Scoliosis – PediaCast 299
Dr Allan Beebe joins Dr Mike in the PediaCast Studio to discuss the nuts and bolts of scoliosis. We cover the cause, symptoms, diagnosis, treatment, complications, and long-term outlook for kids and teens with this common spinal deformity… along with the latest topics in scoliosis research!
- Are Breakfast Biscuits A Good Start To The Day?
- The Spine Program at Nationwide Children’s
- Scoliosis Information Page
- Scoliosis Research Society
- CONTACT DR MIKE – Ask Questions, Suggest Show Topics
- CONNECT NOW with a scoliosis specialist from Nationwide Children’s – Referrals and Appointments
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. 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 on Columbus, Ohio. It
is Episode 299. We were almost to 300. We’re calling this one “Scoliosis”. It is October 22nd, 2014. I want to welcome everyone to the program.
You have to bear with me today. My voice is a little scratchy, so there may be times when I have to grab a drink of water very quickly, but just to give you a heads up. You know, it’s viral season. The kids go back to
school and they start sharing stuff, and you spend much time in an emergency department or an urgent care, and you’re likely to pick some stuff up. So just bear with me.
We do have another nuts-and-bolts show lined up for you today, this time on the topic of scoliosis. I suspect most of you out there have heard of scoliosis, but what exactly is it and why should you care? What, if any, symptoms does scoliosis cause? What complications can result if it’s ignored? How’s it diagnosed? What treatment options are available? What is the long-term outlook for kids with scoliosis and what are the hot topics in the world of scoliosis research? We’ll have the answers to these questions and more coming your way in just a few minutes.
And of course, in our usual fashion, I do have a great studio guest lined up this week to help me talk about scoliosis. Dr. Allen Beebe is an orthopedic surgeon here at Nationwide Children’s Hospital. We’ll get him settled
into the studio and proceed with introductions.
But first, you recall a couple episodes back, we talked about the importance of eating a nutritious breakfast and how research has shown that doing so may actually help prevent Type 2 Diabetes. And, in the course of
talking about that study, I mentioned that the researchers were from the United Kingdom, and that they advised against a biscuit-based breakfast. So my next question and probably your next question as well, what
exactly is a biscuit-based breakfast? Because I really didn’t think the British definition of a breakfast biscuit was the same as the image I have in my decidedly American mind.
And so, I asked if perhaps a British listener would be so kind as to set us straight on the definition of a biscuit-based breakfast so that people in the UK and the USA, and really in other places around the world, could
avoid them. Sure enough, Pippa came through. She wrote in and said, “Hi, Dr. Mike. British listener here. You asked what constitute a biscuit-based breakfast in a recent episode. In the UK, we have a bit of a
fashion for breakfast biscuits at the moment. And by biscuit, I mean what you would know as a cookie. They’re here advertised as a healthy on-the-go choice but they’re pretty high in sugar, and personally I’d grab a
banana. I assume that’s what the researchers were referencing.”
She included a link to a news article from the UK, which identifies the illusive breakfast biscuit and compares its nutritional value to a few other quick breakfast option. So be sure to check that out if you want to know exactly what a breakfast biscuit is, and I’ll put a link in the Show Notes for this Episode Number 299 over at pediacast.org. So, thanks to Pippa for setting us straight on breakfast biscuits.
Also, I want to remind you, our 700 Children’s Blog is available at 700childrens.org, and some recent topics: “What to Expect from Ear Tube Surgery”, “The Dangers of Secondhand Smoke”, and “The ABC’s of Safe
Sleep”. That one was written by Dr. Jamie Macklin who, by the way, I have lined up as a guest on the show next month to talk about safe sleep and infant mortality. So that should be a good one.
Another one of my posts, “Making Baby Food At Home”, this one wraps up my homemade baby food trilogy. You recall that I had written about nitrates in homemade baby food and the risk of botulism. We finished on a
good note with some tips on making baby food at home and keeping it safe. Couple of other topics: “Fevers: What They Are and Why They Happen”, and then, “Looking for Answers: Rare Diseases and Gene Therapy
Research”. So all of those and lots more topic, be sure to check them out on our blog at 700children.org.
Also, I want to remind you, if you have a topic that you’d like us to talk about, it’s really easy to get in touch. Just head over to pediacast.org and click on the Contact link, and ask your question or suggest your topic and we’ll try to get it on the program for you. Also, I 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. Also, your use of this audio program is subject to the PediaCast
All right, let’s take a quick break. I’ll grab a sip of water. We’ll get Dr. Beebe settled in to the studio and we’ll talk scoliosis, right after this.
All right, we are back. Dr. Allan Beebe is an orthopedic surgeon and Director of Pediatric Orthopedic Trauma at Nationwide Children’s Hospital, and the Assistant Professor of Orthopedic Surgery at the Ohio State
University College of Medicine. In addition to pediatric trauma and the treatment of orthopedic injuries, Dr. Beebe has a clinical interest in spinal deformities. He’s a member of the Scoliosis Research Society, and that’s
what he’s here to talk about today, scoliosis.
So, let’s give a warm PediaCast welcome to Dr. Allan Beebe. Thanks for joining us today.
Dr. Allan Beebe: Thank you very much for having me.
Dr. Mike Patrick: Really appreciate it.
Let’s start with just a simple definition. What is it that’s meant by the term scoliosis?
Dr. Allan Beebe: Well, scoliosis, the word itself dates back to the Greeks and it simply means curvature.
Dr. Mike Patrick: So, this is a curvature of the spine that we see. Does the curvature have a particular shape in order for it to be considered scoliosis, or does any shape count?
Dr. Allan Beebe: There’s normal curvature of everyone’s fine. There’s normally the rounded shoulder and sway in the little back. But when you look at the spine from a frontal or from behind, the spine should be
straight. And so, any deviation from that would be considered a scoliosis.
Dr. Mike Patrick: Great. And how common is this condition?
Dr. Allan Beebe: Depending on magnitude, the incidence of curves over ten degrees, which is how we measure the spine, incidence is about two to three percent in the population, and it’s fairly equal boys to girls. If
you look at larger curves, those greater than 30 degrees, the incidence is about one in a thousand and it’s about a ten-to-one relationship, young women to men.
Dr. Mike Patrick: So, they’re equal but the bad more significant ones, you do tend to see those in girls more often than boys.
Dr. Allan Beebe: Yes, that’s correct.
Dr. Mike Patrick: Do you see a difference in different ethnic groups? Or is it pretty equal across the board there?
Dr. Allan Beebe: It seems to be pretty equal across the board.
Dr. Mike Patrick: Great. And what about age ranges when it’s first diagnosed?
Dr. Allan Beebe: Well, there’s sort of some ongoing language changes in our own specialty. We used to talk about scoliosis, either neuromascular or congenital, or idiopathic or unexplained. And then within those, there
is infantile, juvenile and adolescent.
We started to group the early onset scoliosis patients under one heading, that being early onset.
Dr. Mike Patrick: So the idiopathic scoliosis, that’s the one that you typically would see like a kid who goes in for their well checkup and the doctor has them kind of bend down, touch their toes, looks at their back. Is
that what you would consider idiopathic scoliosis?
Dr. Allan Beebe: Yeah, normal screening happens usually the fifth and the seventh-grade and frequently whether it’s a well-child check or a school nurse identifying the abnormality, those are the kids that usually
fit in to the idiopathic adolescent group.
Dr. Mike Patrick: Do we have any idea what causes that?
Dr. Allan Beebe: We really don’t as far as specific causes. There’s certainly a genetic tendency, families that have scoliosis within it. That can be about a 30% incidence of subsequent family members having it. But as
far as specific genetic tests at this point in time, we don’t have that.
Dr. Mike Patrick: This is something, too, that you can see at birth, so you had talked about congenital scoliosis? That’s a little bit of a different… Any idea what causes it if it presents that early in development?
Dr. Allan Beebe: No. It start at somewhere around the six week of gestation. There are abnormalities in either failure of formation or failure of segmentation of the normal segments of the spine. But again, from a
specific cause and point, we don’t know.
Dr. Mike Patrick: Just don’t really know. Are there underlying medical reasons that could contribute to the formation of the scoliosis? So, I’m thinking things like neuromuscular type issue of the back that then could have scoliosis associated with it, then you could say kind of dependent on that underlying problem.
Dr. Allan Beebe: Sure, there are underlying conditions — Charcot-Marie-Tooth, myelodysplasia, cerebral palsy — all of those have a much higher incidents of scoliosis.
Dr. Mike Patrick: Now, what are some science and symptoms of scoliosis? What should a parent kind of be on the lookout for if they’re concerned that their child could have scoliosis.
Dr. Allan Beebe: Probably the most frequent thing we see is or can plainly see is that children are complaining of back pain. And usually, it’s the ones that been diagnosed or referred to us, but up to 80% of the
population can have back pain as a part of their normal everyday activity. Our research suggests or in the field suggests that back pain is not really associated with scoliosis.
Dr. Mike Patrick: So, if kids do have chronic back pain, scoliosis shouldn’t be the first thing that comes into the parents’ mind. There should be probably another explanation for it than the curvature.
Dr. Allan Beebe: Correct. Yeah, if you look at the incidents of back pain in the population, they’re fairly equal between groups of kids with scoliosis and those kids without scoliosis.
Dr. Mike Patrick: Well, let me ask you this first, and I should have asked this back a couple of questions ago, does scoliosis tend to run in families?
Dr. Allan Beebe: It can. About 30% of the time, there can be a second or third generation child having scoliosis.
Dr. Mike Patrick: So, let’s say there’s a family history of scoliosis and a parent is concerned that their child could have it, since back pain isn’t really a good marker, is there something that parents could be on the lookout for to let them know that that’s something that could be happening?
Dr. Allan Beebe: Yeah, the hard thing about that observation from a parent to a child is the children are almost never holding still. But if they’re standing upright, knees straight, arms at their side, shoulder height prominence of the scapula or shoulder blade, waistfold-based asymmetries, those are the sort of cosmetic thing that we look at to try and determine “Could potentially be a scoliosis here?'”
Dr. Mike Patrick: So this really can be a silent problem until it’s a pretty significant curve.
Dr. Allan Beebe: Absolutely.
Dr. Mike Patrick: And really, this is why it’s important for kids to see their doctor every year, and maybe even more often than that if they’re starting to be a curve or there’s a family history of significant curves.
Is it still recommended that kids get scoliosis screens through school? Are school nurses still doing that or not so much?
Dr. Allan Beebe: The trend is to get away. The practice of school screening has not really reduced the incident of surgical treatment of scoliosis, but it’s still a fairly good screening particularly for those children who
aren’t getting regular screenings by their family physicians.
Dr. Mike Patrick: So let’s say a kid does have a screening, or the parents does the screening themselves. Again, just have the kid bend down, touch their toes, look at the curve of their back. You just want a nice straight curve and everything, the shoulder blades looking symmetrical, the waist looking symmetrical, the neck and the head. If there is a concern, of course if the parents sees, then they probably have to bring that up with their primary care doctor so that then they could do an official exam.
But then, how do you go about actual… So you look and you say, “Yeah, it doesn’t look quite straight or it doesn’t look quite symmetrical.” What do you do next to actually make a diagnosis of scoliosis?
Dr. Allan Beebe: Well, the more traditional Scoliometers or external devices to try to determine magnitude are not very accurate. So, really, an X-ray is the most accurate device to actually determine the magnitude of
Dr. Mike Patrick: So you order scoliosis film series and the radiologist takes a look at that and measures out the curves. What kind of degrees of curve are we talking about that would be significant versus not
Dr. Allan Beebe: The radiologist is going to report any degree of scoliosis and any deviation. But from an orthopedic standpoint, under 10 degrees is still considered within normal limits. There’s going to be subtle irregularities. But over 10 degrees, we determine it as true scoliosis and would recommend that child be continued to be observed.
Dr. Mike Patrick: Now, is that an automatic referral to an orthopedic doctor if they have 10 degrees? Or is there a percentage cutoff of when kids should be seen or not seen?
Dr. Allan Beebe: Well, the issues are treatment. And so, the younger the child, if we look at the infantile, juvenile, early onset group, certainly I think most of those should be referred because they have a very high incidence of progression. The older children, it really depends on the comfort level of the primary provider. But from a treatment standpoint, there’s really not much of the elbow to us between a 10 and about a 25-degree curve. So the smaller curves trigger are red alerts for observation, but from a treatment standpoint, we really don’t have anything available to us.
Dr. Mike Patrick: Is it true in saying that the longer that a kid still has to grow when you first discover the curve, that the more likely it is, that it could become greater curve that would go over 25 degrees.
Dr. Allan Beebe: Yeah, I frequently describe to families that the enemy of this condition is growth. It seems to be the more growth remaining, the higher the likelihood of progression.
Dr. Mike Patrick: Then, once you reach skeletal maturity, do you see scoliosis anymore progressing after that.
Dr. Allan Beebe: Based on magnitude — usually the curves that are in the idiopathic group that are under 30 degrees, in general, don’t change. Those that are over 45 to 50 degrees still have a tendency to progress in
adulthood, and that’s why it was considered more of a surgical problem. And those between 30 and 45 or 30 and 50 are a little more variable, so we will continue to watch those.
Dr. Mike Patrick: How do you decide at what point you’re going to stop watching and now you’re going intervene?
Dr. Allan Beebe: Progression and magnitude is really what drives our treatment. If we have a child in the 35, 40-degree range, we’ve been bracing but is progressing despite and still immature, then at 45, 50 degrees, we’re really talking about trying to stabilize the spine and prevent this insidious progression.
Dr. Mike Patrick: Let’s say you do decide that you have a kid and you are going to intervene with the scoliosis, how do you decide if you’re going to… Does everyone just start with the bracing or do you ever start with
surgery? How do you decide which direction to go if you are going to treat this?
Dr. Allan Beebe: Well, again, I think magnitude drives your treatment. If the child walks in at 30 or 35 degrees and you’ve never seen them before, you really don’t have a track record for progression. If they’re
immature and they have extra ways of trying to determine where they are maturation-wise. If they’re relatively immature, we’ve probably be talking to them about a brace. On the other hand, if child walks in the door with a 60-degree curve, a brace is not effective. They seem to only be effective between a range of about 25 and 45 degrees with growth.
Dr. Mike Patrick: Now, let’s concentrate on the bracing for a moment. So, talk a little bit about what that’s like in the family if a child is wearing a brace. Is this something that they wear 24/7? Is it just when they’re up and about? Is there any pain associated with it? Those kind of things.
Dr. Allan Beebe: A brace certainly has a psychological implications. As you can imagine, a middle-school child with hard brace. They are an advancement over 20 years ago. They are hard plastic. They’re worn under
the clothes. We do recommend upwards at 23 or 24 hours. Some studies would suggest that 16 hours may be as good. We at Children’s try and allow the kids to continue to participate in their athletic activities, any
sports, anything that’s organized. We have them out of the brace for those short periods of time but then back in the brace.
From a comfort standpoint, they’re as comfortable as we can make them, but they perform by placing pressure on the ribs, pressure on the sides and trying to reduce the magnitude of the curve while the kids are still
Dr. Mike Patrick: And I can imagine that compliance may be a little bit of an issue with those, just if they’re uncomfortable, and there’s a social stigmata associated with wearing them, that you may have some kids who
just refuse to do it.
Dr. Allan Beebe: Right. And it sets up some very difficult family dynamics. We’ve had some children involved with behavior health, trying to work our way through. Some children are very well adjusted to it. But it can
really be variable.
Dr. Mike Patrick: Yeah. And then, let’s say that you’ve moved beyond bracing or you decide that bracing is probably not going to do too much for you, because it’s so great of a curve and you decide that you’re going go
surgery route. What is that look like in terms of surgery for scoliosis?
Dr. Allan Beebe: Well, it’s a big operation, depending of the magnitude of the curve and the length of the fusion that you’re talking about. You’re basically trying to grab on to various levels of the spine and hold them still, and try to get them to fuse together. So, you’re taking away some of the motion across those segments that you’re grabbing on to. The trade off is you’re trying to prevent that curve in continuing to progress later on.
Dr. Mike Patrick: Now, in doing research for the show, came across something called a growing rod. What is a growing rod?
Dr. Allan Beebe: A growing rod speaks more to the very young. You can stop the curve from progressing by fusing the spine, but you don’t want to do that in a three-year or four or five-year-old because it really
restricts overall torso height. It restricts lung development by inhibiting thoracic height. So a growing rod is an instrument used in particular circumstances in which we want to allow the child to grow but still trying to control a fairly aggressive curve. So it is a matter of installing a rod and then periodically lengthening those rods to try to keep up with the child’s growth.
Dr. Mike Patrick: So in that case, the rod itself is not necessarily directly attached to the spine, so that you can swap them out, so to speak.
Dr. Allan Beebe: Well, we install them in such a manner that we grab on to the top part of the spine and the bottom part of the spine, and then stretch in between on a regular six or eight-month basis.
Dr. Mike Patrick: And just with a longer rod when you…
Dr. Allan Beebe: Well, we have a little connector that fits and there’s actually two separate rods on either side of the spine and so we have an ability to sort of stretch out the accordion, if you will.
Dr. Mike Patrick: Yeah, got you. It’s interesting. I’m sure for the families that… For some families that want to know all the details, and some like, “Don’t tell me, just do what you have to do.”
Dr. Allan Beebe: That’s true.
Dr. Mike Patrick: So, if scoliosis doesn’t really cause much of in the way of symptoms, I guess the next question would be, why do we treat it? So there must be some complications that can arise if it goes too far.
Dr. Allan Beebe: Well, certainly in the very young — we’ve sort of touched on a little bit early — that lung development is a vital part of our youth, and the alveoli continue to increase in number and size up to its thought
about aged eight. So in those vital years, we are trying to allow the child to grow as much as possible and not limit that torso growth.
In the older kids, the more idiopathic curves, there are some long-term studies that would suggest that very significant curves, that there can be some impact on heart and lung function. But we’re talking 120-degree
curves. But if you start with a 60-degree curve at age 14 or 15, average progression in an untreated 50-degree spine is a about a degree to a degree-and-a-half a year. In 30 or 40 years, you’re looking at 90 to a 100-degree curves.
Dr. Mike Patrick: Yeah. And, of course, with that extreme of a curve, you’re going to have some difficulty with moving your bodily function.
Dr. Allan Beebe: Yeah, there’s certainly some studies that suggest that there’s more pain with higher degree untreated curves. Life expectancy has really not been demonstrated to be compromised. But endurance,
shortness of breath with stairs, things that really cause exertion are sometimes compromised by significant curves.
Dr. Mike Patrick: To be fair, there must be some complications that can arise from the treatment itself. What sort of things do you watch for with the treatment?
Dr. Allan Beebe: And you’re talking surgical treatment?
Dr. Mike Patrick: Well, let’s talk braces, too. I guess that pressure sores would be a possibility and then discomfort, but then surgery then would be the main one.
Dr. Allan Beebe: Certainly the braces, it is a matter of pressure on the body to try to create correction, so we’re always monitoring, and the families also are monitoring for the pressure. But probably the biggest is
the psychological aspects that we talked upon — relationship to friends, what can I still participate in, how am I perceived. So there’s a lot of body images problems that we can see.
Dr. Mike Patrick: Of course, with surgery, any of the typical surgery complications, you have to think about in terms of bleeding, infections, those kind of things.
Dr. Allan Beebe: Sure. Infection, it runs between one and two percent across the globe. We’ve been fortunate here. Ours is very low.
The other risk that most people talk about is neurologic risk. Anytime you manipulate the spinal instrument, the spine, there’s a risk of potential neurologic problems.
Dr. Mike Patrick: Is there a way to prevent scoliosis from happening in the first place?
Dr. Allan Beebe: No, we have not found a way to do that. There’d been exercise programs, there’s been physical therapy, and no one’s really come up with a way to prevent it.
Dr. Mike Patrick: What about hot topics in scoliosis research? What kind of things are they looking at right now.
Dr. Allan Beebe: I think a lot of work has been done on the early onset groups, growing rods, different types of growth modulation techniques, whether you can tether a portion of the spine, whether you can stretch it,
whether you can use magnetic link, any advises so you don’t have to revisit the operating room. In the idiopathic, it’s more about technology, motion segments, how many levels can you safely fuse. Are all the problems
above or below your fusion? Those kind of things.
Dr. Mike Patrick: Then, what is the long-term outlook for folks with scoliosis, especially in terms of activities? So you can participate in sports and really maintain an active lifestyle?
Dr. Allan Beebe: I think most people allow the kids to participate in all activities which they’re interested. Even the post-operative kids, we usually have returning to sports, if that’s their choice. We usually will restrict intentionally contact sports – football, rugby, lacrosse.
Dr. Mike Patrick: The Spine Program here at Nationwide Children’s, we have orthopedic surgery that’s involved. Are there other folks that make up the center?
Dr. Allan Beebe: Neurosurgery manages most of the spinal trauma in the cervical spine abnormalities. Orthopedic surgery deals with most of the spinal deformity below the cervical spine.
Dr. Mike Patrick: And then, of course, you have access to everything in Nationwide Children’s. So if you do have a kid who had some psychological issues with the brace, we have psychology, behavioral medicine, social
work, and we have athletic trainers that we can tap into for kids who want to maintain activity.
Dr. Allan Beebe: Right. We utilize many of the arms of Children’s Hospital in getting these kids back to health.
Dr. Mike Patrick: We really appreciate you stopping by and talking to us. I do have some links in the Show Notes for folks. If you head over to pediacast.org and click on the Show Notes for Episode 299, we’ll have a link
to the Spine Program at Nationwide Children’s. Also, we have scoliosis information page that really has a quite a bit of information that’s written at level of parents so you can understand exactly what it’s saying. And
then, we’ll also put a link to the scoliosis Research Society. So we do have some more scientifically adept members of our audience. And so, if you would like to know more about scoliosis research, you can check that
And of course, we always have the Connect Now With A Specialist from Nationwide Children’s, so if your child has scoliosis and you’d like to get connected with a scoliosis expert, we’ll have a link for you that will just
get you connected with the program.
So really appreciate you stopping by and telling us about scoliosis today.
Dr. Allan Beebe: Thank you for having me.
Dr. Mike Patrick: Great. All right, we’re going to take a quick break, and I will be back with a final word, right after this.
Dr. Mike Patrick: All right, we have just enough time to say thank you. I just want to thank all of you for taking time out of your day to make PediaCast a part of it. Really appreciate your listener loyalty to the program.
Also, thanks to Dr. Allen Beebe — he’s an orthopedic surgeon here at Nationwide Children’s Hospital — for enlightening us on scoliosis.
That does wrap up our time together. PediaCast is a production of Nationwide Children’s Hospital. Don’t forget PediaCast and our single-topic, short-format program PediaBytes are both available on iHeartRadio Talk,
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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.