The expert guide to pediatric spine health and scoliosis interventions
Dr. Dennis Cardone and Dr. Anthony Petrizzo cover everything from the importance of diagnosing scoliosis and understanding spine curvature, to the latest advances in therapies and treatments. From braces and physical therapy to spinal fusions, the experts give straight talk on curved spines.
Narrator: SiriusXM presents an NYU Langone Orthopedics podcast. Orthopedics is just very important to the population in this country. Its ability to restore patient function. Problems related to cartilage, to someone who has more advanced forms of arthritis. Getting people back to their activities and the things that they like to do. Featuring NYU's experts in the field of orthopedics trying to figure out that problem before it even is a problem. Problems with solutions. Well beyond physical therapy, to conservative pain management, to surgery. The best medical minds now come together. Applying all of our minds to solve these problems. We're here to get people feeling better so they can get back to their lives. And that's really what we try and accomplish. These are the Bone Whisperers.
Dr. Dennis Cardone: Hello, everyone, and welcome. I'm Doctor Dennis Cardone, I’m also an associate professor in the department of orthopedic surgery here at NYU Langone Health. And we've got a very special webinar today. I think my child has scoliosis. What should I do? And does it get any better than this? True specialist on the topic, one of our spine surgeons, Doctor Anthony Petrizzo, is joining us, and Doctor Petrizzo is chief of orthopedic spine surgery at NYU Long Island, and also associate professor in the department of orthopedic surgery here at NYU Langone Health. And let me just start by welcoming Doctor Petrizzo - great to have you join us.
Dr. Anthony Petrizzo: Thank you so much for the invitation. Yes, uh, it's exciting. This is something that I speak about on a regular basis in the office, and I always enjoy my time with patients, but often it's, uh, followed by another patient and another patient. So here, having some time to sit and really digest this information I think is helpful.
Dr. Dennis Cardone: Fantastic. And really, uh, as you know, and even in the population that I see, scoliosis is very misunderstood. And I think that term gets thrown around significantly from multiple different levels without a good understanding of it. So, number one, let's start out with the basics. What does it mean when you say scoliosis?
Dr. Anthony Petrizzo: Sure. Yeah, you're exactly right. Anytime a kid looks weird, according to the parents, the pediatricians refer to the orthopedist. And when I see the family, they say my kid has scoliosis. And that could vary anything from, uh, postural deformity, a rounded posture, a kyphosis, an elevated shoulder, some asymmetry in the spine. So, yeah, it's very common. That label is carried in the same way that, uh, sciatica is another one, which, you know, I'm sure you hear in the office very often when, you know, more often than not, it's not necessarily sciatica.
Dr. Dennis Cardone: But so people think, so let's say they have an idea, and they think, okay, scoliosis, a curve of the spine. But would you say that everybody has a curve almost, right?Typically, I'll say to patients, hey, no one has a straight curve. No one has this very, very straight spine. And maybe that's not such a good thing. We all have, like, little curves. But does the smallest degree of a curve equal a scoliosis? When can you define it as a scoliosis?
Dr. Anthony Petrizzo: Right, so scoliosis is actually a three dimensional deformity. So the definition of scoliosis is a three dimensional deformity of the spine where the spine is deviating from its normal plane. Usually what's interesting is you'll see it - the significant curves you'll actually see from looking at the back, you'll see an elevated shoulder, you'll see some rotational asymmetry. But really, the diagnosis is made based on an x ray where you're seeing a three dimensional deformity of the spine. And in general, what we do to diagnose the scoliosis is we get an x ray. And with that x ray, we actually measure with a protractor. Well, we used to use a protractor. Now we have, you know, computerized x rays, which actually help us measure the lines. But essentially, we take that x ray, and we look at the bent bones of the back, and we kind of measure the region that is bent out of the plane of looking at them from front to back, or what we refer to as the coronal plane, and we measure that curve. And if that curve measures two degrees or three degrees, you know, we don't call that scoliosis. We just call that some postural asymmetry. But if that curve gets greater than ten degrees, then by definition, it's scoliosis. But, you know, a ten degree curve is not something I worry about as much as, say, a 90 degree curve. But an x ray is a very helpful way to take the subjective evaluation of saying, hey, yeah, something is weird about your back and actually giving it a diagnosis, and not only giving it a diagnosis, but giving it a firm parameter of what that curve is.
Dr. Dennis Cardone: So, you know, I do mostly sports medicine, but occasionally I'll even see a parent will come in with their child and have some concern about scoliosis. So for you being a specialist, most of the patients that you see or come to see you for an evaluation of scoliosis, is it the parents that notice some curve? You know, their son or daughter is taking a shower, or they're walking poolside and they say, ooh, that's a little funny. Like you said, maybe the shoulder's a little high or some asymmetry that you notice? Or is it more the pediatrician who's doing their evaluation picks up something and says, this might be scoliosis, a concern. Let me send you to doctor Petrizzo. Is it more from the pediatrician or more from the parents or really a combination?
Dr. Anthony Petrizzo: That's a great question, actually, that's a question I ask the patients when I'm interviewing the parent and the child. I say, you know, how was this noticed? Was this noticed by you? Was this noticed by the grandma? Or was this noticed on school screening? So we're in New York, and New York has a school screening program, and the school screening program is usually run by the school nurse, where they have the children kind of do a forward bending test, where they actually have them bend forward and they're looking at the asymmetry in the trunk to look for any deviations. And that school screening program has something that's kind of been disputed in the literature in terms of the value of a school screening program. You know, do we perhaps overestimate or underestimate what the true incidence of scoliosis is? However, the, uh, school screening program is one way, probably, that I commonly will see a scoliosis evaluation, and probably the second is through pediatricians. I think the pediatricians do a really good job on the routine annual physical exams, having the kids bend over, especially during that time of growth, during adolescence, and they are able to pick up these curves. And sometimes I'm very impressed when I see the physical exam that the pediatrician saw, but I have the benefit of the x rays, and I can actually see that, you know, in fact, that is a scoliosis, or it's minimal. What we also notice is that males tend to hide the curves a lot better than the females. And usually our understanding is that it's probably because of the muscle mass that's laid on top of the ribcage, which can make it hard to notice. So the school screening tests aren't 100% effective, but they do help select out curves that actually need treatment - so, uh, the larger curves, like curves greater than 20 degrees. Typically, when they do the school screening, they have the child bend over. And when they have the child in a bend position, which we call the forward bending Adam’s test, they have this tool that's called an inclinometer, which actually measures the amount of rotation of the trunk. And once that gets to about seven degrees, or seven degrees of rotation, that's roughly to an equivalent of about a 20 degree scoliosis on x ray. So that's usually something that's significant enough to recommend consideration to a specialist for.
Dr. Dennis Cardone: You're listening to the orthopedic webinar series brought to you by the department of orthopedic surgery at NYU Langone Health. And joining us today is Doctor Anthony Petrizzo, chief of orthopedic spine surgery at NYU Long Island, associate professor and department of orthopedic surgery at NYU Langone Health. And we're talking about scoliosis. I think my child has scoliosis. What should I do? So when should a parent be worried? Let's say the parent notices something, a curve, maybe something just looks asymmetrical. Is that enough for them, do you think? Just that alone to say, hey, you know what? If I noticed it, maybe I should have it looked at? And would you say, in most cases, they should just start with their local pediatrician, or should they immediately call up the office of a specialist, like yourself, a spine surgeon, to have that evaluation?
Dr. Anthony Petrizzo: Those are very common questions that are asked of us. Typically, as I mentioned before, I think the pediatricians do a really good job. I mean, they do well exams, so they're used to examining well kids, and, you know, kids that, on a physical exam, have some deviation that is concerning enough to the pediatrician is usually something that I think provides a valuable intermediary between having a concern as a parenthood and “I think I need to see a spine surgeon.” I think the pediatricians are a good first step, and the pediatricians, they have the tools to see what a normal child looks like or a normal spine. And these deviations that they can pick up and document with their inclinometer, I think, is helpful, and it could save a expensive and timely visit to the orthopedics.
Dr. Dennis Cardone: So the pediatrician, uh, in most cases, a fine place to start with the pediatrician. So you define scoliosis for us, but now there are different types of scoliosis, and by far the most common type, idiopathic scoliosis.
Dr. Anthony Petrizzo: So idiopathic scoliosis is by definition, is an unknown scoliosis. So this is a child that during the growth spurt, starts to get a deviation in their spine. So they go from not having a curve to undergoing a rapid period of growth, which we know occurs during the adolescent growth cycle as well as the growth cycle that they get, uh, during their toddler years. But by far the most common is the adolescence. And that's what we define as the, um, terminal growing period from ten to 18. And so that is idiopathic scoliosis.
Dr. Dennis Cardone: Earlier in girls than boys, or because they typically had their growth spurt earlier. So you would expect to see it earlier in that population.
Dr. Anthony Petrizzo: Right, you expect to see it earlier. The peak height velocity, which is the rate of growth over a period of time, is much more rapid and occurs earlier in females than in males. Uh, um, so some of the physical characteristics of plotting out how they grow and their maturation and other signs of maturity are helpful in me figuring out where they are in terms of their growth. Because one thing that we do know is, although we don't know what causes the scoliosis, we do know what causes the progression of scoliosis. And the thing that causes the progression of scoliosis is growth. So if I see a child in the office that has, for example, a 20 degree curve, and, uh, they haven't even started their adolescent growth spurt, I worry a lot more about that child than I do for a child that has a 35 degree curve but they're 18 years old and they've completed their growth spurt maybe three or four years ago. I don't worry as much about that child.
Dr. Dennis Cardone: Right. So that 10, 11, 12, 13 year old with a curve, like you said, whatever it might be, 15, 20, 25 degrees going into now, maybe their growth spurt years. That's concerning.
Dr. Anthony Petrizzo: Very concerning, right. Because what we do know is that the remaining growth will not only go into growing their skeleton, but it'll also go into growing the deformity.
Dr. Dennis Cardone: So if somebody has a curve, they have idiopathic scoliosis, they're twelve years old, they're going into growth spurt. Is it almost guaranteed that they're going to progress or it's really an unknown? And that's where you just come in and you say, okay, let's repeat x rays every six months. Let's do it annually. Let's keep an eye on it. Can you predict which curves potentially, or who it's going to progress more in one person than the next?
Dr. Anthony Petrizzo: So there are numerous things which helped me understand or try and predict where this curve is going to go. A family history of scoliosis gives me a greater concern, because we do know that a positive family history of scoliosis gives you ten times the likelihood that you will have a curve. A diagnosis of scoliosis with the potential of a curve to progress. If I see someone who is very early in chronologic age and has significant remaining growth, that's someone I have concern about. If I have someone that I saw that I've been following for scoliosis with observation, and I took an x ray and it went from zero or less than ten degrees to 25 degrees in a very short period of time, that's someone that I also worry about. So there are predictors which give me greater concern of the potential for a curve to progress than just what's the size of the scoliosis.
Dr. Dennis Cardone: So, idiopathic, like you said - we don't necessarily understand it or who's going to get it or the cause of the problem, but there are risk factors. So risk factors number one, you would say a family history, like, if you were to speak to a mom and dad, uh, their infant is born. If they asked you, is my child going to get scoliosis? Who's in that risk category? Family history, females a bit greater than males.
Dr. Anthony Petrizzo: So what's interesting is the incidence of scoliosis is the same with males and females, but the chance of progression of scoliosis is five times higher. So if you sample the population of a region and you take x rays on everyone, say, you'll find that the incidence of having a curve or a slight deviation of the spine is about the same. But the chance of a curve getting to 20 or 25 degrees, which is what we're kind of calling the treatable, you know, these are curves that require some form of treatment, you know, which we'll talk about. Um, so the incidence of that is five times higher in females. So, yes, gender does carry with it a risk for scoliosis. But just to put numbers in perspective, the prevalence of scoliosis in the adolescent population is about 1%. And the chance of that curve progressing to a number large enough that will require treatment is a half of 1%. So it's still relatively rare. So, you know, obviously, I see these curves and I follow these children in my office on a regular basis, but the chance that one of them is going to wind up needing surgical treatment is actually still relatively rare.
Dr. Dennis Cardone: We're talking with Doctor Anthony Petrizzo, chief of the orthopedic spine surgery service at NYU Langone Health, also associate professor at NYU Langone Health. And we're talking about, I think my child has scoliosis. What should I do? And welcome to the NYU Langone Department of Orthopedic surgery Bone Whisperer webinar series. And we're talking scoliosis. So let's turn to treatment. We've talked a bunch about what scoliosis is. We've talked about idiopathic scoliosis. How about one step before treatment: congenital scoliosis or other types? So we have idiopathic, other types of scoliosis. Is it just idiopathic and congenital?
Dr. Anthony Petrizzo: Right. So just to give you a layout of the template of how we think about scoliosis. So the scoliosis is the physical characteristic of having a curved spine, right? How do you classify that? Is that something that was normal and then developed? Is that something that developed for an unknown reason, or did it develop for a known reason? So there are certain diseases, especially neuromuscular diseases, where we kind of know that there's going to be a much higher incident that disease is going to carry with it the condition of scoliosis. You know, we see that in cerebral palsy and numerous other neuromuscular diseases. So that's one way to classify the scoliosis is a disease associated with a known entity, like a neuromuscular component. We do know that there is a congenital component, as you alluded to, which is, by definition, means that someone is born with part of their spine deformed, and that gave them a certain curve. Usually that happens by what we refer to as two common things, which is failure of formation, meaning that the bones didn't fully form on one side of the spine or the other side of the spine, or something called failure of segmentation, where the bones didn't fully segment, and both of those diseases will carry with it a scoliosis, which can be seen if the, uh, infant happened to get an x ray and sometimes, very often, we follow those curves as well. But the idiopathic scoliosis is kind of a different entity. And again, it's so much more common than all those more rare scoliosis, such as congenital or infantile or neuromuscular scoliosis. The idiopathic scoliosis is a disease entity where these kids, they're otherwise healthy, and as they go through their growth spurt, their spine starts to deviate from its normal parameters. And basically, we're following these curves, once we have someone who has this physical characteristic of the scoliosis, we measure it with x rays and x rays we measure it with this angle that's called a Cobb angle, which is really based on taking the region of the spine that's bent and measuring it, and then we follow that, and we treat it based on the size of the curve. Because the size of the curve gives us a good idea of what we need to treat and how we treat it.
Dr. Dennis Cardone: So, before, again, we talk about more specifics. Why? Why do you need to treat it? So who cares if you have, I mean, besides the cosmesis, the appearance, of course, that's one. But what about from a medical perspective? So what if the curve did keep progressing? What if it became a 50 degree curve, a 60 degree curve? What does that mean medically? Potentially some complications?
Dr. Anthony Petrizzo: So, again, we have a long history of understanding scoliosis. So, scoliosis, that term scoliosis was assigned, uh, by Galen and Hippocrates thousands and thousands of years ago. So we have a history. And x rays, we've been taking x rays for now, uh, almost 150 years. So we've been following this disorder for a long time, and what we've learned and this information that we've amassed - and again, this isn't just in the states, but this is worldwide - we have a really strong, worldwide international conference, which really helps us exchange ideas and follow these deformities and understand what we're doing and what other countries are doing and figuring out what's the best way to treat this disorder. But what's important to know is, when the curve gets really big, then the chance that it will continue to get big is very high. So once you get to these curves, and we're not talking ten degrees, we're not talking 20 degrees, but once we're at 50, 60 degrees, then that curve has already demonstrated to us that the chance that it's just going to stop is actually very low. And the chance that now you have the biomechanical forces of gravity, the chance that that curve is going to progress is very, very high. And we do know once those curves get to massive degrees and we're talking 70, 80, 90, 100 degrees, then you start to have problems in the region where the scoliosis is, which most commonly is in the thoracic region, where the heart and lungs are. So does that cause heart and lung problems? It does. At the large curves, greater than 90 degrees, we see changes in not only the heart, but the lungs as well. So we have pulmonary function studies that demonstrate significant disease and impairment. And we also see disease in evidence of right heart failure when these are not treated. So you don't want the curve to get to that much. So then how do we stop it? We do surgery to stop the progression. And that's really the best indication for scoliosis. Surgery is when there's been evidence that this curve is at a high degree and it's continuing to go. So every time I see the child, the curve is slightly bigger. The curve is slightly bigger, and once it gets to a number, and that number is based on many, many years of following these children and predicting and following their curves and associating the large curves with following them through and seeing that they continue to progress once that curve gets above 50 degrees.
Dr. Dennis Cardone: So that's a big number. 50, and I guess maybe 40 to 50 degrees, you know, is just a gray zone or following closely to 50. But again, a 50 degree curve, does that say to you, this is surgery? Or again, does it matter if it's a 15 year old with a 50 degree curve or now or a 19 year old with a 50 degree curve, you know, depending where they are in their growth chart and their growth plate? The translation of the whole question is, does every 50 degree curve need your surgical skills?
Dr. Anthony Petrizzo: Right, that's a great question. That's actually a phrase that I commonly share with parents, where it's like, when they're at that 40 degree, I'm worried about it, and I'm worried about it, and I'm trying to find where they are in their growth. Are they done growing? Are they getting any problems from his curve? Is it starting to give them some back pain? Do I think they're done growing? Are the growth plates closing on the x rays? Am I able to assess any other regions to see if the growth plates are closed, like the hand or the pelvis? And see how the child is tolerating that curve. So the forties I'm worried about. But once you get to 50, then the evidence is it's likely to progress. So, you know, that's a shared decision making conference and conversation that I have with my patients where, you know, let's say it's at 50. The kid's been, you know, stressing about this and worrying about this. The kid gets back pain with it. The child's not tolerating the cosmesis of it. That's someone at 50 that has, uh, the evidence that it's likely to progress, and that's someone that I'll consider doing a posterior spinal fusion with. If I have someone who doesn't bother them at all, it's 50 degrees, it seems like it hasn't changed that all that much. That's someone I continue to follow in the office. But again, it's a conversation. I mean, sometimes I'll have someone who's 50 and the parents are terrified of surgery. My concern is in my gut feeling, based on all these other things we spoke about, I think it's going to progress, but the family's really on top of things, and I know they're going to follow up in the office, and I know they'll be available to take another x ray and they're okay doing that. Then I'll see them again in three months and let it prove to us that it's going to progress. But really, the take home is the indication for the surgery's progression. If there isn't documented progression, that's something that you should be following until it proves otherwise.
Dr. Dennis Cardone: So if you're going to intervene with surgery, when is the best time to intervene? Is it - Does age matter? Does it matter if the growth plates have closed or done with their growth, let me intervene earlier on, meaning maybe late adolescence versus early mid twenties? Does that matter?
Dr. Anthony Petrizzo: So I'm a pretty conservative guy in general. So, you know, I follow these curves through a lot, and there are a lot of 50, you know, kind of right on the borderline of 50 degree curves that I follow, you know, in their, uh, teenage years. And, you know, these kids eventually go off to college and, you know, and I continue to follow, and they come back and visit me during the college breaks and we take x rays and see. So there's a lot of them that, you know, I'm measuring them and it's maybe going up a degree, but I'm not really sure. So I'll have them come back and, you know, say it is indeed, you know, progressing, but at slow rate and I wind up operating on them when they're in their twenties. Yeah, they tolerate that surgery quite well. And, uh, do they tolerate as well as they did if they were 15? No, I think the magic age is probably 15, okay. But 16 is absolutely fine. 20 is absolutely fine. They do well with that surgery during the adolescent phase. If it's something that for some reason we have to do later, like when they're in their thirties or forties or fifties, you know, that's also doable. Uh, we tend to not get as good a correction, and the recovery is a bit tougher and the risks are a little bit higher because now you're bringing into all your medical risks that become higher at age. Hypertension may now be present or cardiovascular disease may be present. So that carries with it a high risk. But the indication to rush into surgery for a curve that's not there doesn't justify doing that surgery earlier, if that helps answer the question.
Dr. Dennis Cardone: Absolutely. Pregnancy, is that a risk factor for progressing a curve? So someone's growth rates have closed. You talk about things really slow down, potentially may not progress anymore, or if it does minimally. Is pregnancy a risk factor for progression of a curve?
Dr. Anthony Petrizzo: If the person has completed growth and, say, the curve winds up being 30 degrees and then winds up becoming pregnant? No. The chance of that curve progressing is no higher.
Dr. Dennis Cardone: We won't spend too much time on surgery because so much to talk about. But maybe before we talk about non surgical treatment, we kind of went in reverse order just to close the surgical piece - very different now, right. In years past, I mean, you put down a big rod, a Harrington rod, and, boy, I'm sure you could just go on for hours and talk about surgery then and now. But maybe it's really become a very different type of intervention. Maybe if you could just simplify it for all of us, you know, the surgery for scoliosis.
Dr. Anthony Petrizzo: Sure. Just please don't let me, uh, discuss, you know, the topic in the middle, which is bracing. And bracing plays a huge role in taking these curves that we're worried about, you know, these curves that are big enough to be diagnosed with scoliosis, documented to be progressive, like, say, somewhere in the 25 to 40 degree range, those kids are braced, and bracing is a large part of my scoliosis practice.
Dr. Dennis Cardone: Great. Let's stay there. All right. We'll come back to the surgical part. So. Okay, so, treatment. Bracing. A big part of treatment. When does bracing come up in the conversation with families?
Dr. Anthony Petrizzo: Sure. So, again, to go over the numbers, because the numbers are very helpful, and they're very helpful for the parents because it kind of gets buy in for the parents because they're also speaking the same language, once we have an x ray, we measure the curve. So, once we get to 25 degrees in a growing spine, so, in someone that still has remaining growth, they are candidates to be braced. And the brace is a custom molded brace that gets fitted to the child based on the curve. So if they have a curve that's in the thoracic spine, then the brace has to go all the way to the underarm area and cover that and span through the entire region of that brace. So they're typically thoracolumbosacral orthosis, or TLSOs. And it's interesting because, historically, scoliosis was treated at different regional children's hospitals across the country, and they all developed their own variations of bracing. And the braces are named for the regions in which they were developed. So Boston has a brace which is probably the most commonly used. It's certainly the most commonly used in the northeast. The Boston brace is really a custom molded thoracolumbosacral orthosis, or TLSO, and that's to be worn once the diagnosis is there and the magnitude of the curve is there, that's to be worn full time. So when we say full time, what's a full time brace? A full time brace is 23 hours a day. So you're wearing it basically, for the most part, all day, with the exception of personal hygiene, taking a shower, and if your child's in gym or sports, you know, obviously they take it off for the gym, in the sport, but otherwise, they wear it full time. And why do they wear it full time? Because we did studies, and the studies were repeated and replicated. We have multi center studies that show that if you wear the brace full time, you'll do better than if you wear the brace part time. And, again, the goal of the brace is to stop the curve from getting to those big numbers, and those big numbers are the surgical numbers, just to give you that number. It's about 50 degrees.
Dr. Dennis Cardone: So you would start, so typically, again, you get concerned if a curve is progressing, and once it hits, say, around that 25 degrees is where you really start having a serious conversation about growth.
Dr. Anthony Petrizzo: If they have remaining growth, yes. Yes.
Dr. Dennis Cardone: And most bracing is recommended 23 hours of the day. And then what's a typical duration in terms of one year, two years, five years of bracing? I know, again, depends on how much growth is left. But is that right? Is that the answer?
Dr. Anthony Petrizzo: It's totally based on how much remaining growth. So if I see a, you know, again, we're starting to get into some other diseases, but if I see a seven year old, then that seven year old's gonna have to wear that brace until they're done growing, because we know that growth is the single most important determinant in the progression of that curve.
Dr. Dennis Cardone: All right, how effective are these braces?
Dr. Anthony Petrizzo: Yeah, so that's a common question, because once you show them these kids…
Dr. Dennis Cardone: Doctor Petrizzo, you better prove that this brace is worth it. If I'm gonna have my son, daughter wear this for 23 hours for five years, right?
Dr. Anthony Petrizzo: Uh, that's right. And it is hard, and it's a hard conversation to have in the office. But again, you know, from seeing the end result of these curves and significant scoliosis and the surgery and the recovery and the risks that go along with it, you know, it's something that I try and spend some extra time with the family going into. The brace does not help save everybody from needing surgery. If it did, I wouldn't have to do surgery anymore. But if I have ten kids with braceable curves, so those are curves, you know, that are greater than 25 degrees in remaining growth, I could save three of them from needing surgery. And, you know, if that's your child, you'll do it.
Dr. Dennis Cardone: Yeah. The interesting part, we're going kind of backwards, but over the past years, and you tell me maybe five to ten years, there's also been some evidence in some literature that backs up a certain specific type of physical therapy for curves. And it's kind of interesting because I remember when I was going, doing my training, it was, and again, correct me if I'm wrong, but I'd always hear, well, in Europe, they do physical therapy, they do this and this. But, you know, we don't do it here because we didn't have the evidence or the studies maybe weren't done. But now, I guess there have been some better studies that show that there is, again, a very specific type of physical therapy rehab exercise program that has been shown to work. And how does that come into play in relation? When do you talk to patients families about that? And in terms of that, in conjunction with bracing?
Dr. Anthony Petrizzo: Yeah, that's a great question. Geez, I need an hour for that one. But it's a wonderful topic because it is something that my patients are interested in. And you hit the nail right on the head. You know, historically, the scoliosis research society had published a study in the seventies based on exercise, and it showed that physical therapy or exercise played no role in progression. But if you really look at that study, I mean, you know, what exercises and sports activities were we doing in the seventies? Right? And again, uh, we're facing a population of mostly females, so sports and exercise was much less common back then. That particular study had poor follow up. Most of the participants in the study did not complete the exercise that was requested. So I think we really didn't do a good job back then of really analyzing what specifics we could do from a physical standpoint to try and mitigate scoliosis. And you know, we actually got much better. Our surgeries got much better as a result of that. But, you know, as you alluded to, uh, in Europe, where they were doing a lot of physical therapy and they had specific schools of particular therapies, one that's very commonly, uh, referred to as Schroth therapy, which was started by, uh, Katharina Schroth in Europe, who had published wonderful results of scoliosis-specific exercises to prevent scoliosis. And these exercises are different than, you know, that study in the US on physical therapy for scoliosis. These were exercises which focused on stretching the concavity and strengthening the convexity, also postural awareness. And this is kind of morphed into a whole separate discipline. Instead of calling it Schroth or another particular organization which fostered and promoted the treatment for scoliosis, we refer to them more commonly as scoliosis specific exercises. And that has been gaining ground as we've become more organized as an international body of trying to understand scoliosis. And we have numerous multicenter studies going on now where we're really trying to find what the sweet spot is for that curve. Is that somewhere where we should be starting that at 20 degrees, or is that something that we could start to stop a curve from getting to 20 degrees in our high risk population? The scoliosis specific exercises definitely plays a role at this point. As far as evidence based medicine, it's not high enough to replace bracing. So it's kind of, for me, it's the population of kids that I see in the office that carry the diagnosis of scoliosis. So the curve is greater than ten degrees by definition. And treatment algorithm for that patient is usually okay - you have remaining growth, you have the diagnosis of scoliosis, I'm going to follow you up in, say, six months. And then and the family's like, well, what else is there? What else can I do in the meantime? And I refer to them for these scoliosis specific exercises.
Dr. Dennis Cardone: So also, again, family dependent, maybe, and, um, a little bit, and very individual. I mean, it's interesting about scoliosis compared to many other areas. You know, everyone always thinks everything's so black and white, I guess, treatment. But, you know, especially when it comes to scoliosis, it's really the whole picture that you're taking, you know, looking at age, looking at gender, looking at what the curve has been doing, you know, what's the history of this curve, uh, in terms of your recommendations of treatment today, and then, of course, looking forward over the next several years, potentially. Quite interesting.
Dr. Anthony Petrizzo: Yeah, but it's interesting, and it's part of medicine that I really enjoy because it's the true doctoring. So, you know, we're sharing information with the family and, you know, instead of dictating, well, you're a 30, therefore we're doing this, or you're a 50 degrees, therefore we're doing this. It's more of a discussion to say, hey, this is what I worry about. Look at him or her. You know, there's significant remaining growth, and, you know, look where the curve is now. And let me show you the x ray last year. And, you know, I'm going to put this side by side so you could see the difference. You know, like, I'm worried about this, and, you know, and that's kind of how you get buy in, but you also get a family that understands this. And, you know, to me, that's the most valuable part of medicine.
Dr. Dennis Cardone: Yeah, I mean, really true shared decision making. And the time that I do, you know, in the past that I've done some pediatric orthopedics, you know, it's just extraordinary how adaptable many times, you know, kids and adolescents and children can really be to treatment and understanding, they're just, you know, they're just remarkable sometimes.
Dr. Anthony Petrizzo: Sure. And just to take that one step further, when we say, you know, when you had asked before, do you operate on every 50 degree curve? I don't, and the reason why I don't is because, you know, uh, I'm a spine surgeon. I also see adults with spinal pathologies and, you know, and I see a fair amount of adults with 50 degree scoliosis, and I say, oh, my goodness, did you know you had a 50 degree scoliosis? And they say, yeah, I've had that since I was a teenager. And I say, does it bother you? And again, sometimes the education goes the other way, where the patients are teaching me, and they say, no, it doesn't bother me at all. I play sports, I ran a marathon, I have three kids, I exercise, I stretch, I'm flexing. And that helps me learn, and that allows me to take that information to the next patient.
Dr. Dennis Cardone: And I think that's a great point you bring up, and, uh, maybe towards the end of our conversation is scoliosis and activity. So I guess you would say there's really - You have scoliosis? Okay, but listen, the green light is on. Do whatever you want. Is there a time ever that you restrict activity?
Dr. Anthony Petrizzo: No. No. In one word, no. You know, it's interesting because the very common question that I get is when the child has surgery. Historically, when we would, um, when we would do surgery in scoliosis in the seventies and eighties, you know, they would be restricted forever. And that was the common thing. It's like, well, you know, you have metal in your back, you have hardware, so, you know, you can't play sports and you can't be active and you may wear your back out. So, luckily, we have history, and we have the history of taking these kids that were fused in the seventies and eighties and, uh, even earlier in the thirties and forties, and now they live their life, and we get to see how they do. We did a study here about, uh, ten years ago where we had, uh, the kids return to competitive play. So these are kids we operated on, and they returned to competitive play, and they were able to compete at the same level of performance that they did before they had the surgery. So, uh, I don't even restrict kids after surgery if they want to resume sports and activities.
Dr. Dennis Cardone: Doctor Petrizzo, great stuff, great information. Maybe just for our listeners, I don't know if there's anything that you would say to, uh, parents who maybe suspect, I expect, that their child has some kind of curvature or maybe has scoliosis, maybe in just some, um, parting words of wisdom that you would say to parents.
Dr. Anthony Petrizzo: Sure, yeah. Thanks for that opportunity. You know, basically, the angst of the disease is very often when parents come confused and they say, you know, I don't understand. I saw the pediatrician, they said, she's fine. And then I saw some other doctor, and they said, it's wrong. And then I saw the chiropractor and he said he's going to fix it. And then I saw an orthopedist who doesn't do spine surgery, but he said, this is something that you definitely need to see a spine surgeon for. And I'm just so confused because I'm getting all different answers in that situation. I think the most helpful thing that you could do is get an x ray, document what the curve is, get the numbers, because the numbers are very clear in helping us guide treatment. So if you're not comfortable with the information that you've received, get a second opinion and make sure it's somebody who treats this disease and sees a fair amount of it as part of their practice. And I think you'll see that the treatment for scoliosis is a fairly clear cut algorithm based on numbers and based on growth. And I think if you get all of that together, I think there'll be a lot less ambiguity in your assessment and what to do as far as treatment.
Dr. Dennis Cardone: Fantastic. You've been listening to the Bone Whisperers brought to you by the Department of Orthopedic Surgery at NYU Langone Health. And joining us, Doctor Anthony Petrizzo, chief of orthopedic spine surgery at NYU Long Island, associate professor in the department of Orthopedic Surgery here at NYU Langone Health. And I'm Dr. Dennis Cardone, and we all really want to thank you so much for joining us and really been a pleasure for us to have you with us for this webinar series. Thank you so much for joining us.
Dr. Anthony Petrizzo: Thank you.
Narrator: The Bone Whisperers is a co production of NYU Langone Health and SiriusXM. The podcast is produced by Scott Uhing. Sound design by Sam Doyle. SiriusXM's executive producer is Beth Ameen, and senior operations manager is Emily Anton. Narration and additional sound design by Michael Luce. Don't miss a single episode of the Bone Whisperers and subscribe for free wherever you listen to podcasts. To hear more from the world-renowned doctors at NYU Langone Health, tune in to Doctor Radio on SiriusXM on channel 110 or listen anytime on the SiriusXM app. For the Bone Whisperers podcast, I'm Michael Luce. Join us next time for the latest advances in orthopedics on the Bone Whisperers.