Scoliosis & EOS Imaging – PediaCast 375
- Dr Walter Samora joins Dr Mike in the PediaCast Studio to talk about scoliosis. What causes this common condition? What symptoms result? How is it diagnosed and treated? Then we’ll explore the emerging technology of EOS imaging, which uses very low-dose radiation to create 3D pictures of the spine. We hope you can join us!
- EOS Imaging
- The Spine Program at Nationwide Children’s
- Scoliosis Information Page (NCH)
- Radiology Resources (NCH)
- EOS Imaging
- Skip-Bo Card Game
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.
It is Episode 375 for May 3rd, 2017. We're calling this one "Scoliosis and EOS Imaging". I want to welcome everyone to the program.
So, we're talking about scoliosis today. And it is a topic that we've covered before on PediaCast. You know, you do this for ten years and you're bound to repeat some topics. But the other thing is that medicine advances over the years. And new technology becomes available, especially technology that useful for the evaluation, diagnosis, and management of many conditions, including scoliosis.
So, we do have something to add — EOS imaging — as we talk about scoliosis because that was not an option the last time we talked about in this disease process. But we're going to start with the reminder of the nuts and bolts of scoliosis.
And it's an important thing to do now and then, because scoliosis is a common condition. In fact, you've probably heard of it before. But I bet also many of you have sort of a vague notion of what scoliosis is. You probably know it has something to do with the spine, your kid's back. Maybe you remember from your own time in middle school and high school, bending over at the waist, touching your toes, someone looks at your back. So you know scoliosis has something to do with the spine. But what exactly is it?
We're going to talk about that. So, the basic elements of scoliosis, you know what it is, what causes it, what are the signs and symptoms, how is it diagnosed and treated. And if it's not treated, what happens? And can scoliosis be prevented? So, you know, the nuts and bolts of the disease.
And then, we'll go a step further and talk about something we haven't discussed before and that is EOS imaging. It's an emerging X-ray technology that uses very low doses of radiation to render a detailed 3D image of the spine.
And the low-dose characteristic is particularly important in the management of scoliosis because these kids often get multiple X-rays, often several times a year.
Many times it'll be a few years in a row. And all that radiation does add up over time with the potential for cancer development because the risk of some cancers does increase with radiation exposures, particularly repeated radiation exposure. And it's in a dose-dependent fashion.
Of course, we use X-rays when we have to when the benefit of using the X-ray outweighs the risk, like in the management of scoliosis. However, we realize the risk is not zero. So, repeated radiation exposure can be a real concern. We want to minimize that risk when we can. And a low-dose X-ray technique such as EOS imaging is a great way to do that, to lower the risk. So, we'll talk about that technology.
And to help us understand the ins and outs of scoliosis and EOS imaging, I have a terrific studio guest joining me this week, Dr. Quincy Samora. He's an orthopedic surgeon here at Nationwide Children's with our Spine Center. We'll get him settled into the studio in just a couple of minutes.
First, though, you know it's full-on spring now that we're here at the beginning of May. And that means a lot to those of us living in the northern half of the United States. It means we can get outside, we can take a look around, burn off some recreational calories, get rid of some of the indoor winter weight that tends to accumulate.
And even if you live in a place where it's warm year round, spring is a great time to renew your commitment to be fit and to get out there and move with your kids. And that's a bonus because you're not only exercising and burning calories together but you're making memories and establishing patterns of behavior that can last a lifetime.
So, I need your help. Last summer, I talked a little bit about Pokemon Go and the fun families can have with that game on their mobile devices as they get outside, walk around — and walking is a terrific exercise, by the way — and exploring together. But, of course, keeping safety in mind. So that's one idea of something you can do with your family and your kids to get outside, be active, have a little adventure as you're catching Pokemon.
But that gets old after a while. And you want to come up with some new fun things to do depending on your kids' age. And depending on their age, Pokemon Go may not even really be something fun or safe for you to do, depending on sort of where they are developmentally and with their age.
So, I wanted to ask you as an audience, what ideas do you have for getting outside and having fun as a family? Let's learn from one another. Because there's all sorts of fun things to do with your kids outdoors. Some of them are obvious, like a journey to the playground down the street, or maybe going to a zoo or an amusement park or taking a hike.
But then, you can get a little creative, and maybe there's some not-so-obvious ideas that a particular family would find to be a great idea. Like instead of just going to the zoo or metro park just for a hiker to see the animals, maybe it's a scavenger hunt that you create or a good old-fashioned game of hide and seek in a safe, well-defined area with older kids.
What is it that you like to get outside and do as a family? And then, let's share some of those ideas. It's easy to get in touch with me, just head over to PediaCast.org and click on the contact link. And I'd like to share some of your ideas. We always ask our guests, or not always, but we did for a while. Then, we didn't for a while, and now, I've try to do it again. Because I did get feedback from you guys, "Hey, I liked it when you did that, when you ask about games and activities and things that folks like to do."
Because it does give all of us some ideas that we might not have thought of. And in fact, when I was asking guests about board games, there were several that I had never heard of, that we now have in our game closet that we play from time to time. And I found out about them by talking to guests on the show, things I hadn't heard of.
So, we definitely can get ideas from one another. So, let's share fun-family-outdoor activities so we can increase the social component of the podcast and help each other have a little more fun with our kids this summer.
Again, it's easy to send those ideas, along with the topic ideas for the program, any questions that you have. We love answering your questions. Again, just head over to PediaCast.org and click on the contact link.
Before we get started with the interview, I also want to remind you the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So, if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.
All right, let's take a quick break and I will be back with Dr. Quincy Samora settled into the studio and talk about scoliosis and EOS imaging. It's up coming up right after this.
Dr. Mike Patrick: Dr. Quincy Samora is an orthopedic surgeon at Nationwide Children's Hospital and an assistant professor of orthopedic surgery at the Ohio State University College of Medicine. He treats conditions at the spine including scoliosis along with sports related injuries and the management of fractures and other general orthopedic conditions.
Dr. Samora joins us today to talk about scoliosis including what it is, how it's diagnosed and treated. And he's going to shed light on a unique X-ray technology that uses very low-dose radiation to evaluate the spine, which is particularly important for kids getting frequent X-rays which is common in the management of progressive disorders like scoliosis.
So let's give a warm PediaCast welcome to Dr. Quincy Samora. Thanks so much for stopping by today.
Dr. Quincy Samora: Thanks for having me.
Dr. Mike Patrick: Really appreciate it. So, let's start just with a reminder, what is scoliosis?
Dr. Quincy Samora: Scoliosis comes from the Greek word for crooked and typically defined in our literature as any curvature that's greater than ten degrees and that's in the frontal plane. So when you're looking at the patient from front to back versus looking at them from the side, which would be more kyphosis and lordosis.
The traditional definition is anything greater than ten degrees. Anything less than ten degrees is considered to be spinal asymmetry. So, it's still curvature of the spine but if it's not severe enough or greater than ten degrees it will be called spinal asymmetry.
Dr. Mike Patrick: So, as your looking at the spine from the front or the back it's going to have a C or an S shape to it. Whereas the other ones you talked about, the lordosis is kind of bending backwards looking up and kyphosis kind of more humped back.
Dr. Quincy Samora: Correct. Correct. So, the curvature can be in the thoracic spine where it can start. It can start in the lumbar spine as well. Most curvature is S-shaped and the reason it's S-shaped is because the primary curve will typically be balanced by the body. And so, we worry about curves that are more C-shaped in the neuromuscular scoliosis. These are kiddos that do not have the ability to correct their curves. And so, it's always a red flag if the patient comes in with a single curve or if they come in with unbalanced curvature.
Most curvature and the reasons some curvatures can be found very late is because they're very well-balanced.
Dr. Mike Patrick: And this can be anywhere in the spine, right?
Dr. Quincy Samora: Correct.
Dr. Mike Patrick: So, from the neck down to the pelvis basically?
Dr. Quincy Samora: Correct.
Dr. Mike Patrick: And how common is scoliosis?
Dr. Quincy Samora: Scoliosis is fairly common depending on the studies that you read, assemble, quote. Half a percent of the population up to about 5%. So, it's something that we are certainly concerned about because of how common it occurs. If you look at the incidents of small curves — so these are curves between 10 and 20 degrees — young boys and young girls have the same number of curves.
So, you have an equal number of boys and girls with small curves. However, girls will progress about seven to ten times more often than boys will. So we worry about girls progressing to curvatures that required treatment much more often than boys do.
Dr. Mike Patrick: Do we know why that is?
Dr. Quincy Samora: Not really known at this point. The cause or ideology is unknown. It's taught to be multi-factorial. There are lots and lots of genes that you inherit from different people that can possibly be the cause. Some think that it could be hormonal, which is a part of the reason why girls will progress maybe a little bit more than boys will.
Dr. Mike Patrick: Do you see much difference in terms of different ethnic groups?
Dr. Quincy Samora: Not necessarily. Here in Columbus, we have a fairly diverse population and we see scoliosis in pretty much all the ethnic groups.
Dr. Mike Patrick: And you can see the different ages. I guess when folks think about scoliosis in their own family, a lot of times it's when they're teenagers. It's when you probably see it the most often. But it can happen even in babies, correct?
Dr. Quincy Samora: Correct. So the most common scoliosis that we see is called idiopathic scoliosis. Idiopathic is the joke is it's the Greek word for "We don't know what the cause is." And that's about 80% of scoliosis, which means 20% of scoliosis is non-idiopathic. And those include congenital, so kids that are born with bones that are not shaped appropriately will cause curvature.
And there are neuromuscular types of scoliosis in kids that have cerebral palsy, myelomeningocele spina bifida, Marfan syndrome, different types of syndrome. And then, there are scoliosis that are associated with other things, with tumor type conditions, with masses, with trauma.
So, the most common is the idiopathic where we do a workup and we find no cause. And so, in order to call it idiopathic, you really have to do a baseline workup. Sometimes, we'll get an MRI of the spine to rule out any inter-spinal pathology at which point we can really say that it is idiopathic.
Dr. Mike Patrick: As we think about idiopathic scoliosis, which the most common kind and the one you typically see in teenagers, are there any signs or symptoms other than looking at the shape that would let you know that maybe a kid has scoliosis?
Dr. Quincy Samora: So, the two ways that we detect scoliosis most of the time are either by one of the parents. And when a parent notices it, it's typically shoulder imbalance or trunk imbalance or just asymmetry of the shoulder blades, something of that region or that area.
There are some schools that do school screening in the sixth or seventh grade where they will actually do a Adam's Forward Bend Test, where they will bend the patient or the kid forward and measure the angles of their spine. And so, that is the second way.
The third I guess that I didn't bring up is the primary care providers. So, our pediatricians will check kids. Some are a little bit more fast than others with checking the back and spine as part of their physical exam. And they will pick up quite a few. So, we have quite a few referrals for scoliosis from our pediatricians and primary care providers.
Dr. Mike Patrick: Are there any symptoms that come out as scoliosis. So if a kid has it, are they going to have backpain? Are they going to have anything that might let the parent know, "Hey, someone needs to look at their back?"
Dr. Quincy Samora: Unfortunately, most scoliosis, it's silent. Traditional teaching was that scoliosis is not painful. That it's simply curvature. And so, from a symptom standpoint, we tend to not see much.
However, some newer literature states that maybe 20% or 30% of these kids could have pain. And every now and again, we see kids that come in for pain that get X-rays and they're found to have scoliosis. And really, both have nothing to do with one another, but that's how it was found. And those are kind of incidental findings. But unfortunately, some of the reason why scoliosis can progress quite rapidly or for a long period of time is it's really asymptomatic in most kids.
Dr. Mike Patrick: Is that also true when you get pass the ten degrees? I mean, is there a point at which there's so much curve that you do start to have problem?
Dr. Quincy Samora: Sure. I think when the curve gets really bigger, it's been there for a long time. You start to get some changes in the joints in the back. You can get some early arthritic type changes, which probably the most common cause for pain in these patients.
Dr. Mike Patrick: So we talked a little bit about screening. Then when someone is concerned about scoliosis… So maybe parent notices it during bathing suit season, maybe they noticed that their back looks a little funny, or there's some asymmetry in their shoulder blades. Or the school or the physician picks up on it. How did you go about actually making a diagnosis of scoliosis?
Dr. Quincy Samora: The screening tool is something called as scoliometer. And what a scoliometer is simply a level. And when the patient bends forward, you put the scoliometer on their back, and it gives you an angle. And what we typically is 7 degrees of angle equals about a 20-degree curve. So, from a screening standpoint, that would be enough if they bend forward and have a seven-degree angle, then you would send them over.
However, nowadays, most will send the patient then for an X-ray. And so, the true diagnosis of scoliosis as right now is going to be based on X-rays.
Dr. Mike Patrick: And then, you basically figure out what angle or how many degrees the curve is on the X-ray.
Dr. Quincy Samora: Correct.
Dr. Mike Patrick: On the spine. And then, you talked about ten degrees kind of be in that cut-off of when you would call it scoliosis. What kind of treatment options then are available once a child is diagnosed with scoliosis?
Dr. Quincy Samora: So the treatment options of scoliosis are typically based on two things, based on the age of the patient and based on how much curvature they have. The three general things that were able to do based on our guidelines are one is observation, which is simply having them come back at certain periods of time. Repeat physical exam. Repeat X-rays and then determine progression, things like that.
The second, which is a fairly common thing we do here is bracing. So the criteria for bracing is typically documented progression up to 25 degrees in a skeletally immature patients. So they have to be both immature and that ranges from about 9 to 12 or so from an age standpoint.
Or you can look at their X-rays and check their pelvis. And there's a certain thing that we look at on the pelvis called the Risser sign. And they have to be either Risser 0, 1, or 2. So, they have to be quite immature and also have documented progression to 25.
If they are a first-time presenter and greater than 30 degrees, then fortunately, at that point, you don't have much time to wait. So, if they are first-time presenter greater than 30 and they are immature, then we will brace those kids right away.
Dr. Mike Patrick: This is the reason really to get this identified as early as possible?
Dr. Quincy Samora: Absolutely. The earlier you catch it the better the outcomes. Mainly because the job of the brace is to prevent progression. So, if they show up with a 25-degree curve, your best case scenario, if you put them in the brace is to stop it at 25. So, the curve will not be corrected by the brace. It will simply prevent the curve from getting worse.
Dr. Mike Patrick: Got you. And then, when are there surgical interventions required for scoliosis?
Dr. Quincy Samora: Surgical interventions really vary based on the practitioners. So, the more and most aggressive practitioners will start to talk about surgery right at about 40 degrees. Most will choose somewhere around the 45 to 50 degree range, because that is when our literature shows that the curve will continue to progress despite skeletal maturity.
So once they mature, scoliosis starts to stop unless you have a curve greater than 50 because then muscle imbalance as well as gravitational forces and some disc arthritis and what-not can cause progression of curvature. So, those are the kids that we typically will intervene surgically.
Dr. Mike Patrick: I think it's an important point again to make that bracing just stops the progression. It doesn't make thing straight again.
Dr. Quincy Samora: Correct. It will make thing straight while in the brace. So what you're trying to do is you're trying to rearrange the forces in the spine while in the brace. So, it will look better in the brace. But the job of the brace is once you remove the brace, for the spine to settle back into the position that it originally started.
Dr. Mike Patrick: And once they're skeletally mature, then that's when you could potentially stop doing the brace?
Dr. Quincy Samora: Correct. When to remove the brace is a little bit more challenging because maturity is a little bit more challenging in kids. So, the recommendations for putting a brace on and taking a brace off, typically the brace comes off when they reach several different milestones.
Number one is age of 14. Number two, typically in girls is when they have their menstrual cycles for at least two years. Number three is if their Risserr sign is in the 4 regions. So they're fully capped in the pelvis and then the last one is if they have had a couple different visits about six months apart or so with no change in vertical height. So, you're looking at these indicators of skeletal maturity at which point you can then discontinue the brace.
Dr. Mike Patrick: The bracing process itself is it uncomfortable?
Dr. Quincy Samora: Initially, it can be, it can be very uncomfortable. The two different types of braces that we use are the braces that are worn all day. These are typically the TLSO which stands for Thoracolumbosacral orthosis, of which there are many different kinds. We typically use the Boston brace here. And that is worn somewhere in the 16 to 18 hours a day.
Previous recommendations where you wear it for 23 or 23 1/2 hours. You got 30 minutes to shower or bathe. Unfortunately, that was very difficult for kids. And it was almost prohibitive for living and sports and things . So, a newer article came out in 2013 which outlined the little bit more reasonable expectations of somewhere in the 16 to 18 hours.
If you wear it more than 14, you did okay. If you wear it less than six, it had really no effect. So, it gave us a much better conversation with the parents to say, "You know, you can actually not wear the brace for six to eight hours a day and still have a really, really good effect." But the brace has to be worn at night. So that's the most important thing — you get your growth hormones surge with deep sleep, and that's when it's important.
The second type of brace we employs actually nighttime bending brace which are for specifically curves in the lumbar or thoracolumbar. So, if the apex of the main curve is down in the lumbar or thoracolumbar or where thoracic spine meets the lumbar spine, you can actually place it in a bending brace, which they wear only at night.
Dr. Mike Patrick: And I suppose some kids, especially in the beginning, may have some difficulty sleeping. And so, you may have to… Each kid's unique in terms of figuring out how they can best deal with having this brace on.
Dr. Quincy Samora: Correct. So, most kids will have a period in which they'll wear the brace as much as they can. So, usually, when we prescribe a brace, we won't see them for a first brace follow-up X-ray for about four months or so. Very rarely will a child ever get up to 16 or 18 hours within a few weeks because it's quite uncomfortable. And we certainly tell the parents to wear the brace as much as you can. Maybe start at night, wear it as much during the day as you possibly can.
Dr. Mike Patrick: I would imagine, part of the overall care of the child, and especially in that particular situation — and we'll talk more about the Spine Center here at Nationwide Children's and the multidisciplinary nature of it — but I can imagine that seeing a psychologist and helping resources for the family may be helpful in terms of them dealing with discomfort and wearing a brace in school and all those kind of issues.
Dr. Quincy Samora: Absolutely. The different things that we talk to parents and kiddos about what the bracing is, is they really have to make the brace part of their life. Some will name their brace and they'll develop a relationship with the brace. And…
Dr. Mike Patrick: A love-hate relationship, right?
Dr. Quincy Samora: Likely, yes.
Dr. Mike Patrick: Let's go back to the surgical intervention. What kind of options are there for surgery to treat scoliosis. What do you do?
Dr. Quincy Samora: The surgical options are based on the age of the patient. So, the classic definitive surgical intervention is called the posture spinal fusion with instrumentations. So, the spinal fusion aspect deals with putting bone graft that is commercially available in the back that makes one so the column of bones or the bone no longer moves. Or the bones are no longer separate. The instrumentation is simply what we utilize to straighten the spine. So that when it does fuse, it fuses in a straighter position. And that is typically reserved for mature kids with curves that are greater than 50 degrees or so.
Now, unfortunately, we do have a fairly large number of kids that are very young that have big curves. At which point you're not able to fuse their spines because if you fuse the spine, the lungs don't grow. And they'll develop an entity called thoracic insufficiency syndrome, which can be very, very difficult to manage.
And so, we have growing devices with these kids. The most recent that we started using is called the MAGEC. And it is a magnetically lengthening type rod that you would insert during surgery and then you actually lengthen in the clinic using a magnet. So, this has really revolutionized the way that we treat young spines. Mainly because they don't have to have surgery every six months, which is what we use to have to do. We would take them back to the operating room and manually lengthen it every six months.
There are several different other types of growing devices. There is a VEPTR device which will go on to the ribs and to the spine. There is a shell-type technique which is more of a set-and-forget type of technique, of which we do employ most of those here.
Now, the newest type of surgery that is promising — not quite FDA-approved yet, but we're waiting for the results — is something called the vertebral body tether, which is a technique where they place screws in through the chest with an endoscope and attach it with a rope. And what happens is as the child grows, then the rope will allow the spine to grow straight over time.
So that is reserved for kids that are a little bit older, probably 11 or 12. They are little bit too young for a posture spinal fusion. Because in the age category, they are beyond where their lungs are affected but too early they can get something called crankshaft phenomenon, in which their spine twists around the rods. 3
And so, this is employed. It's a fusion-less technique. And it has made quite as stir in the media unfortunately. Not FDA approved yet, so there are only a few centers around the country that are actually doing that.
Dr. Mike Patrick: Yeah. The spinal fusion and the rods, these are two separate options, right? Or do you do both of those together?
Dr. Quincy Samora: We will typically do both at the same time. So if you're going to fuse the spine, we will typically instrument the spine. In young kids, however, you can instrument the spine and not fuse the spine. So, if you access the spine at all, it will fuse. Kids are so healthy that it's been shown that if you simply dissect down to the spine, the spine will fuse. So, if you do not want to fuse the spine, then we stay away from it.
Dr. Mike Patrick: So just the healing process?
Dr. Quincy Samora: The healing process causes bone to form and the fusion. So, rarely will we ever do an instrumented fusions because they usually go together. You'll straighten the spine out and then put bone graft in. And then, when the bone graft fuses, it fuses in a straighter position.
Dr. Mike Patrick: Got you. And then the rods stay in the persons entire life? Or do they come out at some point?
Dr. Quincy Samora: Correct. The rods are design to stay in for forever. The two different types of metals that we use are typically a titanium and cobalt chrome mix. And that's what we typically employ. You can also use stainless steel. We gotten away from stainless steel as of recently, probably over the last few years.
Dr. Mike Patrick: Is there a reason for that?
Dr. Quincy Samora: Not necessarily, the cobalt chrome is a little bit of stiffer rod and the titanium has a little bit of a better infection profile. It forms up a metal alloy that is resistant to infection and the rates are in the 1 to 2% versus slightly high with stainless steel. It's also MRI compatible. So if you were to need an MRI in the future, a little bit easier with titanium, not as much scatter. So it's a little bit easier to see the anatomy if you need an MRI.
Dr. Mike Patrick: Got you. Now, what can happen if you don't treat scoliosis? So if this does go too long and the curve is going more than 40 degrees or so, what happens if you don't deal with that?
Dr. Quincy Samora: That's a difficult question mainly because we don't know when the scoliosis is going to stop. The reason we typically talk to families about for treatment once it gets beyond the certain point is the lungs. The lungs will usually get affected at about 70 degrees, 72 to a 100 degrees. The question is always whether or not the spine will progress to 70. If they reach 50 degrees and then they're in their teens, and you say well it might progress a half a degree per year, they might be 50 or 60 years old by the time it gets there.
Unfortunately, if they're 50 or 60 and they have a 70-degree curve, it is a much difficult entity to treat then than it is as a child.
Dr. Mike Patrick: Yeah. Plus, you may be dealing with all the adult issues anyway, cardiovascular disease, and those sort of things.
Dr. Quincy Samora: Correct. So what we typically tell our parents is that the amount of correction that you get with surgery depends on where you start. It's a relative type number of which somewhere around 50% or 60%. So if you fuse a 50-degree curve and you get it down to 25 versus fusing a 60-degree curve and getting it into the 30s, it does make a difference on the cosmetic outcome.
It really doesn't make much of a difference on them clinically. There is no study that we know of that tells you what number you have to get to with fusion. It's simply you want to stop the curve from getting worse.
Dr. Mike Patrick: And with treated scoliosis then where we don't see progression once they're skeletally mature, what's the long-term outlook for those? Do they usually just stay that number?
Dr. Quincy Samora: Quite good. Yes. If we treat scoliosis or untreated scoliosis that stops and does not progress, the outcomes are quite good. Similar to age match, so these people of the same age that have never had surgery.
Dr. Mike Patrick: Is there any way to prevent scoliosis from happening in the first place?
Dr. Quincy Samora: Unfortunately, no. As of right now, we do not have a way to prevent scoliosis. The most common type which is the idiopathic tends to occur during the rapid growth spurt, which is when we see it when kids are becoming teenagers. And the only thing that we're able to do is treat. So unfortunately, without a preventative technique, the best goal is early detection.
Dr. Mike Patrick: So wearing a book bag on one shoulder is not going to cause scoliosis?
Dr. Quincy Samora: So wearing a book bag has implications in back pain. There are a lot of things that have implications in back pain, as in slouching, core weakness, improper posture, heavy book bags, things like that. But these are not thought to affect scoliosis in general.
Dr. Mike Patrick: So they can cause muscle strain and stretching of muscle fibers but not bending a bone.
Dr. Quincy Samora: Correct.
Dr. Mike Patrick: And then, quick search of the Internet. You see a lot of stuff, sort of more natural remedy for scoliosis, physical therapy, stretching, exercises, those things really are not a substitute for the types of treatment that we've been talking about.
Dr. Quincy Samora: So there are quite a few people and different types of professions that treat scoliosis, of which orthopedic surgeons are simply a subset. We usually go based on the guidelines of the Scoliosis Research Society, which is our society that we belong to here. And they have a policy statement basically that if you are not being observed, braced, or not offered a surgery, then your treatment is the same as if the natural history of it. So, if you were to do physical therapy or chiropractic, or inversion therapy, yoga, Pilates, all these things can certainly have an impact on your overall health and way of life. However, based on our literature, it's not thought to affect scoliosis.
Now, there are some promising things with a technique called the Schroth method which is a combined brace plus therapy. And there is a subset of orthopedic surgeon that are studying the effect of daily physical therapy, and physical therapy based on scoliosis including this brace, which is a different type of brace called Regutional brace, that is a very specialized brace that very few orthotists are able to make.
So that is really probably for something in the future as we get a better understanding of the way that the spine moves and the biomechanics. It certainly is something that we can maybe look forward to.
Dr. Mike Patrick: And correct me if I'm wrong about this, but there are going to be a subset of kids who, if you did not do your intervention, the progression would stop and it wouldn't go pass 40 degrees once they're skeletally mature. And so, if those kids had physical therapy, but maybe it didn't stop because of the physical therapy. It just stopped because their natural disease was not going to progress. And yet then, anecdotally, those parents would say "Hey, this helped my kid but that's no guarantee that it'll help your child."
Dr. Quincy Samora: Correct. So I think that's the reason why randomized studies are so important. That what you actually find is that there are certain subset of kids, and actually most kids will not progress. The amount of kids that have small curves are quite high. Half percent of 5% but those that progress to require surgery are typically in the .1%.
So most kids will actually stop on their own. Those that don't will stop with a brace. And those that don't unfortunately, will then progress. So we really have no way of knowing whether or not the curve stop on its own or whether or not anything that we did. So it's that correlation doesn't necessarily imply causation, which is a very common theme in medicine.
Dr. Mike Patrick: Yeah, absolutely. And when it's your kid, it's either going to happen or it's not. And you don't want to necessarily look back and say "Boy, I wish we had done something."
Dr. Quincy Samora: Correct. We can use numbers. We can use population studies, but the bottomline is if it's your child, that's really the only thing that's important. So I think the most important thing is early detection, which will allow us to have most of our different types of treatments available to us.
Dr. Mike Patrick: Yeah. We talked about EOS imaging. What is that?
Dr. Quincy Samora: So EOS imaging is a system that we started using in 2015, which is an ultra-low dose radiation machine. It was developed by a scientist based on some Nobel Prize winning technology in which you're able to scan the spine in both the front plane and the side plane simultaneously. And you're then allowed to put those images together and come up with a three-dimensional depiction of the child.
So the regular dose that we first started was thought to be about seven times lower radiation than a standard X-ray. The EOS folks then came up with a microdose which was about 45 times less. So the question usually is how much detail do you want, the lower the dose should go, the less detail you get. But this is a revolutionary machine that really allows us to get X-rays in kids and not worry as much with the radiation exposure.
Dr. Mike Patrick: So is this machine like a booth, sort of like a TSA scanner in an airport?
Dr. Quincy Samora: It's similar. It would be if you tell kids, it'll be like standing in the corner if they were to get in trouble in school or at home.
Dr. Mike Patrick: And it doesn't take long to complete the scan.
Dr. Quincy Samora: Right. So the scan usually takes somewhere less than 20 seconds. So, unfortunately, because the scan is a moving device, you have to stand very, very still. If you were to move in the timeframe that the scan is going on, it makes you look like a snake.
Dr. Mike Patrick: So that can be difficult for some kids to stay in still.
Dr. Quincy Samora: Correct. So it is one of the difficulties in kids that actually cannot stand. We have kids that are unable to stand. At which point, we do have chairs if they are unable to do that. If they can't sit unsupported, that's also a problem. So they would have to be able to sit without moving or stand without moving in order to utilize the EOS machine.
Dr. Mike Patrick: And then, the computer takes into account the images to create a 3D model of what that patient's spine looks like.
Dr. Quincy Samora: Correct. The 3D modeling is actually software that a person has to do. So it doesn't just automatically render a three-dimensional image. It actually requires a person to input certain points that will then give you a three-dimensional image.
Dr. Mike Patrick: Very interesting. So why don't we use this sort of technology for all of our all of our X-rays?
Dr. Quincy Samora: It's very expensive. It's a very, very expensive machine and as far as the billing or cost goes — because it is simply an X-ray — the cost is the same to the child. So it is not thought to be something that is very good business model because it is just an unbelievably expensive X-ray machine. So this is something that Nationwide Children's Hospital has really done for the kids. Very, very expensive machine that really has benefits to them with the low-dose radiation.
Dr. Mike Patrick: Compared to X-rays that you get for following a child with a fracture, could you use that kind of technology for fractures or do you really need the plain X-rays for those?
Dr. Quincy Samora: The plain X-rays are probably better for fractures. The two things where the EOS is really good is scoliosis is one and then lower extremity alignment as well. So leg length discrepancies, rotational problems of the femur, and tibia because you're able to scan basically from the top of the pelvis from the head all the way down to the toes. And there is not as much distortion or parallax because the scan moves as opposed to a single being that originates in one spot.
Dr. Mike Patrick: So if a primary care provider was worried about a child with scoliosis, they would order plain X-rays, and then you guys will order the EOS imaging. Or can primary care doc order the EOS imaging if they're concerned with scoliosis?
Dr. Quincy Samora: They are. So our EOS machine which is I believe to be the only one in Central Ohio is in our Dublin office. And we do see patients there most days. And spine evaluations are there most days.
So if a pediatrician were concerned, they can certainly write a script and send the patient over and get the EOS image. And then, they can look at images themselves. However, if they would like for us to evaluate the patient to see for the need for imaging, we're happy to see them.
Dr. Mike Patrick: So pretty cool technology. Definitely, cutting edge safer for kids in terms of radiation exposure but not available everywhere yet.
Dr. Quincy Samora: Correct.
Dr. Mike Patrick: And then, tell us more about the spine program here at Nationwide Children's.
Dr. Quincy Samora: So our Spine Program is growing. Currently, we have five spine practitioners. And we are a high volume Spine Center. We do pretty much all of the different types of treatments of spine including operative and non-operative bracing, different casting type techniques. We're a busy center and we're growing. So we just hired our fifth.
Things that area a little bit different or unique about our Spine Program is when we do our surgeries, we employ a two-surgeon technique, which is a little bit unique, in which you have two surgeons working with each other as opposed to a surgeon and an assistant. And we think that this is something that allows our results to be as good as they are and as safe as they are.
Dr. Mike Patrick: And then, it's multidisciplinary what you talked about. So you also have athletic trainers, physical therapists, psychologists, just really any support that you would need as the orthopedic surgeon you can really get for the family.
Dr. Quincy Samora: Absolutely. It's a multidisciplinary type service that has dietary, different pulmonary, pretty much everything that we can think of as we know that we treat the patient as a whole.
Dr. Mike Patrick: We really appreciate you stopping by and talking about scoliosis and the EOS imaging technology. Before you go, we've been asking our guests recently about some fun things to do with the family, that you do with the kids in terms of getting outdoors and physical activity and just some ideas. What sort of things have you been doing with your kids now that the weather is getting warmer?
Dr. Quincy Samora: So we try to exercise with our kids as much as possible. My son and I play tennis together. And actually, this weekend, we've convinced my daughter to run or try to run the half-marathon with us. We've done the New Albany Walking Classic together, which is a walking half-marathon. We did that this past year. And so, we try to get out as much as we can with our kids.
Dr. Mike Patrick: How old is your daughter?
Dr. Quincy Samora: Ten.
Dr. Mike Patrick: And for half-marathon, does she run a lot to begin with?
Dr. Quincy Samora: Not really.
Dr. Mike Patrick: No. So you got to give a little training program to get her up to speed, right?
Dr. Quincy Samora: Well, she's a tumbler mostly. She loves to cheer and tumble. And seeing as that half marathon is this weekend, we don't have much time to get there.
Dr. Mike Patrick: No, I don't think so. But you know, if she struggles, you're not going to make her finish the half-marathon.
Dr. Quincy Samora: Well, I know she can at least walk one.
Dr. Mike Patrick: Yeah, yeah, absolutely. All right, well, Dr. Quincy Samora, orthopedic surgeon here with the Spine Center at Nationwide Children's. Thanks so much for stopping by today.
Dr. Quincy Samora: Thank you for having me.
Dr. Mike Patrick: All right, we are back. I ask Dr. Samora what kind of things that his family do in outdoors. And he talked about a half-marathon coming up. And it made me remember just now, as the music ends, I forgot to share what we've been doing outside as a family. And our big thing is really just trying to get in and out of our house without being dive bombed by a mom and dad robin that had made a nest in a tree or a large bush that we have to go right by in order to get to our front door.
And we noticed the nest in the bush that was there probably a month ago, we first noticed it. And the leaves weren't really on the bush quite so much so you could really see it well. And we noticed that this mom was in the nest a lot. And it was kind of out of reach, you couldn't really see it. But you could take your phone and hold it up over nest can take a picture. And there were four robin eggs.
And so, we've been watching those and they hatched about a week ago. And so, the mom and dad robin are back and forth. But, boy, you have to walk briskly from the car to the house door, and from the door back to the car, because they get all excited when you go by their little babies. So I know it's kind of lame. And not exactly a lot of physical activity or brisk walk from the car to the door, but it's the first thing that came to mind, as I think about outdoor activities.
It will be fun to watch as they get a little older and start to fly. So fun stuff, especially when it's right outside your door.
In terms of indoor things, I know, less physical activity. But we've been playing a lot of Skipbow lately. It's from the makers of Uno. And if you're tired of playing Uno and you want a different card game, it's one that we played a lot this winter. It's easy to learn, fun to play, easy to control the length of the game and young players can play it, too.
So if you've not heard of Skipbow before, that's a fun card game that we've been playing as a family.
Don't forget to send your ideas for family fun, especially outdoor activities. Hopefully, there's a little more physical activity involved than running by a bird's nest. But we do want to share your ideas for how to have fun outdoors and be physically active in a safe way with your kids this summer.
I do want to thank all of you for taking time out of your day in making PediaCast a part of it. I really do appreciate that. And thanks again to Dr. Quincy Samora, orthopedic surgeon with the Spine Center here at Nationwide Children's.
Don't forget, you can find PediaCast in all sorts of places. Not sure how you found us today but there may be a more convenient method of listening for you. We're in iTunes and Google Play, also iHeart Radio, Stitcher, TuneIn, most mobile podcast apps. Just search for PediaCast in any of those locations and you should be able to find us. If there is a mobile app that does not have PediaCast as part of it that deals with podcasting, let me know and we'll try to get the show added to their lineup.
For this particular program, we'll have links for you to the Spine Program here at Nationwide Children's, also a Scoliosis Information Page and radiology resources for the EOS imaging. You'll find all that stuff in the Show Notes again over at PediaCast.org. Just look for Episode 375 and we'll have those links for you.
Also, don't forget, PediaCast is part of the Parents On Demand Network, which you can find at ParentsOnDemand.com. Just some free podcasts that are great for parents to listen to and we're happy and proud to be a part of their lineup over at ParentsOnDemand.com, just another place where you can find us easily.
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All right, thanks again to everyone for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.