In this episode of PodMD, Adult and Paediatric Spine Surgeon Dr Meenu Shunmugam will be discussing the topic of paediatric scoliosis. We discuss what scoliosis is, early signs and clues of scoliosis in children, when to refer to a specialist, and more.
- Transcript
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*As always, all in this PodMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Meenu Shunmugam.
Dr Meenu Shunmugam is an Australian-trained orthopaedic spine surgeon based in Adelaide. She completed subspecialty fellowships in adult and paediatric spine surgery and has special interests in endoscopic spine surgery as well as minimally invasive and robotic techniques. Today, we’ll be discussing the topic of paediatric scoliosis.
*Please listen to our disclosure at the end of this podcast
Meenu, thanks for talking with us on PodMD today.
Meenu: Thank you for having me today.
As mentioned, today we will be discussing paediatric scoliosis. To start us off, could you please explain what scoliosis is and how often we see it in children?
Meenu: Scoliosis is a lateral curvature of the spine, of about 10 degrees, as per the Scoliosis Research Society. The most common type of scoliosis we see is adolescent idiopathic scoliosis. Of course, there are many different types of scoliosis, and these can range from congenital scoliosis, whereby patients are born with a structural abnormality of the bone, and this is usually picked up perinatally or intrauterine. It can be due secondary to a neuromuscular cause or a syndrome it causes, such as cerebral palsy or other more common causes, such as Leg Length discrepancy or neurofibromatosis.
Excellent, so there are a couple of different causes for it. When GP’s are doing their routine checks and when they see the patients, what sort of early signs or subtle clues might suggest a child has scoliosis?
Meenu: Idiopathic scoliosis is sometimes quite difficult to pick up and is usually picked up quite late in the process. Sometimes it is noticed by their gym teacher, their sports teacher or over the summer months when they are wearing bathers or swimmers.
In terms of more subtle signs we look for, should asymmetry or a prominent rib hump, especially exacerbated when a patient bends down, and that is what we call an Adam’s Forward Bend Test, where we elicit the amount of rotation in the spine.
Okay, so sometimes it’s not just bad posture; scoliosis could be the underlying cause of it.
Meenu: Correct, the other thing that people normally say is bad posture when patients tend to stoop down. The other condition that some children might have is something called Sherman’s kyphosis, but we are not covering that in detail today. But it is something to think about.
Excellent. At what point should a GP when they see a patient think “Okay I think it’s time I refer this patient to a specialist?
Meenu: This would be based on history, examination and radiological findings as well. So with history, if there are any signs of scoliosis, I would encourage GPs to mainly direct all their questions and examination to rule out a non-idiopathic cause of scoliosis, and this would include asking about perinatal history, any family history of scoliosis. It usually runs in females, so any mothers, any cousins, any sisters with scoliosis and how they had it treated, will tell us how bad the scoliosis was in their family. When did they first notice a curve, is it a progressive curve? In females, we always ask about menarche because that tells us when they are going into peak height velocity, and that is when curves tend to progress quite quickly.
I also tend to ask about any symptoms of Neuraxial issues, so something that is driving the curve, such as a Syrinx or a Chiari malformation, and this would be things like do you have any visual issues, nausea or vomiting, do you have any headaches.
Something else that might cause scoliosis is a tethered cord, usually around the age of about 7 years old or so. Any regression in their milestones, such as bowel and bladder training, any issues with their running, or weakness in their feet. In terms of examination, I would do a thorough examination again to try to rule out any other causes of scoliosis, such as looking at their skin for Cafe Au Lait spots, which would point me towards the neurofibromatosis. The overall appearance of the patient, are they quite tall? What is the height of their limbs compared to their torso,looking at the chest for Pectus Excavatum. Checking their pelvic height really quickly to see if theres a leg limb discrepancy driving the scoliosis.
Of course, as a spine surgeon, I will always do an upper and lower limb examination of power, sensation, reflexes and clawness. The other things we have spoken about already, rib symmetry and shoulder asymmetry. In terms of imaging, a full-spine eosc X-ray or true to scale xray generally has a lower dose of radiation compared to the standard stitched X-rays that are obtained, and so I would encourage, where possible, from a cost point of view and a patient location point of view, to obtain this and this gives us a full length of the spine and also the benefit of lower radiation.
Great recommendations, thank you. What are the Cobb-angle parameters that you look out for?
Meenu: Thank you, great question. A Cobb-angle is something that we measure on the radiographs on AP or PA x-ray, and this is the top and bottom of a curve. Generally, a Cobb-angle of more than 10 degrees is something that I would encourage GPs to refer to a specialist, especially if this child is a younger child and has remaining growth to go. These are children we want to ensure do not need to go into something that needs treatment, such as bracing.
The next Cobb angle we look at is between 20 and 40 degrees, with remaining growth, and I will go into what remaining growth is, with a Risser score of 0-2, generally those we brace these curves. Bracing has been shown to reduce the progression of the curves, and ultimately reduce the number of patients who need surgery. Of course there are a lot of other parameters we need to look at, such as flexibility of the curve, how much it corrects in the brace and of course, compliance to the brace. It is a big undertaking for the child, we generally tell them to have the brace on for 23 hours in a day, as the brace wearing and success is dose dependent, as to how long they wear the brace.
In terms of surgical threshold for a thursaic curve in an idiopathic patient, it is about 50 degrees. Why we say 50 degrees, long-term studies have shown that any cover over 50 degrees has a slow rate of progression, about 1 to 2 degrees per year, and hence those patients are the one’s we would recommend surgery to.
That’s an excellent segue as well, speaking of curves, because when do they tend to accelerate during growth?
Meenu: Curves tend to accelerate when children are going through their peak height velocity, and in females, we look at their menarche. Anytime 1 year before their first period or 1 year after their first period, is when they tend to shoot up in terms of height, but that is also when the curves tend to progress. These are patients who we would monitor quite closely, in terms of 6-monthly X-rays, especially if they haven’t reached that bracing criteria yet, they might very quickly fall into that criteria, and generally those are the patients that we want to see fairly quickly in clinic, so that we can make that decision and monitor them pretty closely.
In terms of other parameters we look at, we look at the change in height every 6 months. In boys, we ask general questions like “are you getting taller?” “are you having to change your pants?” “are you having to buy larger shoes?” So, overall, I am just looking at the growth of a patient.
Excellent. In terms of male-to-female ratios of patients that you see, what does that look like?
Meenu: In idiopathic curves, most of the curves happen in teenage girls, so 90% of my idiopathic scoliosis patients are females. We don’t quite know exactly why this is, but it might be due to certain receptors or periods when they grow. There is also definitely a genetic component,t but nothing has been pinpointed to the exact cause or gene, as to why this is so common in girls compared to boys.
That’s fantastic, thanks Meenu. Are there any red flags that could suggest any underlying pathology rather than idiopathic scoliosis?
Meenu: Certainly, that is something that is always at the back of my mind and as a primary care physician, usually you are the first person that is going to pick this up, so you have a very important role to play here.
In terms of how I elicit red flags, again, I divide it into history examination and imaging. From a history point of view, I have previously touched on, but I will go over it in slightly more detail, asking about neuroaxial issues such as headaches, nausea, vomiting, and visual issues. In terms of milestones, I ask about any regressions in milestones and any pain. Now the pain is two-fold, one radicular pain, any pain that comes down their legs, shooting pain, or any pain around their back, that is particularly pain that is constant or night pain, pain that requires patients to take analgesics.
In particular, more common tumours now tumors are usually rare, but an a osteoid osteoma tumor or a _osteoblastoma_ tumor is always at the back of my mind. The typical pain that these patients get is night back, which is relieved with anti-inflammatories. Why this is, is because these tumours have prostaglandin and COX expression, so non steroids are very effective to manage this pain. Other more common things with __ is weight loss and loss of appetite, are usually later findings.
On examination, any asymmetry and reflexes, or motor power, sensation, would be something that would turn me towards, “Is this a pathological issue?” In terms of imaging, I would start off with a plain X-ray, and it is sometimes difficult for a small tumour or a low-grade infection to show up on a scan, but it can be seen. Then a referral to a specialist to further elicit with your history and examination and your concerns, would spur us to determine if we should get a CT scan or an MRI scan, any spine specialists would be happy to take this to the next step with that baseline information.
Okay, excellent, that is good to know, so start with an X-ray and then refer to a specialist and the specialist can advise on next steps from there.
Meenu: Correct, I think an X-ray is a great baseline and provides a lot of information and can also help with the triaging process.
Excellent, thank you for that. In terms of technological advancements, have you seen any updates or any new technologies being introduced in this area?
Meenu: Certainly. I think from a bracing perspective, that recently, in the past few years, South Australia has picked up, because we have more access and evidence to show that bracing can reduce progression to surgery. So, certainly now we have a lot of patients in braces, and we have different ways of making the brace. So the current way the brace is made is more comfortable for the patient.
In terms of surgical technological advances, navigation technology improves the screw-on-metal work accuracy rate, imaging, such as an EL scan or true-to-scale scan, provides us with a standing X-ray of the patient and helps us plan our levels of instrumentation to try and hopefully reduce the number of levels that we fuse.
Other things that are out there include a custom bent rod or a customised Jigs that can be used for very difficult or challenging anatomy of the patient.
This has been excellent Meenu, thank you very much. To sum up for us, could you please identify the three key take-home messages from todays podcast?
Meenu: So, the first thing would be referral criteria and some numbers to remember. How I remember it is 10, 20, 40, 50. So, a referral to a spine surgeon or a specialist is anyone with a Cobb angle of 10 or more, with remaining growth. In terms of the 20-40, those are the patients that we brace curves of 20-40 degrees with remaining growth. The number 50 is our surgical criteria and that is generally when we would consider or offer surgery to our patients. These numbers are generalised and of course, these will be individualised to patients and their curves and their remaining growth.
The second thing is I would encourage GPs to obtain full spine X-rays in the form of a EL or True-To-Scale X ray where possible. This reduces radiation exposure to the child and also it provides us with an accurate way to measure the Cobb angle of the patient, as this is taken standing and erect.
The thing would be not to forget to elicit for any red flags on the history, examination and also imaging. Please do let us know when you refer them on so that we can triage this patient more urgently to see us.
Well, thanks again for your time and for the insights you have provided today.
Meenu: Thank you for having me.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
