apothesis present. So that's that, you know, the um the yellow shaded area that you see. And as you mature, you go through stages 1 through 5 and at 5, which is where the iliac hypothesis fuses with the rest of the pelvis is where most of us are on this, on this call today. Um, so, you know, you kind of progress through that with time. Now it's not a very, you know, um, specific, um, finding like it's not, it doesn't quite correlate with peak growth velocity. But it does have some value for us for management. So patients that are kind of in the riser 0 through 2 categories are the ones where we think about bracing, um, and kind of uh patients in the 3 and 4 category and certainly the 5 category as where we talk about stopping bracing. So it has some treatment, uh, value, uh, for us as orthopedic surgeons because the studies that we have are based off of the risor sign. Now there are some more emerging technologies out there, you know, one of them is called surface topography, which still is kind of working out, you know, trying to use non-ionizing radiation techniques, maybe, you know, surface mapping to see how does that correlate with spinal deformity. Still, we're a little bit further away from that, um, you know, in terms of clinical primetime use. Um, but we do have a lot of low dose imaging modalities available, um, and so, uh, you know, there's something called the EOS, there's something called the RACs, um, we do have availability of the RACs, kind of, um, low dose, um, scoliosis imaging at Oakland. It's actually one of the few centers in the country that has it. Um, and so there are still a few things being worked out in terms of the ordering process, but I anticipate within the next, you know, 2 to 3 months that should be readily available, and I'm hopeful that we'll be able to kind of, um, you know, provide you guys, um, you know, with more information about how to order that if you wanted to do that for your patients. It's a scoliosis X-ray, it's just lower dose, um, scoliosis x-rays. Now, what about MRI? So I think in general, you know, I think it's OK to defer this decision um to, you know, us in clinic and orthopedic surgery, but you know, the things that where we start to think about MRI's are, um, you know, patients that have certain diagnoses, right? So juvenile idiopathic scoliosis patients, that's where I'll typically order an MRI especially if the curve is of higher magnitude and I feel like You know, or there definitely might be some differences on neurological exam, or if I feel like um the patient will be able to do an MRI without sedation, I kind of talked with the family about the risks and benefits of that. Um, so those are reasons to, to order it, um, you know, abnormal exam findings, so of course, asymmetric reflexes, pain, those kinds of things are, are maybe indications to, to get an MRI. And then, um, scoliosis or idiopathic scoliosis curves tend to have some, you know, characteristics that are more typical. And so these are usually more right thoracic curves. Um, so oftentimes you see a left thoracic curve, that's atypical, and oftentimes we'll think about getting an MRI in those cases, or um high thoracic curves are a little bit more atypical, and short angular curves are a bit more atypical. Um, so those are all things that we think about um as indications for getting um MRIs on patients. Now, what about treatment? So first of all, why is it important to treat scoliosis? So in general, you know, scoliosis can have implications to general health, right? So cardiopulmonary function can be compromised. Now studies have shown the scoliosis has to be quite severe to really affect your cardio pulmonary function. So curves have to be really above 80 or 90 degrees for them to really affect, you know, cause restrictive lung disease and cause changes in PFTs. Um, scoliosis, if left untreated, um, can progress and therefore later in life can cause pain. Um, of course, there's deformity and the cosmesis factor as well, but those are all, um, of the reasons why, you know, we think about treatment. Now, what, how do we determine treatments? So treatment is really based on two factors, the magnitude of the curve and uh and the likelihood of progression or how much growth remaining a patient has. So in general, when idiopathic curves are between 10 and 25 degrees, we will just observe those curves regardless of where they are in their, you know, in their growth. As I, as you saw earlier, you know, a lot of smaller curves will kind of tend to uh stay small um and not progress and so we'll just observe those small curves. Curves that get above 25 degrees, um, certainly getting up to the 45 degree number, so 25 to 45 degree range, in a child who is still, still growing, so these are RIR 01 and 2, patients will think about using a brace. Um, and then in curves that are above 45 or 50 degrees, we tend to think about surgery because those are the curves that progress despite skeletal maturity. So, you know, where does all of this, how do we, how do we come up with this? Well, a lot of this came out, uh, has come up over time, and one of the landmark papers that we have is this study. By Weinstein and colleagues done at the University of Iowa, in which they followed patients with idiopathic scoliosis for about 40 years now, as you can, as you, as you all know, that's a really hard study to do and maybe only doable in a place like Iowa, but clearly they have great data which we can all use to help, you know, patients figure out what's best for them, or families figure out what's best for them. So, um I mean I know it's a very small table, but essentially what it's showing. Is that, you know, um, for curves of greater magnitude, um, those curves are the ones that tend to progress and they progress by about 1 degree a year for, you know, for the rest of your life. So the, the way I kind of put it plainly for families is if you have a 50 degree curve, and let's say you're already skely mature and say the child is maybe 1718. By the time they're 50, that curve is gonna progress and potentially end up being an 80 degree curve, right, which then ends up having significant cardio pulmonary pulmonary issues, obviously causes over time can cause arthritis and pain, um, and can have implications obviously to their medical health, but also to their, you know, well-being, their ability to, to work, take care of, you know, um, other people in their lives. And so that's kind of the, the rationale we use to fix those curves. Now, having said that, curves of slightly smaller magnitude can also progress, um, and it's not an absolute yes or no, but they probably just progress at a slower magnitude and may not necessitate surgical management, which obviously carries risk. Now, what are some of the risk factors for progression? So in general, being a girl is a risk factor. So, um, you know, biological female patients we do have a high risk of progression, curve magnitude, so the higher your curve is at the initial presentation, the higher chances it's gonna progress, and the amount of remaining scale of growth. So pre-monarchal females obviously have a higher risk of progression because their peak growth velocity is generally about a year before monarchy. Um, uh, bone age that can sometimes be obtained, so if you still have, you know, a lot, if you're skeletically more immature than your chronological age, you have a higher risk. The riser sign, which we talked about earlier, which is at the pelvis, and sometimes you'll notice in our notes, I'll, you know, we'll look at something called the Sanders stage, which is a bit more um specific and kind of looks at the hand and looks at the various um vices and the phalanges and the metacarpals and the distal radius. And that can give us a little bit more idea of how much more growth a child has. And so a lower standard stage is often associated with the risk of um curve progression. So in terms of treatment, just to kind of home down on that a little bit again, so curves that are kind of below 2025 degrees will generally just see patients back um in clinic routinely. How often depends on skeletal maturity or immaturity. So if they're skeletally immature, like still growing, I'll typically see them back every 6 months. If they're kind of skeleally mature less often every year, sometimes even if they're older, like 1617, I'll see them back in 2 years. Um, just to kind of minimize the risk, you know, needing an X-ray over and over. I always warned families like there, there could be some change, right? Because again some change can happen, some growth can happen. Um, but first of all, there is variability in X-rays, so the, the standard error on an X-ray is about 5 degrees. Um, and also a little bit of change is OK, you know, going from a 20 to a 25 degree curve does not change much, um, and so it's I kind of lay crepe with that to families so that they're not, you know, you know, um, upset or, or, um, you know, discouraged when they come back and the curve may have progressed a little bit. Now, curves that um may progress after skeletal maturity, these are the ones we fix with surgery. And so these are the thoracic curves that are above 50 degrees and lumbar curves generally have a little bit of high risk of progression. So sometimes, you know, 45, 50 degrees is kind of the cutoff that we use, um, but generally, you know, that's what we use for, for surgical management. And then what if they have a a reasonable curve like say a 30 to 45 degree curve, but they're sky mature. They those patients generally should get some follow up over time too. And so these would be like, you know, follow up every 5 years, you know, with a pediatric orthopedic surgeon with an adult orthopedic surgeon, just to ensure there's no degeneration happening, you know, they're not having any pain and the curve isn't slowly progressing more and more. So for bracing, just again to hone down on this point, curves between 25 and 45 degrees with growth remaining, those are the indications. Um, this is a really important point. Um, the purpose of a brace is not to make the scoliosis go away, it's to really stop progression. Um, and so that's really important to, to kind of tell families because, you know, when you take the brace off, you want the curve to look exactly like it looked like when it started. It's not gonna miraculously look any better, but you just don't want it to look worse. Um, it is a commitment and so compliance is really important, and as you can see in that, um, in that line graph, you know, uh, we generally recommend over 18 hours a day of brace wear because that's where you see you've kind of reached maximal efficacy of the brace. And so compliance is really important and that's why we don't willy-nilly put on brace, you know, put braces on everybody, but we also are mindful of when we stop braces. There is a dose response effect, and that's why it's important to be compliant and wear the brace for at least 18 hours a day. And then like I mentioned earlier, we typically will get X-rays, um, you know, only every 4 to 6 months just to ensure the curve is, um, is, is staying stable, um, and assess any issues that may there may be with compliance. The one thing that's shown there on the bottom is you'll notice some families who do have braces will have these thermal sensors. This allows us to kind of also look at compliance. And see, you know, how many hours a day a child might be wearing a brace. Um, I find this helpful. I will say it's kind of sporadic on how often the I actually get a report from the orthopist about this, but if when I do, it kind of helps me figure out, OK, Saturdays, you know, some certain days of the week are not great for you, so we can talk a little bit more about strategies to improve compliance on those days. Now surgery um is generally indicated for a child who's still growing and a curve above 45 or 50 degrees. The goal of surgery is to stop progression and achieve a fused balanced spine. And so I tell families three goals of surgery. Number one is their safety. Number 2 is making the scoliosis look better, and number 3 is stopping it from getting worse. Um, and so those are kind of the, the, the way I kind of put it together for families in terms of what we, you know, what we're trying to do here. Um, the way we do this in North America in 2025 most commonly is with something called a poster spinal fusion in which we make an incision on the back, we place screws into the pedicles of the spine going back to anatomy, you know, so the pedicles go from the poster elements of the spine to the to the. a body. And so you now you kind of cannulate those pedicles, um, different ways to do it, um, but you know, we oftentimes will use some kind of intraoperative, um, CT scanner or navigation techniques to kind of make sure this is done kind of in the state of the art way and the safest manner. Um, and then we place rods to kind of de-rotate and correct the scoliosis. Um, and it's really a three dimensional correction. So not only is it a correction in the coronal and sagittal planes, but it's also an axial correction. And then the rods and screws just hold the spine stable while the body fuses it. So we'll put bo bone graft there to kind of serve as a scaffold um for the patient's body to put down bone. Um, there are some other techniques available, you know, anterior fusion techniques, so doing in surgery through the front of the body, so there's different, you know, either through if it's in thoracic spines, thoracotomy, or, um, retroperitoneal approaches in the abdomen. Um, they're useful for select indications, but um a lot of them have kind of been falling out of favor because pedicle screw instrumentation through the back is just so much more powerful. Um, there are some more kind of emerging techniques, so you may have heard of things like um uh spinal tethering or stapling, you know, um, these things are kind of still kind of being worked out as to what they actually do and what the indications are. So, um, the FDA has approved it for certain indications, um, but it's a very select group, so it's oftentimes thoracic curves that are kind of in the 40 to 60 degree range. Um, and oftentimes it's in skeletal immature patients because what you're trying to do is you're trying to harness their own growth to try to correct the curve as they grow. So the way to think about it is like it's almost like an internal brace of sorts. Um, but you know, um, there has some, and there are obviously some uh pros to it, which is like maintaining motion, you know, grow, it's kind of motion sparing, maybe is a little bit less invasive and faster recovery, but it also has a failure risk and so even in the best studies. The risk of a failure or something like a tether is about 25%, um, so be tether failing or progressing to a scoliosis. So it is really important to have a frank conversation with families whether it's the right thing for them. In general, outcomes are quite good, uh, good functional scores and maintenance of correction at 10 or 20 years of the fusion. Back pain in general is comparable to the general population, but full disclosure, there's probably gonna be some disc issues at the next level. And so that is a little bit more TBD. We don't have good long term studies yet on that. Um, so I do tell families that it is possible there could be additional surgery in the future. It's probably a low risk, but it is a risk, a risk uh nonetheless. So bringing it back to you guys, you know, when, when should you refer, um, this is a, a, a, a table out of JAMA, um, and so obviously if there's a concern on your screening exam, so if you have an inclinometer reading greater than or equal to 7 degrees, um, you know, if the patient has uh syndrome, you know, things like Markan's disease, neurofibromatosis. But then, um, certainly, um, reasonable to send them for for screening, um, and then, you know, what, what do you do while you're waiting? Well, you can get X-rays, so those high quality scoliosis X-rays, AP and lateral views, um, and you can provide some patient education, um, and I'll provide you guys with a couple of links towards the end, um, on that. Um, last kind of thing, you know, what else do we do here at Sur's Hospital when patients are indicated for surgery, right? This is obviously a big decision. Um, it's a big undertaking for the family, it's a big undertaking for the people taking, you know, the surgical staff and, and us, but it's a big undertaking for you as primary care doctors. And so oftentimes, you know, um, you know your patient best and so we try to make sure you're involved in that process. Um, we do have anesthesia, does, um, see all these patients either virtually or in person. Um, and oftentimes, um, for my practice I will oftentimes have them see you as well, uh, before surgery to make sure that you're aware of what's going on. Uh, make sure you're not concerned about something that, you know, we may be overlooking. Um, oftentimes we'll get preoperative labs on these patients, um, just to ensure we're not, you know, there's no obvious. You know, they're not anemic to start with, or they have some, you know, bleeding disorder that we didn't quite pick up on our, um, history. Um, and so those are things we do. A skin evaluation is also important in the pre-op evaluation, you know, make sure, you know, there's no open injuries or, or, um, um, pressure wounds in the back or, um, another, um, common one is acne in the back. So oftentimes if I see that, then I'll often times have them see dermatology and treat that um because potentially that could be associated with a high risk of infection. And then post-operative we have various pathways in place um at at our campuses in Mission Bay and here in Oakland, um, and so we have pathways to try to get these patients home um as efficiently and safely as possible, um, and those are the things we work on our pain control, diet, activity, um, and so on and so forth. And then lastly, um, on the topic of idiopathic scoliosis and surgery, you know, in general, surgery for idiopathic scoliosis in 2025 is relatively safe. Um, and so you can see, you know, the rates of, um, major complications are very low, um, you know, then the rates of things like neurologic complications are also quite low, they're less than 1%. Um, the highest risk ends up being infection, um, and so that's something that I oftentimes will counsel patients about, you know, the risk nationally is about, uh, 1%, a little bit higher. Um, unfortunately, like, fortunately, our rates a little bit lower here, um, um, but, you know, overall it's a relatively safe surgery in 2025. So with that, and the next, you know, 10 to 15 minutes, we'll switch gears a little bit and talk about a few other types of scoliosis. So the ones, you know, here to talk about our um congenital scoliosis is probably an important one to talk about um and this is really results from abnormal growth or development of the vertebral column. So as I mentioned earlier, this can be a failure of formation. So in the bottom left you can see formation basically means the vertebra forming appropriately, or failure of segmentation, and segmentation means essentially the vertebrae separating from each other. So if you remember back to embryology, right, things form, they're fused and then they separate from each other. Um, and so you can have either fail or formation, failure of segmentation, or both. Um, and the reason why this is important is because that actually helps us figure out what is the risk of progression. So, um, kind of in a quick 20 minutes to 22nd summary, you know, essentially if you have a, a bar on one side with a hemivertebra on the other side, that's kind of the highest risk of progression because the growth plate of the fiss is right at the end plates. And you have a tether on this side. So if you have something holding it at one side and growing on the other, that's probably gonna be the most um most likely one to progress, and that does have some value to us, um, as surgeons. Now, going back to embryology, um, you know, as the spine is forming, there's other parts of your mesoderm that are forming around that time that this is most commonly your genitourinary system and your cardiac system. So oftentimes patients with congenital scoliosis on X-ray, I'll oftentimes say, you know, we need to get an echocardiogram to ensure there's no cardiac anomalies. Cardic anomalies can be somewhere in the 10 to 25% range for congenital scoliosis. And also a renal ultrasound to ensure there's no genital urinary abnormalities, and that can be a bit more higher. It's more like 20 to 40% of the cases. Um, and so sometimes if you see my notes or one of my colleagues' notes, you know, that's the reason why we're sending it to you is because, you know, I want to make sure that, you know, we're getting the echo and we're getting the GU ultrasound and making sure the renal ultrasound to make sure there's no abnormalities there. Um, Treatment is a bit more controversial in terms of indications for treatment. And what to do. So it really depends on, um, is it progressing or not? Is it affecting the child's balance, so kind of like, you know, um, kind of in the frontal plane and the sagittal plane, the side view, and also what their age is. And so those are kind of the, uh, without going into too much of the weeds, those are kind of the things we think about for management. Um, is it progressing? How is it affecting their balance and how old are they? Um, bracing, sometimes we'll try, especially in younger kids that might be progressing where we don't have a great surgical solution, but the indications are really unknown, um, and efficacy, excuse me, is really unknown. Um, and so oftentimes it's just kind of a temporizing measure and we're just waiting for the child to get older before, um, we do an operation on the child. Now, what about other types of neuromuscular syndrome scoliosis kind of grouped them together, um, and so these are patients that have, you know, conditions such as cerebral palsy, you know, muscular dystrophies, um, certain syndromes like Marfan's and Estamos, um, and we think the etiology here may be kind of a combination of muscular weakness, uh, muscle imbalance, and spasticity. And therefore it results in imbalance, um, and from a caregiver perspective can have issues with uh providing care, can oftentimes these curves are higher in magnitude, can affect um cardio pulmonary function, and oftentimes affects their sitting balance. So, you know, families will say like, you know, so and so is, is just tipping more and more in their chair. Um, and so those are all things that, you know, um, are things we think about when we're deciding whether it's, it might be worthwhile to to manage with surgical management. Now, these curves do have a kind of a a bit different of different look. So you can see, for example, this is one of my patients, um, and you know, her curve is a bit more of a long sweeping C-shaped curve, and so that's often typical of, of neuromuscular curves. Um, you can also see there's pelvic obliquity with one side of the pelvis being higher than the other, which tells me as a surgeon that the curve includes the pelvis, um, and of course that can affect their sitting balance, can cause pressure ulcers on, you know, on if you're just loading one side of your istrium. Um, and so those are all things I look at. And then surgery is generally considered for patients with, again, at a minimum 50 degree curves, but oftentimes curves that are, you know, higher in magnitude and progressive. Um, and so, um, you know, this neuromuscular scoliosis patients for surgical management do, unlike the idiopathic ones, do have a higher complication profile or or or worse complication profile. So the risks of infection and for example, in neuromuscular patients. In the literature have been reported to be as high as 25%. Fortunately, it's not as high as that in our practice, but it is, um, certainly not 1% or lower, um, and so it is important. You know, to, to talk to families about that. Um, this is oftentimes the reason why surgery, planning, surgical planning for these patients takes months because, you know, we're ensuring that they're medically optimized, making sure their nutrition is optimized, you know, they're actually gaining weight and not losing weight, um, you know, ensuring that their seizures are well under control, um, you know, um, so if they have open wounds, make sure those wounds are taken care of. And so there's a lot of things that that go into the, the thought process for the surgical management of these patients. And oftentimes this is why there's only a certain certain centers in the country that take care of these patients because there is obviously risk associated with managing them. Now, um, last couple of minutes here, just a, a bit of word about kyphosis. So kyphosis, um, and oftentimes, as I mentioned earlier, this is again looking at the side view, right? So we all have normal kyphosis, which is generally 20 to 40 degrees. So increased kyphosis is more than 40 degrees, um, thoracic kyphosis. And so, um, the two buckets this falls into is flexible or postural kyphosis and rigid kyphosis. So postural or flexible kyphosis is more of a cosmetic concern. And these are the patients or some of us even who kind of sit in a hunched position, and then if you tell us to sit straight, we sit perfectly straight. So that's just flexible kyphosis. It's typically not associated with any pain or progression, it's more of a cosmetic concern, and this is often has managed with just some reassurance and if families or caregivers are really concerned, you can oftentime recommend some physical therapy for some hyperextension exercises, core strengthening, um, and that oftentimes helps with their posture. Now rigid kyphosis or structural kyphosis is um the most common one in our country is something called Sherman's disease, um, and this is rigid, right? So that there's this is the one where you tell the patient, hey, can you sit up straight and I can't, right? And so it's kind of stuck in that position. There is an X-ray criteria for diagnosing this, and this is basically wedging of three consecutive vertebrae on X-ray, um, that is more characteristic of a rigid kyphosis. And then treatment is really based on how much kyphosis they have, presence of symptoms, and whether it's gonna progress or not. So, you know, etiology is unknown, but curves, if they're, if the kyphosis is more than 70 or 75 degrees, we often think of surgery because those ones are likely gonna progress with time. Um, curves that are are are uh progressive in a younger child will think about surgical management. And curves that have uh or patients that have symptoms. So oftentimes this can cause back pain because if you think about it, right, you're wedging your discs asymmetrically, and so it can cause degeneration of the discs and patients can have pain. And so sometimes we'll think about management, surgical management in those cases. Short of, you know, progressive curves, higher magnitude curves, or pain, if they still have significant rigid kyphosis kind of in the, you know, 50 to 70 degree range, some things we'll try are bracing and so this would be a hyperextension brace, um, uh, which we can sometimes use in kids that are still growing. We can also sometimes try physical therapy, and that's oftentimes my first line, especially in a kid who may not have a very high magnitude on X-ray but has pain. I'll try some um physical therapy first to see if that kind of helps. um, but physical therapy and bracing have some role in kyphosis, rigid kyphosis as well. Now, we've covered a lot in the last, you know, 40-ish minutes. Um, so what are other things that, you know, you guys can look at what are things that you can offer to your to your patients, um for kind of resources? So for those of us that that do spine surgery, many of us are members of a of a community called the Scoliosis Research Society, and they have a great website, it's SRS.org, and they have fantastic resources both for parents and for patients. So, um, you know, you can have patients navigate to that that um that page. And they can look and, you know, click on their appropriate websites and talk and look at, you know, information about scoliosis. I find it particularly helpful for patients where I'm thinking about surgery, because it oftentimes goes over a lot of the FAQs that, you know, patients may have, and also helps, you know, kind of, you know, kind of motivate them to ask more questions at their preoperative visit, um, you know, things that may not have been asked in that in that sheet. Now other um websites that are available, so Ortho Kids, which is uh through the pediatric orthopedic Society also has great resources on um scoliosis and different types of scoliosis. Um, the American Academy of Orthopedic Surgeons also has great information that's at orthoinfo.org. Um, AP also has great resources on scoliosis as well, uh, which can, you can, you know, you know, provide the URL or copy paste into your after visit summary. And then here at UCSF we've kind of worked hard on revamping a lot of our education over the last 5 years and so we have resources available not only on scoliosis, but also our resources available on fusions for patients undergoing surgery, tethering, um, halo gravity traction, which we didn't talk about, but it's, you know, more for patients that have severe curves that are going to be staying in the hospital for a few weeks to have a halo applied, um, and these resources we've also worked hard. We did a study showing that. You know, we obviously have some disparities in care in terms of how we're providing education. So we worked hard to kind of provide um educational resources that are readable and at an appropriate level and and also available not only in English but also available in Spanish, um, so that we can, you know, serve our patients more equitably. Now, in the last minute or so before um I get to some questions, you know, just some examples here. So this is a patient of mine who had idiopathic scoliosis. You can see, you know, a spine surgeons we look at X-rays as PA X-rays, so that's why the left is on the left and the right is on the right. And so you can see, you know, they had a left thoracical lumbar curve. They were braced in the brace, you can see the curve gets better, right, but it doesn't go away. And again, remember the goal of the brace is not to make it go away, it's to stop it from progressing. And this was at the conclusion of bracing about a year or two later, and you can see the left image and the right image look the same, and so this patient was successfully braced. This one is a patient who had a fusion, so they had about a 50 degree right thoracic curve, but they underwent, you know, screws and rods to correct the scoliosis, and again the goal here is to make the spine straighter and to get the spine to fuse in that position. This one is a little bit different, so this is a patient with syndromic scoliosis, um, and so you can see she had a curve over 100 degrees, um, and so she was placed in a halo for a couple of weeks and then had something called growing rods. So growing rods are where you place screws in the upper part of thoracic spine, and screws either in the lumbar spine or sometimes in the pelvis, and you place two rods so that you can distract those rods and therefore correct the scoliosis. But you avoid fusing the thoracic spine so they can continue to grow. So this is effective or helpful in patients that are still undergoing pulmonary growth. So you generally kids under the age of 8 or 10 where their alveoli are still developing, um, and so that's one technique and a similar technique that we use is something called magic rods. These are so growing rods, you have to go back to surgery every 6 months to lengthen those rods manually. Magic rods have the ability they magnetically controlled growing rods, and so you can provide an you can place an external magnet and these rods can distract using an external magnet. Um, that's done every about 3 months in the office, um, obviously saves the trip to the operating room, but has some limitations as well in terms of how much force you can apply, um, and, um, depending on and it has various other technical considerations as well. So in conclusion, um, spinal deformity can be seen in children of all ages. Um, it is important to value for scoliosis and kyphosis as per our guidelines. If in doubt, obtaining an X-ray and then and a referral is obviously uh totally warranted and oftentimes, you know, as you all know, it can be an anxiety provoking, you know, thing for a lot of patients and caregivers, um, and so, uh, if in doubt, get an X-ray and then, and, uh, you know, provide more guidance that way. Um, consider associated conditions for patients, um, especially if they have certain diagnoses or have abnormal physical exam findings. Observation and bracing work for the right for the right indications and our successful strategies, and spine surgery is a major surgery, but it's generally safe and associated with good outcomes, um, in 2025, and then perioperative management and patient education is critical, um to ensuring patient safety outcomes and satisfaction. Um, I've left my email here. It's my first name.my last name at UCSF.edu. If I don't get your questions today, I'm happy to answer those at a later time, um, and via email as well, and I will stop sharing. Thank you. And we'll make sure we put um your email in the uh in with, with the slides that we send out to all attendees too so they can get a hold of you. OK, I'm gonna share my screen. I'm gonna put the QR code up so you all can scan it with your phones if you'd like to do that now and then we, Doctor Support answer some questions. Let me pull this up here. So there's the link to the QR code to the oops, to the survey, and then uh you'll also get it in your email too. OK. Maria, I see some questions already. Do you want me to just go ahead and Yeah, if you can just read them out loud first so people know what the question is, that'd be great. Thank you. Yep, no problem. So the first question is, um, can you address whether there is any role for back exercises, for example, the Schroth um method or Schroth exercises for idiopathic scoliosis. Also, should we be referring or getting screening X-rays for asymmetry or paraspinal muscles without any obvious curvature. So, um, great question, thank you for asking that. Um. So Schroth exercises, you know, uh, the, the short answer is TBD, right? And so what I tell families is there clearly is probably some benefit to core strengthening and postural retraining, and studies have shown that roth posture retraining rather, like, you know, having a having a child sit in certain ways, strengthen their core can have some benefit in how their curves look, but there are also studies that show That it does not necessarily have any long term benefits. So if you get the same X-ray two years later, the curve may go back to where it where it was. And so, um, I oftentimes, you know, I definitely I tell families shroth in isolation probably has very limited benefits. Um, however, in patients that may have pain and some scoliosis and and we've ruled out all the atypical causes idiopathic scoliosis, sure, there there's certainly could be some benefit because you're doing some core strengthening. So schroth in isolation probably has some limited benefit. Where it may have some benefit. I if you know, one of the concerns patients and families have is if you're bracing a child, they're wearing a brace for 18 hours a day. And so they're like, well, you know, they're not doing any, they're not doing a lot of, you know, engaging their core or functional exercises. So oftentimes I say like, OK, why don't we do both, right? So that way you're actually doing dedicated physical therapy exercises, and also doing the brace, um, and so that may be a happy medium, and the other time I tend to use it. It's kind of the two ends of the spectrum. So if they're kind of approaching bracing range, and the family really feels like they want to do something and they, you know, have a strong interest in like manipulative type of, you know, treatments or uh physical therapy, then that's OK. Or the other end of the spectrum where we're just kind of stopping the brace and we're coming out of a brace, but family is a little nervous, like, hey, you know, can we do anything just to kind of minimize the risk of progression? Then I say there's really no downside to it, so sometimes I'll use schroth um in in that in that manner. Um, and then for screening X-rays, you know, I think, um, Again, probably more so based on your physical exam. So if you find that there is, you know, thoracic or lumbar prominence and forward bend, it does measure, you know, 70 degrees or more, then I think getting an X-ray, a screening x-ray is a great first step, um, and then referring, um, if appropriate. Um, the next question is, even if the goal of bracing is to not improve, how often do you see improvement with bracing alone? Um, rare, you know, I think, and again, to be clear, we're talking about adolescent idiopathic scoliosis, right, like I mentioned before, infantile idiopathic scoliosis can get better with time, but for true adolescent idiopathic scoliosis diagnosed after age 10. It's rare to see curves get better with time. Um, again, 5 degrees better doesn't mean better, right? Because that's variability in the X-ray, and so it's rare to see that. Having said that, have I seen curves get a little bit better with time? Yes, I have. Can I explain it? No, but of course, like, right, we can't explain everything in what we do, um, but it is more, it is rare to see that. Um, the third question, um, here is excessive use of mobile phone or working on computers and laptops are causing mild kyphosis and neck pain? Yes, for all of us, um, please comment on prevention, um, thanks. Uh, I think, you know, I agree with that, and I do think I do see patients and a lot of families concerned with kind of like the, you know, having the neck down and kind of using your thumbs a lot, you know, at some point a lot, all of us will have basal joint arthritis as well. Um, and so what I tell families is, um, ensuring that patients are engaged with physical activity, you know, so actually exercises outside of the house, you know. Uh, playing outside, um, you know, doing some kind of core type of exercises, whether it's, you know, engaging in yoga or doing, you know, um, uh, planks or, you know, doing things as a family to promote having a strong core. Those are probably all the things that we can do as preventative measures and we could all probably do better for ourselves. Um, and then of course if they actually truly have pain, then, um, physical therapy, um, certainly has, has a great role, um, in that. Perfect. That looks like that's all the questions. I'm going to stop sharing and again, please look in your emails for a link to the uh survey if you don't get a chance to take it or scan it with the QR code. Thank you, Doctor Swarro so much for presenting to us today. We really appreciate your time. Thank you all so much for attending, and we hope to see you next week for our GYN uh reproductive health uh Q and answer session. We hope you all have a great rest of your day. Bye, everyone.
