Chapters Transcript Curves of the Pediatric Back: Kyphosis and Scoliosis Blake Montgomery, MD, presents on "Curves of the Pediatric Back: Kyphosis and Scoliosis." Today, we have Doctor Blake Montgomery, who specialized in spine orthopedics. And just before we get started, a reminder to keep your cameras turned off and your mic's muted during the session, and there will be time at the end for questions, as well as the QR code will be available at the end for you all to scan for credit. And with that, we'll go ahead and give our attention to Doctor M. Great. Uh, hello. Thank you all for joining, uh, this early birds. I really appreciate it. I have some new names here. So once again I'm hoping that this is a bit more of a conversation more than anything. So if you have any comments or anything throughout the presentation, so free, you know, raise your hands, speak up, write in the comments, all that is welcome. That's good I'm sorry, yeah, so this will be curves of Pia bag. We'll focus a bit more on kyphosis and then we'll also touch base on scoliosis, especially since it's so common. So let's see if we're able to, I think it to change slides here pretty easily. Great. OK, cool. So I have nothing to disclose. That's good uncle, uh, so just to outline of today's talk, so it'll be, I just touched a little bit on my personal background since I do recognize a few new names here. And we'll talk a bit more of Sherman's kyphosis, we'll talk about the diagnosis and what to expect from these kids long term, like what is their future look like? I'll talk about the evaluation and treatment options for these kids. Then we'll transition a bit to scoliosis, you know, there's so many different types of scoliosis, you know, in each type varies pretty significantly. Um, but we will also do, um, the diagnosis natural history, uh mainly adolescent idiopathic, and we'll do, and we'll do evaluation and treatment, and then we just have one case for the. I was good uncle, I was good uncle, I was good uncle. I just a bit of a personal background. So, you know, I was born and raised in Saint Louis. You know, I'm from a really big family, so most of my family is still here. So it's been really great, uh, being home, uh, and really great, uh, practicing here. Uh, I went to Pena High School, which of course is the, you know, the Saint Louis question, and I had 4 surgeries in high school. I played sports and had 4 surgeries, 3 of those were shoulder surgeries, one with hip surgeries, so these are all orthopedic related. Uh, I think was further furthered my interest in orthopedics. I then went to UMKC for undergrad in med school. That's where I met my wife, who's a pediatrician and her two kids. I did a a year of research in medical school. I still very interested and very active in our research for now. I went to residency at Stanford. And I did a fellowship at Boston Children's and that was PF orthopedic fellowship, and then I did another year of specialization and just uh complex pediatricsine in New Zealand. Uh, and so now we're back from New Zealand and New Zealand was a great year and but it is nice being back home and closer to family. So, um, no, so that's enough about me, and we'll talk a bit more about what everyone signed on to here, and that's more about uh kyphosis. So, Uh, Sherman's kyphosis, uh, this has been around for a while. This was described for, you know, a little bit over 100 years ago. Uh, and really, Sherman's kyphosis is, uh, that really describes the vertebral body wedging. So, you know, this is, I don't know if you can see my mouse at all, um, but Uh, maybe not, probably either. I'm not sure if you can see the mouse, but it's really, oh good, perfect. So if you notice here on the left, uh these vertebrae are very square. Now it gets these vertebrae are not wedged, and that's what we see in the normal spine. But in Sherman's typhosis, you can tell that, you know, the implate, the upper endlate is more wedged when compared to the lower endlate, and the number that we're looking for is 5 degrees. So there's 5 degrees of wedging. Yeah, at 3 consecutive levels, uh, and that technically meets the diagnosis for typical Sherman's disease. So, you know, yeah, there's a, you know, we'll get a little bit into what we think causes this, but that's what really what we're talking about with Sherman's, uh, Sherman's skytosis or Sherman's disease. It's really the wedging of the vertebrae which creates that, you know, forward rounded back appearance. So. So who, who, who gets Sherman's sis? Well, it's it's a lot of people actually, so it's really common. It typically occurs around the growth spurt, so we're thinking around age 10 to 12, you know, often around, like, you know, early puberty. Uh, that's when kids notice it, and that's when the the wedging really takes off, uh, and it can be up to 10% of the population. And so it can be pretty challenging sometimes, or not challenging. There are really two different categories we'll talk a little bit about later. It's the postural kyptosis or the kids that just like to slouch, and which is very different from the kids who actually have a bony deformity, and they can't straighten their back. So it's postul kyphosis versus Sherman's kyphosis. So, uh, a bit different, but overall, Sherman's itself is, is common. So what causes this? Like why do some kids develop this 5 degree pledging or or more and that ultimately leads to this rounded back. Well, the long and the short is that we don't know. Um, we do have many theories, so we're definitely not short on the theories, uh, and I think the, the leading theory is that it's really just compression of the growth in the front of the spine, uh, leads to the wedging more than anything else. And, and we think that some kids are more susceptible to that compression based on probably genetic factors. Some studies point to hormones, you know, other studies, you know, point to a bit of tissue laxity or just, uh, but essentially for whatever the reason, which we don't know, the front of the spine is growing less quickly when compared to the back of the spine, which creates the wedging. Um, so with these kids, you'll also notice in addition to the wedging, they'll have in plate changes often. So there's something that is going on with the inlates here of the vertebrae which sometimes they'll have, like, it looks irregular, sometimes it even looks, you know, arthritic, and it has the degenerative change to it. Sometimes you'll see even a bit of the vertebral disc herniating into the body. And so we know that there's some abnormalities around the edges of their vertebral bodies, which probably plays into the fact that it's wedged, but again, you know, at this stage, we really don't know why some kids develop and some kids don't, but that family history and genetic component that has been well established, so it can run in families. So, we see a kid, you know, you see a kid with Sherman's psychosis, what should they expect for long term when you're talking to these, you know, families, and what kind of things should we expect for them 2030 years down the road? Well, we don't have many long-term studies, but from the few long term studies that we have, uh, we see that if we look at 32 years, you know, these people have more intense back pain. Uh, these people chose jobs that were, that required, you know, less activity and less physical labor. And these people have less range of motion. You know that overall sounds pretty dismal, um, but in that same study, it also showed that there was no difference in their level of education, so these people didn't necessarily drop to school early. Uh, they didn't necessarily just work a lot due to their back pain, so they may not have a job of physical labor, uh, necessarily, but then maybe the best job that they have, they're still able to go to, to, to work and they weren't necessarily home on disability. They didn't have any. You know, any difference in the neurological symptoms, so no numbness or tingling in your legs. And, and they didn't really have social limitations, at least from their study. Uh, they weren't bothered by their, you know, the help in their back when they were in their 50s. And they didn't have any change in the level of recreational activities when they get to their, you know, 50s and 60s. Overall, the downside of this study though, this study was this study took place in Iowa, and it was published in 1993. So, That can be quite, so these people were born in their 50s, 60s, and so even that generation, they have a different perspective than, you know, kids that we're seeing now. You know, maybe this generation is so I mean these people from the study now are in their 60s and 70s, and they may have and again from one region of the country from Iowa, a 60 or 70 year old in Iowa may not have that same, you know, opinion or may not have the same wants as someone who's growing up in Saint Louis in 2025. Uh, so it's, uh, it's, it's or someone who's grew up in New York or, you know, Alabama or California, that that's one of the, the downsides of this study. Uh, the other study that we have uh to rely on is a study from the UK, and that was published in 2021, uh, which looked at the average follow up was 27 years, and in their study, they showed uh their uh curve in their back, actually how it continues to get worse throughout their life, so it gets worse so it gets worse uh and slowly. Um, it's worsening at a rate of about 0.5 a degree per year, but for those kids that In their at maturity they had a curve that was 66 degrees on average, that curve became about 80 degrees over a period of 25 years, and overall with that study, they found a worsening functional outcome. They found worsening functional outcome measures and pain for these for these adolescents, and they had for these adults at this point and they have lower self image. So it's definitely a more recent study that was published, again showing that is. It's not as moving as we sometimes, uh, as we sometimes think, uh, and for these families kind of hoping that, you know, what they may have a bit of back pain uh throughout their life and I think figuring out, not figuring out, but having good methods of ways to deal with that like through physical therapy and other functional. The Um, fighting, uh, physical therapy and, and other ways to help build that pain to you the best quality of life is, is help. So, uh, so when these kids are in clinic, we were taking the history, sorry, one second. Uh, OK, cool that, uh, so when we're taking less uh. Um, we are first, really, uh, so we're taking the history we get for your kid with Sherman, you know, they, these kids are often coming in and they are, and they have a, a chief complaint of. Uh, one of a few different things. Uh, one is, uh, poor posture. Yeah, that's really, that's really from the parents, you know, it's really the, the mom, uh, the mom and dad can often just, you know, really be concerned about their city. or the kid won't sit up straight. That that's pretty common. And so, you know, sometimes if the kid has sherber's kyphosis, well, they can't sit up straight, like their bones are completely wedged, so this posture can't change but that's very different than the kid who just has postural kyphosis, or I'm sorry, just is essentially slouching. Um, so there's two different groups are working out, those two different groups, you know, that's one of the primary. Uh, goals of the visit. So, a poor posture is one complaint often that's coming from the parents. A lot of these kids do have pain, uh, so, uh, kids can come in with concerns of pain, which is often in the thoracic region, but it could also be in the lumbar region too. Uh, and a component, uh, as well is that some of the kids just don't like the appearance, and I think we're all aware that kids in school can sometimes be quite harsh, but some of these kids are, you know, called hurtful things like hunchback and uh it uh it can be quite difficult from the social perspective too, which we feel is very important as well. I definitely can lower kids' self-confidence and, and, uh, change their day to day uh behavior. So that, that's important as well, and that's a, that's a common for these kids. So, uh, when we're taking the history for uh the kids with Sherman's, you know, I think understanding that the family history is helpful, uh, maybe there's a a history. of, you know, multiple people in their family which have really rounded backs and just that kind of helps differentiate. Is this someone who's just slouching or is this truly, you know, someone who has Sherman's kyphosis? Uh, do they have pain? Uh, you know, do they have fevers and night pains? You know, this is more so red flag symptoms. But as we'll talk about later, you know, uh, around the back, maybe Sherman's kyphosis or it could be something else, you know, maybe tumor or, or other things. So just ruling out the, the bad things are always important. Um, and then with Sherman's, we expect that pain, it's often in the thoracic region, but it can also, uh, I'm, I'm sorry, the thoracic region, the area of the rounded back, but it can also be lower than that in the low back, and we think that the lumbar spine can't have pain because it is trying to compensate for the, for that curve. So, that's important as well. Uh, these kids can have, you know, some numbness, uh, tingling, so just trying to tease out, are they having any neurological symptoms? You know, are they having any red flag symptoms, which for us would be, you know, bowel or bladder changes, lower extremity weakness. Uh, those are things which, which would really trigger us to think about other causes of kyphosis, uh, outside assurances, um, and really trying to decide, you know, or trying to determine how much this really bothers the kid. You know, is this something that their parents are more so concerned about than, you know, what they are, or is this something that prevents the kid from doing their social activities or are they, you know, getting teased a lot in school, and this is like a, you know, a really big problem for their day to day life. But really, I think spending time on that aspect is, is pretty important. I've had kids that, you know, I bring it up one clinic visit and they kind of shuffle through that, you know, questions and then the follow-up clinic visit, that's the first thing they want to talk about. It's like, hey, you know, you really ask me about my self-image. Uh, I, I said it wasn't a big deal, but you know what? It actually is. Can we talk a bit more about it. And that's not uncommon, uh, for people to, at least it's not uncommon for people to bring up and it's nice that they can feel validation that at least we, you know, want to talk about it too and that we think it's important. And then other things that they've tried, you know, have they, have they tried physical therapy? Have they tried any, any of the anti-inflammatories and have those things worked, um, and so that's, that's pretty helpful for the history. And then on physical exam, you know, a lot of the physical exam is geared at, you know, trying to make sure that this is truly Sherman's and that there is not something else that could be causing their forward curvature. Um, so, you know, we are starting off with the walk and we'll do a bit more about this, a bit more in the exam when we, uh, when we talk about scoliosis, you know, we wanna see how they're standing. Are they pretty balanced. You see here. On the, uh, the side view that, you know, this spine looks OK. This is a pretty normal and typical amount of curvature. Uh and so that's, that's what we expect to see and with Sherman's, you know, we, it's, it's a lot more pronounced. Um, so, Uh, these are all just part, part of the typical physical exam for someone if we're, we're examining for Sherman's yosis. Uh, we're palpating, we're filling on the spine, making sure it's not uh too painful, and we're doing the typical neurologic exam. Which includes motor sensation, especially the lower extremities, and checking their reflexes. So if someone has really is really hyperreflexic or they have clonus, that would also give us a clue that maybe there's something else there. Maybe there's a syrinx or a chiari or, you know, tumor or uh some sort of other issue that we need to pursue. Uh, so that's uh pretty helpful. And then looking at their spine range of motion is very helpful too. So, uh for kids with Sherman's, what you'll see is that this is a on the right, this is a pretty pronounced case. It's usually not that dramatic, but just for this example, you know, we can really see that forward positioning of head and neck. Uh, you can see the increased lumbar lower doses or the sway back here in their low back. This is all trying to compensate for their upper uh curve that they have. So the low back is trying to compensate. And that's why they also can get low back pain. So these muscles are working extra and they're in overdrive. Uh, so that can, that can cause issues. Uh, these can sometimes can have a pretty, uh, prominent belly, and especially if the, like this curve, which is pretty high here. This curve is a little bit lower, it really creates almost like a pot belly. Uh, and that can be just from a social standpoint, some kids really, uh, it can be bothersome for them. Uh, but you can also appreciate that on physical exams. Sometimes you'll even see like a pretty prominent crease here, uh, in their, in their stomach area, in their abdomen. Um, and then skin changes on the back. So depending on where the curve is located, this can also be the first thing that hits the chair. And it can get uh essentially like a callus formation. It could be hyperpigmented and you'll, you know, notice this for a handful of kids it's, yeah, you get like extra skin, almost like a callus uh that forms on the, on the back and it can have some additional skin changes too. Uh, so it's, uh, these are all things that we appreciate for the physical exam for, for Sherman, so. And I think one of the key physical exam, uh findings or physical exam tests are having the kids lie prone on, on the table and being able to see how much their back can flatten out. For someone who does not have Shermans, they should be able to flatten out their thoracic spine, uh, when they're lying prone on the table and they're looking up at the ceiling. But if a kid has Sherman's triosis, they cannot, they will continue to have a rounded back even when they try to completely flatten it. So this is a great test for trying to determine is, is this kid just a kid that likes to slouch and just has poor posture, but the bones and everything are normal? Or is this a kid who slouches because they can't, they can't straighten their back more and they really have a structural uh deformity. So the postural curves or the kids who like to slouch, those curves curves are flexible, uh, but the Sherman's kyposis curves, those curves are quite rigid. So, and that's what we're really trying to determine when kids are coming to clinic. And you can imagine, you know, a kid who has a Sherman's kyphosis just like in our photo, even when they lie flat and try to look up at the ceiling, they're still gonna have a rounded back. So that's a great test. We're trying to differentiate between kids who like to slouch and someone who truly has Sherman's and a and a rigid curve. So, after our physical exam, the next step would be X-rays. And so the standard X-rays for both Sherman's kyphosis, as well as scoliosis, uh, those are standing PA and lateral uh scoliosis X-rays. So these are stitched images, so they're all in one view. Uh, it was all in on one image and we're able to make the measurements and really get a good understanding of the bones, the structure, how the kids stands, the overall balance. So the X-rays, uh, having the appropriate X-rays of standing PA and lateral is really, really, you know, important, uh, and we can see that there's even a little bit of scoliosis here, uh, on the X-ray, which we'll talk a bit more about later. But let's zoom in a bit and let's really, you know, dive into what we see here on this X-ray. So, first, let's take a look in the low spine. And this is what uh essentially a, a healthy disc looks like. You know, you can see how much space we can see here between the vertebral bodies. Like this is a nice amount of space. It looks appropriate. You see how smooth the implates are? That's really what we wanna see at just about every level of the spine. And we, if we look in the low back, uh, more, you can see that these are all healthy discs, and that's, that looks pretty appropriate. If we look in the chest region, Now we see an unhealthy disc, and these are not uncommon in Sherman's kryphosis, but we see the implates, like look at how the implate here is even curved down a bit and it's almost making like, you know, a bit of an osteophyte here, some extra bone that's bridging off, but these implates are not smooth, the gap is not that great, it's OK. But and these are just becoming more sclerotic and white and just the abnormal structure here. You know, we, overall, we call that in plate changes, but you can see that's pretty abnormal. And if you look at the other disc in the spine, well, this one's abnormal too and so is this one. So this is not uncommon to see in kids with Sherman's skosis. Now, if we assess for wedging, and we look and we measure, so if we, if we look down at the lowest part of the spine, this looks like a box, you know, this, this vertebrae is not wedged. Now, we look at the thoracic spine, and if we measure the degrees between the and the upper endlate and the lower end plate, uh, we'll notice that, you know what, it's a bit wedged here, and that's at least 5 degrees or more. And then if we look at the other implates as well, we can see that, well, this one's wedged, this one's wedged. So technically meeting that criteria of having Uh 5 degrees of wedging at 3 or more consecutive levels. Uh, so it not only looks like Sherman's, it's also meeting diagnostic, you know, radiographic criteria Sherman's. Um, and the next thing we would do as well, like how severe is the Sherman's kyphosis. Uh, and to determine that, you know, we would do a measurement and for our measurements, we would look at, so for the top level of our, you know, our angle here, our top. We want the most tilted vertebrae, and we want the top of that most tilted vertebrae. So we, you know, I look at each level and I see that this is quite tilted, but you know, there's a little bit more tilt, even up to here, and that becomes the top angle of our kyphosis. So I want to know what is the angle between the most tilted top vertebrae and the most tilted lower vertebrae. And then so we go all the way down here to the other side. I'm sorry, that was a little bit fast, but, uh, either way, we can see that. This is, uh, this is the most angle vertebrae at the bottom. And so I wanted to, like, we want to know what is the angle between these two lines. And you can see that that almost makes a right angle, um, and it does, and that's about a 90 degree uh Sherman's kosis curve. So that's a little bit, that's on the more severe side as far as Sherman's is concerned. And keep in mind that normal or a typical curve is about 50 degrees or less. So it's not normally in the thoracic spine, it's not perfectly straight, but a typical curve is should be 50 degrees or less, so. Something to keep in mind. And how about our treatment options for kids with Sherman. So, You know, the first treatment option is physical therapy. And thankfully, physical therapy is a good treatment option whether you have, you know, posture kyphosis or the kids that like to slouch or whether those kids truly have Sherman's khosis. I'd say for kids with posturekyphosis, it could just teach them not to slouch, you know, if, if they're having any pain or discomfort with slouching or if they just wanna have a better posture on a day to day basis. The physical therapy works for that. And for kids with Sherman's, you know, it's more so physical therapy to address their pain. Uh, if a kid just presented the clinic and they had Sherman's triosis and they had no pain and it was pretty mild, uh, I, I wouldn't necessarily recommend that kid go to physical therapy. Uh, but if they're having pain, then I'd recommend physical therapy to help treat their pain more than anything else. Well, how about bracing? So I think we're probably all familiar with bracing for idiopathic scoliosis, but, you know, our braces really used in Sherman's kosis? And you know, I think the literature is pretty mixed on this. Bracing one, it can work, that's for sure, you know, and braces can be. Given for kids who have growth remaining, but overall, it's really not frequently used, you know, uh, we definitely, uh, you know, I, I, I talked with families about bracing and if they want to go down the bracing route, I'm a pretty big bracing advocate and I push, you know, for it, but I I don't necessarily recommend this for all the kids, and part of the reason why a lot of us, it's not part of our standard practice, at least not everywhere, is because these braces are even a lot bigger than the uh braces for idiopathic scoliosis. So you can see this front piece here, it can be quite big and cumbersome. And this is just an example brace. Sometimes the front pieces are even bigger, but it really deters, or at least adolescents really don't like to wear this brace as much. Uh, our previous brace would actually go up to the neck, a Milwaukee brace. We don't use the Milwaukee brace anymore. But now, in order to control the kyphosis, we do need at least some piece up here on the chest, and that definitely decreases compliance. So I think the overall take home for bracing is that for kids who have a lot of growth remaining and have a big curve, bracing is an option though it's not often prescribed. So something that can be done but definitely not part of the normal workflow like it is with scoliosis. And then the last treatment option is surgery. And, you know, with surgery, that's opposed to your spine instrument fusion. Uh, you know, thankfully, most kids don't, uh, progress to surgery, but, you know, we definitely, you know, we, surgery is an option for kids who have large curves and they're in a lot of pain and it, it does help. Uh, after surgery, you can see that, you know, in these photos, uh, on the left is the pre-op, and the photo on the right is a post-op, uh, image. You know, these kids, you know, we expect that they start medications over, you know, the, after about 2 weeks, uh, turning to school, 3 to 4 weeks for some families, but it really just depends on how much the school can accommodate. Sometimes that 4 week mark can be 55 weeks or so. Uh, and then getting back to their sport at around 6 months or so. And I typically kind of give caution to football and wrestling, you know, or, you know, or gymnastics, those kind of really intense sports. Uh, but the other sports, baseball, basketball, tennis, uh, those kind of things, volleyball, uh, uh, typically kids are able to get back to. And then, uh, just last thing for kyphosis as well, kyphosis may be Sherman's or maybe not. And, you know, we see here in this image, this 3D CT is another kid, uh, you know, that has congenital malformations. We can see this vertebrae is split here and it'll spin around again. And so this bone formed abnormally in utero, uh, and that's causing the typhosis. You see this, these, these bones are incompletely formed and that's causing the spine to be, uh, have that forward bend. So it could be Sherman's when you see a kid who has a rounded back, but it may not be. So it could be uh abnormal bone formation or that's we call that congenital kyphosis. It could be a post-surgical issue. Some kids have surgery and then they start bending forward. Um, it could be from a trauma or infection or tumor or uh sometimes it's radiation associated or sometimes it's, uh, through a dysplasia like achondroplasia. Some of those kids have tho uh have thoraccal lumbar kyphosis, so. You know, if you just, if you see a kid with a rounded back, it may be Sherman's, but it may be someone else. So I think part of that history and going through is trying to tease out, you know, are there other causes for the, the rounded back appearance, so. I think enough about kyphosis, even though I really enjoy talking about that. How about we just transition a little bit to scoliosis. So, uh, scoliosis is, you know, as, you know, I think we're all aware, it's a bit of a curvature of the spine, you know, we diagnose scoliosis whenever curves reach 10 degrees or more. Uh, overall, this is pretty common with about 3% of the population. You know, I'm meeting that diagnosis of scoliosis, but thankfully, the really big curves, the curves that are 50 degrees or more, those are pretty rare, you know, with only about 0.3% of the population having a curve that size. Uh, any curves that are less than 10 degrees, we just call that spinal asymmetry and that's just a variation of normal from our standpoint. When we think about scoliosis, we think about a three-dimensional deformity. So that is a coronal curve, uh, which we see here, and that's the, that's the curve that we measure on an X-ray. Uh, there's also a rotational curve, uh, which we see here where when we do that atoms forward be, what we're really seeing is the rotation of the ribs. So the ribs on the right. Uh, those ribs are rotated back while the ribs on the left are pushed forward. So it's really the rotation that we're seeing when we're doing the atoms forward fin test. And then lastly is the sagittal plane deformity, and that's either kyphosis or lower doses. So those, uh, so while we measure scoliosis just on an AP X-ray, it's really a three dimensional deformity that that occurs with these patients. And there are different types of scoliosis, and, you know, I think part of the thing when we see someone for You know, scoliosis that we think is idiopathic, the first step is just ruling out everything else. And so that's, you know, cause our idiopathic diagnosis is a diagnosis of exclusion. And so, you know, we are definitely trying to make sure nothing else could be causing the scoliosis. So, you know, some conditions, neuromuscular conditions can cause scoliosis. I think most commonly, that's what cerebral palsy, palsy, but can be other things. Uh, muscular dystrophies can cause it, you know, uh, uh, syrinx can cause scoliosis. A lot of things can cause a difference in the muscles, which ends up leading to a curve pattern. So that's, you know, we're trying to rule that out. Uh, the skeletal dysplasia can cause it. So we have kids that are coming in that are, you know, less than, you know, if they're kind of falling off the growth chart. So it's really, uh, you know, helping out or at least sending these kids to, uh, genetics to help to see if there are skeletal dysplasia that could be contributing to their scoliosis. Uh, the congenital scoliosis is just like we saw that 3D CT spinning around where the bone didn't form all the way. Well, that can not only lead to yosis, that can also lead to scoliosis. So we, uh, we're trying to rule out those causes as well. And there are a few different causes of scoliosis that we're not gonna get into now, but essentially once we've ruled out all those other causes, then we can kinda, then we can put them in the idiopathic scoliosis category and you know, can treat them treat them accordingly. So it's really, though it's the most common. You know, we really have to focus on ruling out all the other causes of scoliosis before we uh give someone this diagnosis. So, uh, what's also important is the age that scoliosis develops. And I think the most important take home here is that really uh scoliosis that develops at a really young age, especially before the age of 3, you know, and even in that 49 range, that's, that's one of the, those are one of the few types of scoliosis that can actually be deadly and can increase mortality. So we don't often talk about increasing mortality with scoliosis, but for kids who develop scoliosis at a really young age, Uh, especially under age 3, but, you know, even in that 4 to 9 range, um, as the scoliosis gets worse, it can prevent their lungs from developing appropriately and can, uh, also, uh, really prevent their heart from working appropriately, and those kids can die from, uh, uh, from cardiac and pulmonary issues at an earlier age. So, yeah, that's, those are some of the kids that we are more aggressive with. Uh, kids that developed scoliosis later between the ages of 10 and 18, that's our most common variant, uh, typically adolescent idiopathic group. And then kids that develop or people that develop scoliosis after age 18, would say it's adult onset, so. So what causes scoliosis? Well, we still don't know. We do, we put in a ton of money for research trying to figure out what causes scoliosis and ultimately, we still don't have an answer. Uh, we do know that there are certain risk factors and, you know, people that have a family history of scoliosis, there are higher likelihood of developing scoliosis. There's about 11 degree, uh, you know, percentage developing. Uh, 11%, you know, developed within their 1st 1st degree relatives, and we do have several genetic sites that probably contribute, but we just, we really don't have a true cause or any one specific gene. So likely multifactorial, uh, but definitely a family component is, uh, is important. Uh, as far as other reasons and theories on why kids develop scoliosis, you know, we, again, we don't know, but our theories, our leading theories are that maybe it's a connective tissue issue. You know, maybe it's, uh, it's, uh, the tissues are a little bit lax, uh, which allows the spine to bend a little bit more than maybe it typically would, and then once it starts to bend and grow abnormally, then the scoliosis is kinda set to take form. Another issue, or another thought is that maybe it's like a leg length discrepancy, you know, with the leg length discrepancy, one, you know, femur grows more than the other. Uh, maybe one side of the bone in the spine grows more than the other, and that causes, you know, abnormal positioning which leads to a little curve, but then that abnormal growth over time leads to big curves, you know, that's one of the leading theories as well. And then one of the more controversial theories is that maybe it comes from the central nervous system, but there's definitely, there's some evidence that supports that. There's a lot of evidence that does not. And so I think that one is less common overall, but it's still out there. So at the end of the day, we don't know why kids develop scoliosis, but definitely that family component is important. So what's gonna happen to these kids over time? Let's say we have a kid with scoliosis and they're 18 and they have a, you know, 50+ degree curve, like what happens to them in 2030 years? Well, oh, well, I guess let's say let's start into the small curves. So for kids who have 3030 degree curves or anyone who has curves under 50 degrees, those curves tend not to significantly progress uh throughout the those people's lives, so they overall live a really like, you live a pretty good life from a back health perspective. Uh, they have a bit more pain, um, but they still are able to obtain jobs similar to their peers, uh, when cars are less than 50 degrees. Um, with continued scoliosis, you know, when curves are above 50 degrees, those curves tend to slowly get worse throughout the, uh, that kid's life, you know. So, uh, that's something that we like to talk to families about. And when the curve gets above 50, those curves tend to just keep going. Uh, it's at a slow rate, about a degree per year, but does continue to get worse throughout their lives. So, and we say that, you know, surgery later in life, that's a bit more challenging than having surgery as an adolescent. It's just more complications, often bigger surgeries. Of the, you know, the fusions go down to the pelvis. So it's just a bit of a different surgery uh if, you know, the adolescents get surgery in their 30s and 40s, uh, versus that, you know, have them before, you know, at least, you know, before 18 or so. And here's an example of, of what that can look like as that curve progresses. You can see here it's a small S and this kid, this person is skeletically mature, maybe age 18 or so, we see all the growth rates are closed, uh, but this is a small S and that can progress to, uh, quite a large curve now in a, you know, 3 year old, but this is a big surgery for, for anybody, but especially for an adult, uh, with a really long fusion, that would be a lot longer than if it were treated as an adolescent. Uh, so that's just part of the discussion that, that we have to you as far as when families are deciding which way they would like to go for treatment. Uh, as far as screening is concerned, you know, our society, the scoliosis Research Society, you know, we recommended that females are screened at age 10, age 12, uh, and that males are screened at age 12 or 13. Uh, and this is also in light of the, you know, AAP's Bright Future guidelines, which at least in 2017, 2019, just kind of give a general recommendation of an examination of the back, uh, just to, uh, again further assess for scoliosis. Uh, and this is coming like too that the US uh PSTF, um, they don't really, at least 2018, they didn't have a conclusive recommendation. Um, we do think that this may be revised in the future now that we have such great evidence about bracing, like early diagnosis and bracing changes the natural history dramatically. And can prevent a lot of kids from progressing to surgery. And so we do think that, you know, I think, uh, we do, we do think that there are a lot of, there are a lot of reasons to catch these curves early so that we can brace and prevent surgery, but these are nonetheless, these are the uh positions of each of the societies. So, when taking history for kids with scoliosis, you know, important is the family history, just the girls for. Back pain, uh, you know, I think previously it was thought that kids with idiopathic scoliosis don't have back pain, and now we know that that's not, that's not necessarily the case. So kids with scoliosis can have back pain. Uh, and actually about, you know, 23% of those kids do. Uh, thankfully, that pain often, you know, somewhat improves with physical therapy, but kids with idiopathic scoliosis can still have back pain and do have it more often than their peers. Uh, when kids do have pain, we do wanna rule out, uh, you know, other causes, you know, pars fractures, spinylysis, you know, tumors, you know, we, we still have to go down that path, but kids with idiopathic scoliosis can still have back pain. Uh, in part of our history, we are also assessing for any neurologic symptoms as well. Again, the main goal of the history for kids with idiopathic scoliosis is to rule out any other causes, you know, before we say that, oh, this is an idiopathic case. So we just want to rule out all the bad things. Uh, for physical exam, our typical exam is just a it again focuses on just trying to rule out anything that's abnormal. So we go through a pretty extensive exam for them, uh, doing a gait, their toe walk, hill walk. We want to see how they're standing, uh, how are they balanced. We, we're inspecting their shoulders for any asymmetry, which can come with scoliosis, and we're looking at the flanks. That can also be an early sign of scoliosis when one side of the flank is concave and the other side is convex or a bit pooed out. That's a Uh, telltale sign that scoliosis is present, um. And then we're doing the atoms forward bend. So just really looking for that rotational deformity that we spoke about a bit earlier. Uh, so that's uh part of uh our typical exam and you don't necessarily need a scoliometer. A lot of people do this with their phone, uh, and that's uh totally fine too, so. Uh, and for our lower extremities, you know, often doing the lower extremity strength and sensation, you know, we're checking the reflexes, you know, if someone were to have really abnormal reflexes or have clonus, you know, that would be concerning and that would be a reason to, you know, you know, pursue MRI's and other things sooner assessing for those things are, you know, clonus, I'm sorry, assessing for syrinx, you know, TREs or tumors. And then for X-rays, you know, we mentioned the standing PA and lateral X-rays are, you know, standard for scoliosis evaluation. Uh, and that's, uh, and that's, that's true. That's what we want here, that's what we want for kyphosis. You know, I'd say that. And before we get into this X-ray, one nice component that we have available now, uh we have the low dose imaging. And that's what the true scale with EOS imaging, which provides 2 or 3 times less radiation, at least, sometimes even more, or even less. So, uh, and that's available at Orange Jewish West County. That's at CSCC South County, and it's also coming soon, uh, to Missouri Baptist and Saint Louis children. So having this low dose imaging option really decreases the amount of radiation, uh, these kids are seeing long term, especially as we're following them year after year for their scoliosis. So, uh, that part is, that part is helpful. It's nice that we have that here in Saint Louis. Um, and as we dive a bit more into the X-ray, you know, I think that's something that we like to look at is, you know, we kind of send these notes back and we talk about cob angles. And I think it's just nice to just spend a little bit of time and just maybe dive through how we look at these X-rays. So, you know, kind of what is the cob angle? And I think as we look at this X-ray, I think the first thing is, well, let's identify the curves. And so for identifying the curves, I like to say it's just like recognizing the C shapes, OK? So, say that the main C shape is here. Yeah, so that's one curve. There's another C shape going this way, that's another curve. And then there's a little small C shape here at the top. So that's the first step, it's just recognizing that, OK, there's one C, so that's one curve, and that curve will have an angle. There's another C below that, it's another curve, which will also have a corresponding angle, and then there's a little small curve at the top. And then maybe we'll jump, we'll zoom in a little bit here. And so what are we looking for to really make our angle measurements? Well, for each of those C shapes, we want the most tilted vertebrae at the top. We want to know that angle compared to the most tilted vertebrae at the bottom. So for here, uh, for this curve, I would see that, oh OK, this is my C. Well, this curve, this is tilted, this is more tilted, even more tilted. Oh, that looks like it's maximally tilted. Uh, so this is where I, uh, measure one angle. At the top angle and then at the bottom, I do the same. Like this is a little bit tilted. This looks like a little bit, uh, maybe this is actually the most tilted vertebrae here. And so I, that's what I would, that's what I use to measure, uh, uh, the curve, and I will want the angle between these two vertebrae and that will be their curve, or that will be their, um, that will be their cob and that will measure about 40 degrees. And I do the same thing with the other, uh, measurements as well. Uh, and so, so then deciding, well, do we just stop at X-rays or do we go further for an MRI? Like who gets an MRI? And the answer really is anyone who doesn't fit into that standard box of adolescent idiopathic scoliosis. If we're at all concerned that there are other things at play, like maybe they have abnormal reflex exam or they, you know, have their strength is asymmetric, one side is stronger than the other, like those are all reasons where, you know, we'd recommend MRI right away. And looking for things like you see here in this MRI, uh, with this big syrinx, uh, here and, uh, uh, here in the middle of the cord. So that's abnormal, shouldn't be there. Uh, so those are things we're able to catch just with, you know, uh, a pretty thorough physical exam. And so, uh, history and physical exam. So if anything's abnormal, then we tend to recommend a spine MRI to make sure there's nothing else contributing to the scoliosis. So how about treatment options? Well, you know, a lot of treatment options, we're definitely not talking about all those today, but, you know, observation, just watching scoliosis is really common, physical therapy, bracing, and then we'll talk a little about surgery. So, observation, you know, we do that most often for curves that are less than 20 degrees, uh, we. Also observe curves that are less than 50 degrees after the kids are done growing. So with the, you know, a 17 year old with a 35 degree curve, well, nothing to do about that. We can just watch that and see if, see if it gets worse over time. Usually it doesn't for our studies, and so we just keep an eye on that. Uh, physical therapy is great for kids who have pain. Uh, so physical therapy, you know, really works on the periscapular strengthening and core strengthening, and doing just physical therapy 1 or 2 times a week, uh, and having a good routine, uh, does help decrease the pain for For kids with scoliosis, uh, we found that it works a little bit better having the kids go to physical therapy, you know, at least for a couple of months, uh, versus just going there once and doing a home exercise plan. The kids just don't do it as reliably and don't get as much pain relief. Um, but physical therapy is great for pain. There's something called scoliosis-specific physical therapy, which we won't have time to talk about today, but, uh, that can also be a good avenue as well. Uh, and, you know, the other conservative treatment option is bracing. So when do we use a brace? Well, braces we only use when kids have growth remaining, and those kids typically, and the curve magnitude is between 20 and 45 degrees. I would say overall, I'm pretty, I'm a pretty aggressive bracer, uh, just because I like the idea that we can prevent these curves from getting to surgery, uh, but that's our typical threshold. You know, full-time bracing is 18 hours a day. And there are multiple different types of braces. We use the, uh, Boston TLSL. That's the one that's most commonly used here in the US, but there are definitely a lot of different types of brace braces as well. Uh, overall, I think the number to hang your hat on is that for every 3 kids that treated, that is treated in a brace, it prevents one of those kids from, you know, progressing to surgery. So the number needed to treat is 3, which from our standpoint is excellent. Uh, and that's what I think the big reason why I'm such a big advocate for bracing early when we have an opportunity, and I try to bring this up to families as early as possible. So, um, bracing is, uh, bracing works, and we have great data that supports it. Uh, and lastly, we just talk about one of our surgical options, which is the posterior spinal fusion. Uh, this is really the gold standard as far as, you know, when scoliosis gets beyond 50 degrees, you know, it's done through a single incision, and we focus on correcting the deformity. uh, and really the goal is to prevent these curves from progressing throughout, uh, the kids' lives. So, you know, we don't, we're not necessarily shooting for a straight spine. Those spines do become straighter in the process. You know, usually you get about a 70% correction or so. Um, but our main goal is we don't want this 55 degree curve to be an 80 degree curve when this, you know, when this kid gets to their 50s and 60s. So to just stop that progression, uh, and uh, we have great data that shows that it does stop the progression of the curve over time and so, uh, hopefully kids don't worry about it later. Uh, overall, the reoperation rate is low, uh, and again, the, the, uh, outcome measures that kids do quite well after the surgery. Um, so what to expect after spine fusion? Well, we typically have the restriction of, you know, limiting the lifting, bending, twisting for 6 months. You know, post up day one, these kids are sitting in a chair and standing. They're also, uh, often getting them up to walk, and then usually leave the hospital 2 or 3 days after surgery, which is a lot faster than what, you know, kids left the hospital even 10 or 20 years ago. So it's quite a different surgery, quite a different recovery than what had been, uh, uh, than what was done in the past. And you know, a lot of these kids depending on where the fusion, uh we expect these kids to get back to sport. You know, this is Shalia Williams who also had, uh, spine surgery and, you know, playing a little basketball. It really depends on how big the fusion is and what sport the kid wants to play, but most of these kids, we expect to, uh, get back. To their sport. Uh, and for me the recovery protocol is after 6 months. And I think a lot of surgeons use that too, is after 6 months, slowly getting back into their activity. Uh, but, you know, I usually give caution against sports like gymnastics, football, and wrestling. It's really intense sports, but for most others, kids are able to get back. Uh, and then lastly, we have a case just, um, you know, 17 year old who presents with concerns of around the back and that thoracic back pain for two years. The pain is worse with activity, that's running, jumping, um, and walking for long periods of time. And she was working at a grocery store, but due to her back pain, she had to stop working and she wasn't, was not complaining of any neurological deficits. And she previously has tried physical therapy, uh, without much relief. Uh, on physical exam, uh, she has significant thoracic kyphosis, and on her forward then there's a little bit of scoliosis, and, and she has full strength in her bilateral extremities, and, uh, when we do the prone testing, we can see that her kyphosis is very rigid, uh, so likely at Sherman's kyphosis. So we can see that here, uh, the Sherman's kyphosis, these are X-rays that we have from earlier, uh, and a little bit of scoliosis here. So she has a little bit of both. It's not uncommon to have scoliosis with Sherman's skyphosis. Uh, and then when we talk about treatment options for this patient. You know, we talk about observation. You know, these kids don't need surgery. You know, I, we talk with them about what does their life look like if they were to have surgery and what does it look like when they're, if they're not to have surgery. And to me, it's up to the family to decide, uh, we're just trying to give them the information to make the best decision for, you know, for, for them. Um, so er operation, they can still observe this, you know, if you don't necessarily need, need the surgery. And we talk about physical therapy, uh, bracing wouldn't be an option for her because she's already sculply mature at 17. And we don't brace people that don't have growth remaining, so I wouldn't recommend a brace here. And then lastly spoke with them about surgery. They have pretty much tried all these options before, uh, without success. They were really interested in having surgery. Uh, so she had a post your spine fusion. Uh, you can see when, you know, after a surgery like this, you know, if we look at these images and look at how much of a, uh, around the back she had beforehand just how far her back is from her legs, you can see that now this is a much more appropriate. Uh, distance of her back to her legs, and she is very happy. Her pain is, uh, her pain is much improved. Uh, she's back to doing what she wants to do. She's back to work and she's really happy with, you know, her confidence and cosmetic appearance as well. So it's not everything, but it does, it is something, so, uh, and, and that is the talks. Thank you guys so much for your attention. Thank you so much, Doctor Montgomery. We really appreciate it. It was a great talk and uh thank you again everyone for sticking with us. I'm gonna pull up the QR code and if you have any questions, please feel free to unmute and or type them in the chat. Created by Presenters Blake K. Montgomery, MD Assistant Professor, Orthopaedic Surgery Division of Pediatric Orthopaedic Surgery Spine Section View full profile
