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What Is Scoliosis
Interviewer: Scoliosis, or an abnormal curvature of the spine, affects some Ìð¹ÏÊÓÆµren and teens in their growing years, with mild cases often requiring monitoring or bracing. But more serious curvature may need a surgical correction.
Today, we're joined by Dr. Joel Turtle, a pediatric spine surgeon with a PhD in neuroscience. And he's going to give us some insight into when surgery is recommended for scoliosis, how it works, and what families can expect from care at the Ìð¹ÏÊÓÆµ of Utah Ambulatory Care Center and Primary Children's Hospital.
Now, Dr. Turtle, before we get too deep into this, why don't we just start with kind of a basic understanding of scoliosis? What is scoliosis, and how common is it in kids?
Dr. Turtle: Scoliosis is relatively common for relatively mild curves. And so with an incidence of about 2% to 3% of people having scoliosis, it's relatively common, with about a tenth of those patients having curves that progress into sort of the larger range.
Scoliosis is a growth phenomenon, and this is for adolescent idiopathic scoliosis, which is the most common type of scoliosis. It is a growth phenomenon where... what we think is that the front of the spine, the vertebral bodies, grows a little bit faster than the back of the spine.
This leads to a twisting three-dimensional deformity of the spine where we see curvatures when we're looking at patients from the front, a little bit of flattening usually when we're looking at patients from the side, and then a twisting that makes prominences of the lower back musculature or of the rib cage when we're looking at them sort of down the channel of the spine.
How to Spot the First Signs of Scoliosis in Your Child
Interviewer: How do parents usually catch this particular condition when it comes to their Ìð¹ÏÊÓÆµ's spine?
Dr. Turtle: Yeah, the most noticeable thing that kids and parents, and even pediatricians, the thing that they notice is oftentimes, when Ìð¹ÏÊÓÆµren are bending forward, you'll see a prominence on the back. And so that can either be a prominence of the lower back musculature or of the rib cage, or sometimes even of one of the shoulder blades. All of those indicate, like I mentioned before, a sort of twisting of the spine. That can be one of the first things that we see with scoliosis.
One of the other things that patients can see—or parents, or pediatricians—is an asymmetry of the shoulder with one shoulder higher than the other, or even a waist asymmetry where the waist appears shifted to one side or another. Those are other things that we can see that can indicate scoliosis.
When Bracing Isn't Enough, It May Be Time for Surgery
Interviewer: Now, we've done another piece about some of the first-line treatments. We've got bracing, etc. And I'll include that link in the show notes. But at what point does scoliosis become something that needs surgical intervention over just observation or even bracing?
Dr. Turtle: The best indication for surgery or the best reason to have surgery is a curve that is progressive. So we expect that scoliosis is going to progress while Ìð¹ÏÊÓÆµren are growing because it is a growth-related problem. But once scoliosis curves get big enough... and usually big enough is somewhere around 50 degrees. Once curves get big enough, they continue to progress even if a kid is done growing.
And so if a curve is 50 degrees, and let's say a Ìð¹ÏÊÓÆµ is 18 years old, those curves tend to progress at a speed of about one or two degrees a year, which doesn't sound like a lot, but over a couple decades that's another 20 to 40 degrees of curvature.
And once curves get into the range of 70 to 90 degrees, that's when patients will experience severe pain. They can have limitations in their pulmonary, or their lung, function, and also in the function of their heart.
And so having a curve that's bigger than that 50-degree threshold is a very good reason to have surgery, mainly to prevent a bad outcome that we know is coming down the line without it.
What Scoliosis Surgery Actually Aims to Fix
Interviewer: So when we talk about a surgical intervention for something like this, what are the main goals that you, as a surgeon, are attempting to do to make sure that the Ìð¹ÏÊÓÆµ's spine is able to not impede their quality of life?
Dr. Turtle: So my main goal with surgery, and the main goal of surgery for scoliosis, is to prevent that detrimental outcome with progressive curves. And so the number one goal is to prevent the progression.
Of course, we have several secondary goals, and the secondary goals we've been showing to be really important in improving the quality of life and improving the outcomes.
But the primary goal is, again, preventing that progression. Secondarily, we want to achieve as much correction of the deformity as we possibly can. So when we're looking at kids from the front on their X-rays, we want to straighten that spine out as much as we can. When we're looking at kids from the side, we want to match the natural shape of the spine from that side view. And then we also want to derotate, or remove that twisting from the spine, when we're correcting that spine. And so those are kind of all secondary goals, with the primary goal being to prevent that progression.
How Doctors Determine the Right Time for Surgery
Interviewer: How do specialists like yourself assess the candidacy and even the timing for a surgery? Are we talking X-rays? Are we talking about just some general assessments?
Dr. Turtle: Once a curve crosses that 50-degree threshold... and that 50-degree threshold we measure on standing X-rays. So, kids who get a standing X-ray and have a Cobb angle of 50 degrees or more would be candidates for surgery.
Obviously, taking into account a Ìð¹ÏÊÓÆµ's overall health and making sure that the surgery is as safe as possible are important factors to consider as well. But in general, any kid with a curve greater than 50 degrees would be a candidate for surgery unless there are some other precluding factors.
As we are working to schedule surgery, fortunately, scoliosis is not an emergency in the overwhelming majority of cases. This is something that we can take care of in a somewhat more convenient way. It's not something that we should allow to sit for, say, a year, but it's also not something that surgery is needed for that same day.
In general, most kids who are scheduled for surgery for scoliosis will get taken care of at some time that's convenient in the next few months for the family at their convenience.
Posterior Spinal Fusion Explained
Interviewer: What are some of the surgical techniques that specialists like you are most commonly using to treat the curvature of the back?
Dr. Turtle: So I will say there are a couple of techniques, and the first technique that I'd like to go into is what we, in the pediatric spine surgery world, would largely view as the gold standard technique. And that's what's called a posterior spinal instrumented fusion.
This is a surgery where we use metal rods and screws to hold the spine in place and then fuse the spine. And so what that means is that our spine, which is normally made of many vertebrae that all can move relative to one another, a posterior spinal fusion, we use screws and rods to hold those bones in place. And then we use a technique to essentially scuff up those bones and trick them into thinking that they're broken, so that those bones then heal together.
And once those bones heal together, they turn from multiple bones that can move relative to one another into a single larger bone. That's the best way of preventing that progression of scoliosis, like we talked about earlier.
What Spine Fusion Means for Your Child's Movement
Interviewer: Now, if a parent is listening, I hear that you are fusing the spine, and it makes me worry, "Is my Ìð¹ÏÊÓÆµ still going to be able to move their back? Are they still going to be able to twist and turn?" What are some of the ways that the fusion actually helps with that kind of quality of life?
Dr. Turtle: So every scoliosis curve is a little bit different. And what we try and do in planning these surgeries is minimize the amount of levels, meaning the number of those bones that we fuse together. We try to minimize.
Now, the bones that have ribs attached to them are called the thoracic vertebrae, and in most people with or without scoliosis, the amount of motion that we get from the thoracic vertebrae is relatively little. Most of what we think of as back movement actually comes from our lumbar spine, so the vertebrae that are below the thoracic spine.
And so in general, when we're planning our surgery, our goal is to try to minimize the amount of lumbar vertebrae that we fuse because we know that that will take away motion from the spine.
For kids that we are able to do what is called a selective thoracic fusion, where we fuse from the upper thoracic spine and stop at T12, the last thoracic vertebra, and the loss of motion is relatively minimal. It's still present, but it's relatively minimal. We lose more and more motion the further we go down into the lumbar spine.
And so, as spine surgeons, our goal is to minimize how far down the spine we have to go so as to minimize the amount of motion loss.
Now, again, as I mentioned earlier, the number one reason to do this surgery is to prevent the progression of a significant scoliosis. What we know is that, without surgery, the spines of Ìð¹ÏÊÓÆµren with severe scoliosis will continue to have progression, they'll have loss of motion, and they'll have significant increases in pain. And so even though a spinal fusion does result in some loss of motion, that loss of motion is less of an impact on the quality of life for that patient than the continued progression of a severe scoliosis.
Exploring VBT as a Motion-Preserving Option
Interviewer: When I was doing some of my basic initial research, there was another procedure that I came across called VBT. Would you mind telling us a little bit about that, and maybe some of the pros and cons, and when it would be a good option?
Dr. Turtle: So VBT is an acronym that stands for vertebral body tethering. This is a newer surgery than posterior spinal fusion, and it's one that is gaining some favor but has had some drawbacks as well.
The basic premise of vertebral body tethering is that instead of making an incision along the back of a patient, we actually come in through the side. And so oftentimes, for the thoracic spine, again, those vertebrae that are attached to the ribs, we'll be going in sort of between the rib cage and through the thoracic cavity next to the lung. For lumbar curves, they can go through the side of the abdomen and work alongside the muscles there to get alongside the side of the vertebrae.
The general premise is that instead of fusing those vertebrae together, we put screws that go horizontally through the sides of the vertebrae and then use essentially a surgical rope to tether the vertebrae. And this tensions it along the long side, so the convex side of the spine, to kind of straighten things out.
The thinking is that we can straighten the spine out by pulling it tight along that side, and then also hope to see some changes in growth of the bone and kind of slow down the progression, and potentially even correct the spine with growth.
Now, this, like I said, is a little bit of a newer procedure. It does, we believe, or at least theoretically, preserve some more motion of the back. Again, the goal is not to fuse those bones together. It's to allow some motion to remain.
Given that this is a little bit of a newer procedure, we need more data and more time to figure out exactly which patients are perfect and exactly when to do it. And because of this, we see higher rates of complications with VBT than we do with posterior spinal fusion.
The main complications that we'll see are under correction of a curve, meaning instead of getting the spine fairly straight, we still have a pretty significant curve. We can see overcorrection where a Ìð¹ÏÊÓÆµ grows more than what was expected, and the curve actually starts to go in the opposite direction. We can see that the rope breaks.
Basically, there are a lot of complications that we, as a field, are working to figure out exactly what the best patient and the best time to do it. And so it makes it a little bit challenging to compare the two, as one of the surgeries has a much lower complication rate.
The last thing that I will say about the VBT procedure, and one thing that steers some surgeons away from it, is that the VBT procedure doesn't directly correct two of the planes of the deformity from the spinal deformity.
So in the spinal fusion, we are able to correct the coronal plane, or when we look at a patient straight on, we're able to correct sort of the curvature in that plane, we're able to match the natural contour of the spine from the side, and we're able to untwist the spine in that third plane.
With the VBT, we are really only able to correct the curve from that frontal plane with some nuanced ways of partially correcting those other planes. And so this is another thing that steers some surgeons away from the VBT procedure.
What Recovery Really Looks Like After Spine Surgery
Interviewer: Now, focusing on the more tried-and-true, less-complication spinal fusion... it sounds like a really big surgery to me as an outsider. I'm not a surgeon, right? What does, say, recovery look like for someone's kid once they've had this procedure?
Dr. Turtle: Make no mistake, it is a big surgery. So for a posterior spinal fusion that we are dealing with for scoliosis, this is an incision that goes a significant portion of the way down the Ìð¹ÏÊÓÆµ's back, but it is something that, for kids, recovery goes quite well.
What I tell families before surgery is that they'll show up on the morning of surgery and then come back into our operating room. In the operating room, they get several lines and treatments after they're asleep with our anesthesiology team, our neuromonitoring team, and our nursing team, all designed to make the surgery as safe as possible.
This will include an arterial line to give real-time blood pressure measurements, multiple intravenous lines to give medicines and fluids during surgery, electrodes to measure and make sure that the nerves are still working, a Foley catheter to drain the bladder, and a breathing tube to keep the patient breathing during surgery.
Then the patient goes face down on the surgical table for the surgery, and we perform our exposure, where we move the muscles aside from the bone to be able to see the bones. We then sometimes will make cuts in the bones to help loosen the spine and make it so that we're better able to correct that deformity.
We'll place metal rods and screws in, correcting that deformity. Again, trying to correct the curvature when looking at the patient from the front, match the natural profile of the spine from the side, and untwist the spine along that third axis.
Once all of this has been done, generally, somewhere in the vicinity of three to five hours for most idiopathic scoliosis patients is something that would be a reasonable expectation. We close the skin up. Usually, we're able to close the skin in multiple layers using all dissolving stitches, so nothing needs to get removed down the line. And then the patient gets flipped back onto their back and goes to the recovery area.
Life After Surgery: Back to Sports, School, and What They Love
At Primary Children's Hospital in Salt Lake City, we have a rapid recovery pathway that we have kids work on. And so on this pathway, immediately after surgery, kids have a push button that gives them IV pain meds for the first night that goes in and allows them to be relatively comfortable after surgery. The day of surgery, so that evening, we have patients sitting up in bed.
The following morning, we get the kids out of bed and walking. We remove the Foley catheter. We switch them over to oral pain medicines and really try and get them moving relatively quickly.
Most of our kids, then, on the second day after surgery, are again walking outside their room, working with physical therapy on being able to safely navigate stairs, and oftentimes are leaving the hospital on that second day after surgery.
In general, the patients are fairly sore for the first couple of days, somewhat sore until the first couple of weeks, and usually out of school for about a month.
And then we have restrictions for most Ìð¹ÏÊÓÆµren out to about three months, where kids are not supposed to bend, lift, or twist. That's a 10-pound lifting restriction. And again, trying to avoid things that put excess stress on the back while they're healing.
At about three months, we let kids get back into recreational activities, competitive sports at six months, and then, depending on the surgeon, all sports are relatively minimal restrictions at about a year or so.
Long-term Quality of Life Changes After Surgery
Interviewer: Gotcha. And then after that first year, what are some of the long-term changes a patient can expect in their spine health, their quality of life, in comparison to if they had not had the surgery?
Dr. Turtle: I think the main thing is, again, we're hoping to avoid progression of scoliosis. And so with a fusion, we relatively infrequently will see progression of scoliosis above or below the fusion, and kids are getting back into doing essentially whatever it is that they want to do.
This is something that inherently removes some flexibility of the spine. And so there is a little bit of loss of motion, but the vast majority of kids are able to get back into doing all the activities that they enjoy.
Considering Spinal Surgery for Scoliosis? What to Know Before You Decide
Interviewer: Now, Dr. Turtle, what message would you give to families considering scoliosis surgery but are maybe feeling a little uncertain, a little anxious? I mean, you've mentioned that sometimes it's teens who are going through this, and they might need to miss class. What message do you give to them?
Dr. Turtle: Yeah, that's a great question. Like we discussed earlier, this is a fairly substantial surgery. I think it is very normal to be nervous about this surgery. And in fact, it is more worrisome to me if a family or a patient is not at all worried about the surgery than if they have some worries. It's normal, it's expected to be something that you should think about, but it is something that we know is beneficial in the long term.
For kids who have progressive scoliosis that don't get surgery, it is a problem that is only going to get worse. And addressing it during Ìð¹ÏÊÓÆµhood, fortunately, Ìð¹ÏÊÓÆµren are very resilient. They recover very quickly, and the majority of my patients come through surgery at the end thinking that the recovery was actually easier than they expected.
So this is something that is treatable. We can get kids back to doing essentially everything that they want. And while it is a big surgery, I think for progressive scoliosis, it is the right answer.