Scoliosis Awareness Month: Sharing Knowledge and Celebrating Advances in Care!

Dr. Roy: Hello everyone and welcome to Spine Talks. I’m Dr. Rita Roy, CEO of the National Spine Health Foundation, and today we’re shining a light on scoliosis where we’re sharing knowledge and celebrating the incredible advances in the treatment of this condition. It’s my honor to be joined by two of the world’s leading experts, Dr. Suken Shah from Delaware, and Dr. Larry Lenke from New York. Our program today is being produced in collaboration with our friends at the Setting Scoliosis Straight Foundation, where Michelle Marks is the executive director. Michelle, tell us a few things about the Setting Scoliosis Straight Foundation.

Michelle: Thanks so much for allowing us to collaborate with you on this incredible event to, uh, celebrate Scoliosis Awareness Month. So the, uh, HARM Study group is the research arm of our organization and has been doing research in scoliosis treatment outcomes for decades. And we also have a nonprofit arm called Setting Scoliosis Straight, which is dedicated to empowering patients with evidence-based information so they can really navigate important treatment decisions.

Dr. Roy: And at the National Spine Health Foundation, our purpose is to give people knowledge and hope so they can be better informed about their treatment choices. And we are thrilled to partner with the Setting Scoliosis Straight Foundation where we partner in advancing successful patient stories and again, sharing that evidence-based information so that people understand the complicated and confusing word world of spinal healthcare.

So today as we get into our program, we’re going to be talking about both pediatric (kid) scoliosis and adult scoliosis. And I think there’s a lot of confusion out there about what that means, what the range of scoliosis is. And we’re so lucky to have our experts joining us today. And, um, and so we’ll start with an introduction, um, with Dr.

Shah. Dr. Shah, you could tell us a little bit about your practice and the kind of patients that you treat.

Dr. Shah: I’m pleased to be here. I’m trained as an orthopedic surgeon, specifically a pediatric orthopedic surgeon, who has now, uh, devoted his career to the treatment of children with spine problems. That includes things like scoliosis, kyphosis, and

Dr. Lenke: spondylolisthesis.

Dr. Shah: I practice in Wilmington, Delaware at Nemours Children’s Hospital.

Dr. Roy: Dr. Lenke, tell us about your practice and the type of patients that you see and that you treat.

Dr. Lenke: Again, I’m Dr. Larry Lenke. I’m based in New York City at Columbia University in the New York Presbyterian Och Spine Hospital. And uh, I, my practice is similar to Dr. Shah’s that I treat pediatric patients with various types of spinal deformities, including scoliosis, kyphosis, and

spondylolisthesis.

And in addition, I also see adults. All the way up, uh, of any age really, that have similar conditions. So only treating patients with various forms of, uh, spinal deformity, but both about 50% of my patients, uh, are children and 50% will be adults.

Dr. Roy: Okay. And both Dr. Shah, Dr. Lenke have just shared some really big words with us, a lot of osis and isis, and, and so we’re gonna get into what some of that stuff means as we move along in our program Now, um, So, so moving, moving right into our content here, we understand that scoliosis can affect both kids and adults, and we wanna understand what are some of the similarities and what are some of the differences as we think about the word scoliosis.

Deformity in the spine, what, what does that really mean? And what are those differences and similarities? So that, that’s a, that’s a big question. I know, but I’m gonna turn that over to the experts.

Dr. Shah: And you’re right, there are a lot of complicated terms and there is also a lot of complicated causes, or etiologies of scoliosis, both in children and adults.

And I think we should cover some of those, but it’s impossible to cover everything. The most common type. Of scoliosis in a young person is adolescent idiopathic scoliosis. That means it typically progresses most in your growth spurt. We don’t know the cause, but it’s likely genetic. It creates a three-dimensional curvature of the spine, both the side to side curvature that everybody knows about, but also a loss of some of the side curvature that is normal.

But specifically also a third component called rotation that, uh, will cause a rib hump or rib unleveling that most school nurses and gym teachers, for instance, are taught to screen for. It’s important to diagnose these conditions at the earliest stage that it becomes clinically apparent or a parent to a family member or school screening person, or your pediatrician primary care provider, because there are treatment methods.

When the scoliosis is still small, when the child is still growing, that we can apply that, um, have very successful long-term outcomes. Occasionally, however the scoliosis can progress, it can become severe, and surgical treatment is necessary, and I’m sure we’ll cover that today. But I see children through their growth spurt into perhaps young adulthood.

Dr. Lenke has the benefit of following patients over many years, decades, even. And can comment on what can happen to an adult who was previously a teenager with scoliosis. And some of the changes that happen with aging,

Dr. Lenke: for instance, over time, there are patients that we see with scoliosis and we’ll focus today mainly on scoliosis, uh, who are diagnosed, uh, as a, um, uh, young child or teenager.

Uh, and for whatever reason, uh, they’re not treated, maybe because their curve was not that large and. Is, uh, and can tolerate, uh, non-operative treatment or observation. And, but as, uh, uh, one ages into, uh, young adulthood and then, uh, later adulthood, uh, often the curves can progress. And these, so these are curves that are present as a child or teenager and even, even in, in the form of, uh, adolescent idiopathic scoliosis is, was mentioned.

And, uh, over time, depending on the size of the curve, uh, uh, they can continue to slowly progress. And typically it’s. Very, very slow. Only one or two at most, three degrees per year over the course of 10, 20, 30, 40 years. That can add up to quite a large degree of, of curvature present when one is, uh, in their fifties and sixties.

So that’s certainly one very common type of curves that we’ll see, curve pattern will see in adulthood. And unfortunately with that, not only the curve progression becomes more problematic, but also, uh, clinical symptoms start to increase. Um, uh, and mainly with pain. Um, because as the curves get larger and patients get older, there’s often arthritic changes that occur on the spine that cause arthritic type of, of degenerative pain.

Uh, and even things, if the curves get more severe, uh, some respiratory dysfunction, uh, and other, uh, medical issues that, uh, that can become problematic. So, uh, that’s the, uh, type of scoliosis that, uh, is present in childhood and, and just slowly progresses into adulthood. The second type of scoliosis that we commonly see in adults is what called de novo, uh, degenerative scoliosis, where there’s no curve present during, uh, childhood or teenage years.

But, uh, over time in adult years, uh, with arthritis and, and, uh, degeneration of the spine, a degenerative scoliosis occurs. And that typically, again, presents with arthritic back pain and often even. Spinal stenosis or pinching of the nerves in the lower spine because of the curvature of the degeneration in the arthritic changes.

So a separate type of, uh, scoliosis, uh, but still, um, a, a, a, a continuum of, of conditions that need to be evaluated and often treated as, as one ages.

Dr. Shah: We just talked about two different types of adult scoliosis and we mentioned adolescent idiopathic scoliosis in the young folks. But there are so many other causes of scoliosis that are much less common.

So if we look at adolescent idiopathic scoliosis, which affects 3% of the population worldwide, that’s a lot of people. But there’s definitely rare conditions such as different syndromes, congenital vertebral malformations, or a misshapen bone, um, and maybe even some neuromuscular problems such as cerebral palsy or spina bifida that can cause scoliosis and other types of deformities to the spine.

They each have customized treatments, they each have their different situations and, um, that that treatment really needs to be customized. Um, and it also comes with an entirely different complication profile and thought process for both treatment and management, um, with surgery or without. And, um, I think what we should probably focus most of our attention on today is the idiopathic, uh, types of scoliosis and de novo.

Dr. Roy: And just to explain to our, our listeners, the word idiopathic is maybe not obviously understood by a lot of people, even even people who understand what that word means. Can you, can you help us understand really what that means in the context of, of

Dr. Shah: scoliosis? It’s, uh, originally a Greek word now sort of modified in Latin, but it means that the cause is unknown and, um, So if you break it down, adolescent means that during typically during the growth spurt middle school age, child idiopathic, is we don’t know the cause and scoliosis we just discussed.

Someday we’re going to know the etiology or the cause of many of these curves. Right now we have to lump them in an in a bucket because we don’t know the cause. The child is apparently normal looking, normal functioning. The M R I scan is normal. The bone density is relatively normal. They don’t seem to have any blood work abnormalities.

But there may be a very subtle neurologic abnormality. There may be a very subtle hormonal abnormality. There’s definitely a growth asymmetry that occurs and how the curve progresses. And, um, there’s ongoing research in, into trying to identify the genes for progression or protection. Um, but there are, this is a disorder that’s very complex.

It is multifactorial. The inheritance pattern is not quite delineated and the condition is expressed in various degrees. Some people have no curve. Some people have a very small curve and some people have the most progressive form of the condition, and that can be in the same family. So studying families didn’t work out very well.

Now we can do, um, cast a much wider net through genome-wide association studies and figure out. In all the population of patients with scoliosis, what genes do they have in common for progression and, and work on, work on it that way?

Dr. Lenke: Right now, it really still idiopathic is the diagnosis of exclusion. You know, the, the job of the practitioner is to exclude other factors is was mentioned, neurologic issues, um, uh, um, uh, neuromuscular issues, uh, to make sure that we are truly have an idiopathic condition and, uh right.

We do have a lot more work to do to define that further, especially genetically, but, I think it’s, uh, uh, inherent, uh, uh, to the practitioner, to, to ensure that this, that everything else is excluded and we truly are dealing, dealing with an idiopathic curve, idiopathic and maybe idiopathic patient.

Michelle: Thank you, Dr. Lenke and Dr. Shah for really, uh, identifying the differences in the presentation and the diagnosis of, uh, Pediatric versus adult scoliosis. Do you mind highlighting some differences and some similarities in the treatment options that a pediatric patient might have compared to an adult patient?

Dr. Shah: Observation is one. We have many patients with small curves while the child is growing. We wanna monitor their curve for progression that can be done clinically. We also measure their height. We do a neurological examination, and frequently we do a low dose x-ray. The x-ray is very important because. The curve can be changing, but the external appearance of the child may be quite similar.

And so we need a objective measurement by the x-ray to see if the curve went from say, 10 degrees to 15 degrees, or 20 degrees to 25 degrees. And observation really means you come into the office, we examine you, we get an x-ray, and it might be every six months, it might be every year, but there’s no active treatment such as exercise or bracing, or certainly not surgery.

And I think that we would have a lot of overlap for children and adults who present with curves in the, say, mild to moderate range that don’t need any treatment except just surveillance.

Dr. Lenke: Absolutely. And again, the gold standard in adults is, uh, uh, similar in that it’s really the, the, the x-ray, uh, similar.

We try and use low dose x-rays if we can, in adults to minimize the radiation burden that can be quite, uh, extensive over the course of one’s lifetime if you’re being monitored for scoliosis, uh, over, over many decades. Uh, and again, um, observation is probably still the number one, um, treatment option for adults with scoliosis, especially those that are not too symptomatic and, um, and curves are in the, in the mild or moderate range, uh, we’re maybe a little more aggressive with making sure patients stay healthy, their bone density is being optimized, cuz there’s other health factors obviously that come into play when one starts aging with the scoliosis.

But again, uh, by far the vast majority of patients who have adults idiopathic scoliosis, uh, will be either monitored or, or given, uh, non-operative treatment for their curves.

Dr. Roy: For those patients in that, um, observational stage, how important is it to, to share with them? Um, you know, core strengthening activities, um, you know, maintaining healthy body weight, things like that.

How, how much does that factor into the progression or lack of progression of their disease?

Dr. Shah: I think for children and adolescents, I can’t say there’s direct evidence to correlate that not exercising or having a sedentary lifestyle necessarily predisposes, you to scoliosis, but it can make the mildest form of the condition symptomatic.

If you’re lacking good core strength or you might be overweight or sedentary because, um, just for general health aspects, it’s very important for children to be active. We recommend, uh, at least an hour of outside activity daily, both for vitamin D exposure, bone density issues, muscle strength to prevent, um, gaining weight and a healthy lifestyle is very important.

And so along with counseling them that. We don’t think your curve is going to progress or your curve has maintained, uh, a stable alignment. We do recommend vitamin D replacement for people who are at risk for vitamin D deficiency, and we do recommend a healthy lifestyle, including daily exercise.

Dr. Lenke: And for adults it’s, it’s quite similar.

Uh, although in the adult world, obviously, uh, health becomes, uh, much more an important factor in. Staying active, staying fit, uh, uh, uh, uh, watching, uh, carefully. The bone density, again, there really isn’t good scientific evidence that, uh, uh, any type of, uh, active exercise or therapeutic program will, will limit curve progression.

If curves are gonna progress, they’re gonna progress this no matter what non operative treatments apply. And I think that’s true with, with children too. Uh, besides bracing, obviously, which has definitely shown and shown to, uh, to alter the course the actual history. Yeah. Uh, children with scoliosis, but for adults, really nothing has been scientifically shown.

Uh, so if, if someone has a. Uh, continually progressive curve. Again, albeit slow because most adult curvatures do progress quite slowly. Um, maintaining a healthy lifestyle unfortunately is not gonna change the fact their curves are gonna continue to progress, but it can limit their symptoms. And so that’s why we do emphasize, uh, living a healthy lifestyle, keeping yourself fit and active, watching your bone density, watch your, your diet, uh, and things like that, uh, just to, uh, keep your symptoms under control.

And keep yourself as healthy as you can, which has, uh, is obviously good. No, no matter what happens to your scoliosis does to stay healthy and fit.

Dr. Shah: And I would just underscore exactly what Dr. Lenke said. The lack of proof doesn’t mean there’s a lack of existence and no one would, no one would, uh, say that these exercises are harmful.

If your primary care provider or scoliosis provider has recommended physical therapy and exercise, I would definitely do it. There, there, there, there are other benefits besides just controlling curve progression, uh, to doing these activities.

Michelle: So I know you are both very passionate about research. Dr. Lenke, you have served as the Scoliosis Research Society President. You were a founding member of the HARM Study Group. You’re actively involved in the International Spine Study Group. And you, Suken Shah, are in the presidential line for the Scoliosis Research Society and have recently been named the President of the Harm Study Group. With these amazing accolades and the fact that you have dedicated so many hours of your practice and your time to improving care for patients with scoliosis.

Could you highlight a few of the more recent, uh, advances that have come about in treatment and care, um, due to research in scoliosis?

Dr. Lenke: Well, thank you, Michelle. Appreciate that. Yes, it’s been a, a great journey so far and I’ve been really blessed to be able to, to, uh, not only help my patients, but you know, through research we help other patients.

Right. And it’s really an exponential reach, uh, of your, uh, of your efforts. So it’s, it’s, it’s obviously very important and. And obviously there’s so many people that also do this type of clinical research, so. That, uh, that we all benefit from. So I think in, in, uh, I’ll focus more on, on adult scoliosis. Um, the major, uh, improvements over the last, uh, two decades have been, uh, number one, um, uh, the use of, uh, more, uh, posterior or, or kind of one, one approach surgeries, uh, to patients who need surgery.

Um, when I was, uh, in my early practice in the 1990s, uh, Very commonly adult patients require two surgeries, uh, surgery, uh, accessing the front of the spine through a side incision. Then usually on a separate day, a second surgery accessing the back of the spine, uh, to what’s called a posterior approach.

And, um, uh, things were often treated, uh, quite well with that approach. But there was a lot of what we call approach related morbidity, especially from the lateral or anterior approach. And we, we studied that and was pub and published on that and, and we found that, um, uh, we had to get away from some of that approach related morbidity that was leading to.

Adequate alignment of the spine following surgery and adequate, often fusion of the spine into a good position. But, uh, residual complications from the approach. Um, uh, things like hernias and swelling and pain, uh, uh, in the area of the approach that was not, that was basically, uh, obviating other than otherwise good result.

And so, um, what we started to kind of trend was, uh, trying to avoid the anterior approach. And so by. About 20 years ago or so, we, we became able to treat really any type of adult scoliosis with a, a posturally approach, aviating the anterior procedure with actually even better radiographic results, uh, uh, soon thereafter because of the use of, uh, of various types of screw fixation and modern instrumentation techniques.

And also, uh, osteotomies are more different carpentry above of the spinal elements to, to loosen up the spine to allow for adequate. Uh, an optimal three-dimensional correction. So, uh, things change so we can do everything kind of from a single approach, often, usually in a single day, uh, with much less morbidity to the patient early and, uh, long term postoperatively.

So that’s been one of the major changes in, in the adult world, um, in the last two decades. And then, uh, added to that, the last decade or so, it’s been, uh, uh, even some of this work being done through less invasive techniques, which is very exciting and still, Uh, has a way to go, but is, is definitely, is the, is the future of, uh, the way adult scoliosis will be treated, is using, uh, these type of, uh, techniques where less invasive, uh, and smaller incisions are used to, uh, correct deformities,  uh, and, and make the spine stable and long lasting and a, and a better, much better position.

Thank you

for that, and I know you’re a huge contributor in those advancements, so thank you for all that you’ve done to improve care for patients, Dr. Lenke.

You’re welcome.

Michelle: Dr. Shah, you have such an exciting career happening and in the future, please tell us about what you’re highlighting in research in pediatrics.

Dr. Shah: One of the reasons many of us do research is to answer common questions that we encounter with a patient or in daily practice, and that’s how some of these research ideas have been stimulated patients. Kind of, uh, inspire us to answer some of those questions and improve improve care. Um, I think we’re going to talk about bracing a little bit later, but we have a, a pivotal study, uh, published about 10 years ago now, um, in which bracing was proven to be effective in a randomized arm, um, of the BRACE study, which we can discuss further.

Um, but one thing I really wanna emphasize during the last two decades is improvements in the classification of idiopathic scoliosis, and we have, uh, one of the authorities here today, which is a, a great pleasure. But, um, Dr. Lenke’s classification system is used worldwide, uh, for anyone who treats scoliosis especially, especially surgically, in order to go through a standard framework of classification.

Trying to decide which regions of the spine should be treated surgically and how best to do that. Because if we’re not all speaking the same language and not applying standard treatment techniques, uh, it still becomes more of an art rather than a science. And we know that variability is never very good in terms of patient care.

The better we can get with standardization of that treatment, I think, uh, the better the outcomes will be. Um, and in addition to classification, I think that a lot of the innovation. Technology has led to improvements in surgical treatment. We now get much better correction, alignment, preservation of that alignment and correction safely, uh, than we ever did before.

And this has led to both rapid recovery of the patient and allowing, at least in my case, in my patients, allowing kids to be kids, allowing teenagers to go back to sports. Very little time missed from school and for their caregivers. Very little time missed from work. And with this rapid recovery, we’ve also had massive improvements in neurologic safety.

It is extremely unusual to encounter a permanent neurologic problem after idiopathic scoliosis surgery at least. In, uh, the contemporary way, we monitor patients and perform surgery today. We rarely have to transfuse blood anymore in children undergoing scoliosis surgery, and the pain management is much safer and superior.

To what it was just about 10 years ago with, um, rather than lots of opioids being used for pain management, we’re using opioid adjuncts or pain medications that trick the pain receptor into seeing an opioid type of, um, medicine. But more importantly, not having the side effects and allowing the patient to mobilize in physical therapy, eat, drink, and go home much sooner than was ever thought possible even 10 years ago.

Michelle: Those are amazing highlights and really congratulations to you for all that you’ve done thus far in your career. I know it takes a lot of extra time to serve as a president of Scoliosis Research Society and of the HARM Study Group, so we thank you for all that you’re doing to advance care for patients.

Dr. Roy: And both of you have been so involved in the evidence development around.

Treatment advances and, and, and, and we thank you for your work. Um, and we’re excited to see some of that work that you’ll be able to share with us now.

Dr. Lenke: So this is an example of a frontal, uh, x-ray of a 60 year old female, uh, with adult idiopathic scoliosis. So again, this, um, uh, lady, uh, knew she had scoliosis as a teenager.

Her curve, uh, wasn’t that large, did not need to be treated. Uh, but now, and presented to me at age 60 now with, uh, a fair amount of back pain. That was her main complaint. And as you can see here, she has, uh, how we measure the curve, uh, a 86 degree, uh, curve in what’s called the focal lumbar region. So, uh, just below the ribcage and, uh, above the pelvis.

You see that, uh, we look at the x-ray, uh, um, as we’re looking from the back of the, uh, the body. So to the left is the left right is right. So this curve is going to the left and she’s also, uh, imbalanced to the left. So her whole trunk is leaning to the left. So she has a lot of left sided, uh, of, uh, back pain and pelvis type pain.

So again, uh, it’s hard to see the details, but obviously the, the curvature is obvious. The arthritic changes aren’t as obvious, but we can see those, uh, on, uh, advanced imaging such as CT and MRI scans. Uh, so again, it’s a combination now of a long-standing idio idiopathic curve now with arthritic changes that have evolved over time because the, the spine’s been out of alignment for basically over 50 years of her life.

And so now this is the adult sequelae of longstanding idiopathic, uh, uh, scoliosis, uh, and, and problems that we see. Clinically that matched the radiographic a lot. Now, alignment that we’re seeing now, this is a little bit older lady. This is a 72 year old female. Um, and these are total body images that we get.

So we get the X-rays of the entire skeleton. And I wanna highlight this patient because she’s 72 year old, 72 years old. It’s very difficult even to see and measure her scoliosis, uh, because of her. Uh, a collapse of her trunk cuz she’s not only scoliotic but she’s also bent on what’s called kyphosis or, uh, got abnormal bending from the side view.

So on this X-ray you see her, her head in her pelvis cannot even be on the same x-ray. She’s so bent forward. But this is a not too uncommon presentation of a, of much older patient that has long-standing scoliosis and now severe degenerative changes and truncal imbalance that occurs because of not only arthritic changes of the.

Vertebra, but also muscle imbalance that occurs with time, severe pain, and these posture and the then the results in posture abnormalities that occur. Uh, and this kind of patient obviously is, is, uh, very challenging. Uh, not only from a a, a spinal column and spinal, uh, alignment perspective, but also from a health perspective.

This patient’s is not, is not really healthy because of this longstanding deformity. So, To even, um, begin to help treat this patient. We need a total and comprehensive evaluation, uh, with our medical doctors. Our, our, she needs her bone density, uh, check. She has a fairly significant osteoporosis. Uh, she, uh, uh, her GI system isn’t functioning well, so she needs help with nutrition.

Her pulmonary system is not working well, so she needs to see a pulmonologist, so, Again, a really, a multidisciplinary healthcare team needs to be involved in the evaluation of this patient, uh, to try and, uh, get their health optimized to see if they can be potentially a candidate for surgical correction.

That’s really the only way this lady’s gonna ever stand upright is with a significant surgery, but, Some patients in this age category really aren’t healthy enough to undergo that surgery without significant optimization from a medical and health perspective that needs, that needs to occur. And that’s really one of the changes in the last decade that this is recognized that modifiable, uh, risk factors of the patients with adult scoliosis need to be optimized prior to undergoing surgery.

These are elective surgeries typically. So we have time, uh, to optimize the patient’s health and medical condition, which obviously will make, uh, uh, going through surgery safer, uh, with less complications. So we spend a lot of time and energy on patients like this now to, to ensure that, um, uh, they’re optimized before we would ever consider surgery for this condition.

So here’s, uh, uh, scoliosis, adult scoliosis surgery, uh, uh, one of my patients from 1998. So here we have, uh, you see a very large, what’s called double major curve, uh, thoracic curve. Uh, uh, and a lumbar curve on the frontal x-ray on the far left. Uh, and you can see in the right side there’s, um, uh, a fairly straight thoracic spine.

There’s not much what’s called thoracic kyphosis, which is typical in. In various scoliosis conditions. Uh, and her alignment is from the side is, is, is fairly acceptable. But you see here she has equipment in and, uh, instrumentation in, uh, in, in the, in the, uh, second and fourth x-rays from the left, uh, after undergoing both an anterior and posterior spinal fusion.

So she had a side approach and the lumbar spine, uh, through a, on one day and approximately five days later, had this. Posterior instrumentation system applied to, uh, correct the curves, partially, uh, keep her balanced and actually have a fairly successful surgery. She had really no perioperative complications.

Uh, she stayed in the hospital probably a total of about two weeks or so. Which was fairly common then, um, and long term, she actually healed well. But, uh, her only complaint over the years was that she’s had a lot of, uh, side pain from the, uh, anterior approach. As I mentioned earlier, that was very common, that patients had, uh, uh, long term morbidity from, uh, the extensive, uh, anterior component of this surgery.

That’s now in the last 20 years, we’ve gotten, uh, away from most of us doing adult uh, scoliosis surgery. But again, You know, a very good result for the time. But, uh, but things had improved because this wasn’t ideal long term and wasn’t optimal for the patient. So now, uh, a similar type of curve, uh, treated in 2022 by myself, uh, shows this type of condition where, again, we have a large scoliosis, more, more of a focal lumbar isolated curve.

Uh, the same patient we saw earlier, uh, in the Sagal plane, she has what’s called a thoraco lumbar kyphosis. So, Her spine is rotated and, and, and, uh, out of alignment in the Sagal plane. Um, basically in the thoracic region and, and the region between the thoracic and and pelvis region. Uh, and here she has a, what’s called a posterior only spinal fusion.

So we only access the spine from incision in the back of the body. You see, we apply a fair amount of instrumentation to be able to correct the curvature. It’s an optimal position where she’s well aligned. Both the frontal and, and lateral or side plane, uh, and basically this surgery, uh, takes around seven or eight hours to accomplish and I know, uh, I remember her well.

She left the hospital four days postoperatively and has done very well. I just saw her back for her one year post-op visit. She’s doing extremely well. Is actually back to playing tennis and golf and, and leading a very normal life, uh, in her sixties. And this is again, what modern day adult scoliosis surgery really should look like, uh, for the vast majority of our patients.

Dr. Roy: That is incredible. And Dr. Lenke your patients look like they physically get taller as well as you correct these curves, right?

Dr. Lenke: They actually do, because if you’re gonna see actually on the X-ray show, the best way to look at that is look at where the. Lower end of the ribs are in relation to the pelvis.

Uh, pre-op actually almost touching the pelvis, the lower ribs and post-op, they’re literally about 10 centimeters away. So yeah, the average height gain for someone like this is somewhere between eight and 12 centimeters of height gain, uh, during the surgery. It’s, it’s quite extensive and patients notice that right away and obviously one, one of the benefits of surgery and, and, and basically, although a lot of it is, uh, a cosmetic improvement that they see visually.

But the health benefits are also quite substantial because by elevating the trunk, we’re increasing the room for both the thoracic, uh, cavity, which includes the heart and the lungs, and also the abdominal cavity, which includes, uh, obviously your GI system. And very commonly patients, uh, tell us that the, the breathing much better postoperatively and, uh, their GI system. Nutritional system and nutritional health is much better after surgery as well. So, Yeah, definitely h uh, health benefits from this type of surgery that are, that are real and, and are, are objectified, uh, uh, as well with our research.

Dr. Roy: That’s fantastic. And, and again, just summarizing that, the first case you showed us from 20 years ago, patient in the hospital for about two weeks, which was standard at the time, and now with this patient that you’re showing us, um, they were in the hospital for about four days.

Dr. Lenke: Four days, yeah. Uh, I think the shortest is, uh, is around three days for this type of surgery and. Typically it’s very unusual to stay longer than a week. Um, uh, that was unheard of even 10 or 15 years ago. So a lot of strides, again, as Dr. Shaw mentioned, in, in, um, anesthesia pain management. These, the same improvements that have been made in the pediatric side have been adopted as the adult side as well, uh, for the betterment of patient care and outcomes.

Dr. Shah: Where we came from historically and, and the institution that I work in, uh, a lot of this surgery was. Um, it very innovative at the time. In fact, one of the braces that we use is, is in fact the Wilmington brace. But where we came from is that we didn’t have those, um, really elegant implants that Dr. Lenke showed.

Much of this surgery was done with. Traction and casting, and you would often spend many months in the hospital. In fact, kids would go to school. In this hospital, you had very limited correction because we couldn’t apply internal forces and a very high reoperation rate. That means the patient would have to come back to the operating room many different times along the way.

You can see one such cast here, you would turn this cast turnbuckle and it would correct the curve slowly. Then you’d have to go back and operate through the cast. But the film on the right shows a Harrington rod. Um, this was very innovative at the time in the early sixties, developed by Paul Harrington in Houston, Texas, and was originally, um, applied perhaps for polio, scoliosis, and perhaps for young children with, uh, like a growing rod type of construct.

Then later was used worldwide for both children and adults with scoliosis in order to assist with diffusion. Um, you could also get curve correction, but what you see on the right is that many of the patients fell forward and revision surgery was probably necessary many decades later to treat a secondary problem called lumbar flat back Where we are now is really an attention to the.

All three dimensions of scoliosis, treatment and alignment of the spine, rapid recovery and early return to activities. So progress really has been made in that time. So we talked about idiopathic scoliosis and some of the health effects. We don’t see those health effects when the curves are are small, but children and their parents do see the shoulder rib and truncal asymmetry.

Um, it’s already a tough time to be a teenager. Now, on top of that, you have this issue, which can affect self-esteem. Rarely though in children is pain an issue? If it is, um, a further workup is absolutely necessary. The evaluation of the patient involves their pediatrician, gym teacher, school nurse, physical therapist looking, um, at various children through their growth spurt.

Perhaps in sixth, seventh, and eighth grade is the best time to be checked for adolescent idiopathic scoliosis. We look at the patient standing and then we bend the patient forward specifically to highlight any change in the rib alignment. And if one ribcage side is higher than the other, that indicates the spine is rotated or shifted over.

We have some ways of quantifying those measurements. But just picking this up is an important screening test. And then that patient should be referred to a scoliosis provider for an x-ray in, in a full examination. Prognosis is really the central issue. Many of these small curves won’t change. That creates an issue for anxious parents, repetitive x-rays and office visits, and trying to pick out those patients that really will progress seems to be our biggest challenge.

Fortunately, we do have forms of non-operative treatment. As we talked about, you can observe the patient, but bracing is really the mainstay treatment for curves in growing children between 25 and 40 degrees, sometimes bigger because many of these curves will progress and you can have full-time or part-time bracing.

And bracing, interestingly enough, was controversial. Uh, when I first started in practice, many, uh, many people didn’t think the evidence was strong enough. That was really settled by Dr. Stewart Weinstein and his colleagues at the University of Iowa. We were one of the 25 centers fortunate to, uh, participate, I’m sure Dr.

Lenke’s Center was as well. And this was really an NIH funded trial, not very common in orthopedics at the time, which really looked at, uh, patients who were in a brace such as this one with curves between 25 and 40 degrees. And so you can see how the brace changes their alignment, but only when they’re in the brace and only when they’re in this growing phase.

You can see another child now with a lumbar curve or a curve lower down in the body, and the brace can be used for both thoracic, lumbar, and double curves. Um, but it only works if the patient is compliant and the brace is well made. So in this study, um, over, uh, near various institutions in North America, they stratified the criteria to be very homogeneous or certain children with certain curves.

There were two arms. You could either be randomized or later select your treatment. Their treatment in the brace was monitored with a compliance meter, and this was then compared to a control group or children who didn’t wear the brace. Then we looked at whether they progressed to surgery or were done growing and saw what their curves did.

This trial was terminated prior to when it was supposed to be stopped because the results were so overwhelmingly. Positive in terms of bracing that it was unethical to control, uh, for these patients without a brace. And what I’m showing you here is that about 75% of the time in the child who is compliant, the brace worked to prevent surgery.

Sometimes these curves would change a little bit, but the point is, if you’re giving a child, a child, a brace and they wear it, they’re very often going to be able to avoid surgery. Another secondary conclusion of this study is there’s a dose dependent response to bracing. That is, the more they wear it or the better they do with bracing, the more successful they are at avoiding surgery.

Next steps in, uh, this non-operative treatment are 3D printing or really assessing that rotational phenomenon of scoliosis that we talked about. Current bracing technology should be customized, but we can even get to next generation technology, which monitors compliance reminds you on your phone perhaps, that you need to put your brace on and records those hours over time to really approve compliance and reinforce education, which is so important.

We talked earlier about low dose, um, x-rays, which visualize the entire patient. Very important for us to realize what’s happening all the way from the head to the pelvis and even. The lower body and to see how patients can compensate for their various mal alignments. But this is a patient with a more severe curve.

You can see how the rib prominence is a little bit bigger and she has a trunk shift and some shoulder imbalance and a waistline that’s asymmetric. These are things that she can see, um, and has, has significant self-image concerns. When curves become this big, these are her x-rays, and you can see. Much like Dr. Lenke showed. This is a large curve causing a lot of mal alignment, both in the frontal plane, but not very much in the side plan except for the ribs. Children and young adults can compensate for years with very bad side to side curvatures until, uh, later in life when the aging process sets in, they lose muscle mass, they lose bone density, they lose the ability to compensate.

We can feed these x-rays through computers. Machine learning is be, uh, will become very important for us to surgically plan and perhaps even tell the computer that we’d like the ultimate alignment to be something, um, uh, that we can program in like this, uh, and like this. Then perhaps a custom rod can be developed for us to be, uh, to be used in surgery.

We can then overlay the preoperative condition to the postoperative plan and really, uh, step by step execute that plan in surgery so we can get the best alignment and go from something like this, uh, to this, where you can see that the ribcage and the alignment is much, much better. Uh, but these are still two dimensional x-rays for a three-dimensional problem, so, These are the three-dimensional x-rays of the same patient.

And just as Rita mentioned earlier, um, the patients do grow after their curvatures are corrected. Uh, they like that. But what’s most important is the long-term benefit and not having the degenerative processes set in and to the aging spine and making scoliosis more of a health, uh, related quality of life issue much later in life.

As you’re an adult, this is another patient with a similar type of scoliosis. It has also been well corrected. Now we’re focusing on how to preserve motion, and as I spoke about before rapid recovery. And here are the three dimensional images as well. And you can see how malaligned the spine is before surgery and how surgery can really affect all of those, uh, three dimensions, uh, to restore kyphosis, improve that rotation, and obviously make the spine straighter in the coronal plate.

What we might be looking at more of in the future is trying to preserve motion, um, while still correcting the scoliosis and growing children with something called vertebral body tethering. But the evidence on that, uh, we don’t have the same track record, um, of long-term follow-up. We would say that this is still under investigation, uh, in most places.

Uh, but there are various centers really pioneering this treatment and hopefully we’ll see where it has a role in the treatment of scoliosis overall.

Dr. Roy: Dr. S Shah, that was such great information, so much information in there. You know, coming, coming at us quickly. I think, you know, the, the, the miracles of modern spinal healthcare are so evident in what you’ve shown going from those early days of a full body cast to, you know, 3D printing navigation and, and patients being able to literally do a backend after having, you know, surgery, their back’s, uh, used for scoliosis surgery.

So it’s, it’s really, it’s really remarkable. There’s so much to learn and to know here. I’m so appreciative for you taking the time to go through that with us. You know, I think the message to patients is that the right treatment for you depends on what you need, right? And, and so how, how do we help patients find the right doctor and the right treatment?

Everything from, you know, for, for adolescents, from bracing. We talked about things like compliance. Oh, of course compliance is difficult for kids cuz they don’t wanna wear a brace, you know, for long periods of time and, and yet look at that evidence that shows that it can work. And then how did some of those patients end up with surgery and sort of that whole big decision path along the way.

Can, can you come, I know that’s, there’s a lot packed into, it’s a lot to unpack in a short, um, session here, but what are some tips or things that you can say to parents. Who are, are looking at, um, dealing with scoliosis, adolescent idiopathic scoliosis.

Dr. Shah: What I think you’re doing with your foundation and what we’re trying to accomplish with some of our professional societies as well, is just get the right information to the right people.

Um, continue to learn and educate yourself about your condition, um, and seek um, really well qualified evidence-based treatment. To see if you’re a candidate for that.

Dr. Roy: And Dr. Lenke, so much of the time people think that scoliosis is something that just is for kids. You’ve shown us today, there are adult versions of scoliosis that either stem out of childhood or happen just happen in in adulthood.

Um, Again, the miracle of modern spinal healthcare is giving people choices that they never had before. I think what you’ve shown us today is there are patients that maybe in prior years would not have been a candidate for surgery. Can you tell us how patients can, can go down that path, find a doctor, find out whether or not they could be operated on, and where’s, where’s the hope, uh, for, for those patients?

Dr. Lenke: The hope, uh, is be, has really became manifest the last decade or two with, with knowledge. Knowledge is Hope is in, obviously National Spine Health Foundation is, is very well aware of that. So getting that right knowledge, uh, of your condition, uh, finding, uh, uh, the right, uh, expert who can analyze and give additional information to you on your specific condition cuz it.

Uh, no, no two patients are exactly the same. Certainly we have categorizations and classifications that group patients similarly, but, uh, in children and, and even more so in adults, there’s very uniqueness to every patient that, uh, has to be taken in consideration, including not only their, their curvature, but their overall health, their fitness level, and.

Their needs and desires and, uh, and even social issues, right, that become important. So, uh, getting knowledge is important. Uh, having someone, uh, provide options that, uh, and, and, um, uh, allow you to basically kind of help direct your own care. So, uh, obviously we, you know, our job is to educate and, and the patient’s job is to decide how they best wanna be treated based on the knowledge that they have.

And so it, it’s a great time. Obviously, the, the knowledge is definitely, uh, So much more plentiful now. And, uh, it’s being, it’ll be organized. It is being organized and will be even more organized in, in more, uh, um, uh, futuristic ways of predictive modeling and, uh, ai AI research where, uh, we’ll be able to kind of hand a patient a package of options that will have scientific proof as far as their risk benefits and complication rates and, um, a means of success and outcomes that we now have kinda bits and pieces of, but it’s not as formalized.

But in the very near future, we’ll be able to. Educate our patients on with real time information like this that will help them decide how the best way they should be treated. Because it’ll be very factual. You know, data’s very powerful, right? Knowledge is powerful and data’s powerful, and that’s what we need to use to, to provide the best care for our patients.

Dr. Roy: Thank you, Dr. Lenke, for that. And thank you, Dr. Shah. I know that both of you are so committed to that patient, that optimal patient outcome, and when you see your patients, Enjoying their lives and living their best lives, that that is a happy day and that is a day to celebrate. And, um, in, in your hands, you are giving people their lives back and we celebrate you.

We applaud you. We thank you. You are healthcare heroes. And not only do you do that with your time, but you also carve out time. To spend with us so that we can share that good news with the public and let people know that there are answers and there is hope. Um, our work at the National Spine Health Foundation is only powerful because of your contributions and in informing our coalition for spine health, where we work in close collaboration with the professionals and with groups like the setting scoliosis Straight Foundation.

We can carry that banner for patients all across the country and all across the world that there are treatments that work and you can get back to your life. Don’t have to live in pain and you don’t have to be disabled, but it is a journey. And it takes work. So thank you for contributing to our Spin Talks program to our body of knowledge.

We give unparalleled access to world class experts. That’s you. And, uh, I’ll let Michelle. Have a few closing remarks.

Michelle: Honor to collaborate with the National spine Health Foundation to celebrate June Scoliosis Awareness Month with disseminating this incredible education from these incredible spine experts, but also to celebrate

these advances in care due to research.

So again, thank you both for all that you’ve done in your careers and will continue to do. Um, it’s just truly an honor to to be with you and to, and to work side by side.

Thank you so much.

Dr. Roy: Thank you everyone. Thank you for joining. Please visit Setting Scoliosis Straight Foundation or spinehealth.org for more information.