Dr. Purnendu Gupta explains how scoliosis is evaluated and treated in children in various age groups.
Melanie Cole (Host): Scoliosis is a common condition that affects many children and adolescents. However, in some cases, if left untreated, scoliosis can get worse and may cause chronic back pain and other issues down the line. My guest today, is Dr. Purnendu Gupta. He’s the Chief of Staff and a Pediatric Spine Surgeon at Shriner’s Hospital for Children, Chicago. Welcome to the show, Dr. Gupta. It’s such a pleasure to have you with us, today. Explain to the listeners what is scoliosis and do we know what causes it?
Dr. Purnendu Gupta (Guest): Great question, Melanie. Scoliosis is the curvature of the spine, and that implies that the spine is curved and also is rotated. It happens in all ages, and we treat patients from infants, toddlers, teenagers with scoliosis for a host of reasons. It does have a genetic predisposition, but there are different age groups that it can affect. It’s a variety of different genetic origins, and those genes continue to be mapped, and a lot of great research is happening to understand this better.
Melanie: How do we know if – would you be able to see in utero or once the baby is born, can you see this curvature or is it something that develops over time, and you might notice when a child starts to walk or play sports?
Dr. Gupta: You can see it from newborn age to the age when they start to walk. I think that usually what the parents will notice is that the spine appears curved when looking at the child from behind. I think that it’s not always readily apparent at first, but as the child grows, if there’s a curve, the curve possibly can worsen and then the parents will notice it.
Melanie: If parents do notice, they bring them to their pediatrician or to a specialist – is there screening, Dr. Gupta? Is there some sort of screening that you can do for children with scoliosis to find out beforehand?
Dr. Gupta: Sure. I think the first thing is always bringing the child to the pediatrician for a good evaluation. Most pediatricians are pretty attuned to picking up scoliosis, and the easiest way to do that in a child that can stand is to help them to bend forward and look at their spine from behind. What we can see is there’s a mismatch in the height of the rib cage, or there is asymmetry in the truck area. If it’s a child that’s sitting or not quite crawling yet, well, you have to sort of very keenly look at their spine to pick up on it.
There are screenings that are done for scoliosis. Many years ago, we had a school screening program that was in many states. That is not as robust as it used to be, but schools still do some screenings, and many times, they’re done around athletic physicals. I think this is primarily the mechanisms of picking them up. We have this very simple device called a Bunnell Scoliometer, which we place on the child and it shows the tilt in the trunk to determine if there’s scoliosis. Believe it or not, there is an app for that, as you might imagine. There are lots of ways to pick that up, and as I mentioned, if there’s ever a question, it’s best to bring the child into the pediatrician, and then they can refer them on to a specialist.
Melanie: Before we discuss treatments, Dr. Gupta, what doesn’t cause scoliosis? Break up a few myths for parents. Does a heavy backpack, or their shoes, or limb length discrepancy, or any of these other things – poor sleeping, poor posture – are there any of these kinds of things that we can look to as a myth, and you can say, “You know what? That’s really not what causes this.”
Dr. Gupta: I think you have very good points. Simply slouching, or carrying something heavy, or always carrying it a certain way is not going to lead to the development of scoliosis. There definitely is a genetic predisposition, and so I don’t think those things will cause scoliosis. Leg length inequality can make someone appear as if they have scoliosis because their pelvis is tilted and as a result, they end up having trunk asymmetry. We're very attuned to that when we examine patients who have scoliosis.
Melanie: So the first line of defense, if you determine that a child does have this – depending on the age of the child when you do diagnosis it, what do you do first for them?
Dr. Gupta: I think the first thing we do if a patient comes to see me in the office – obviously a good, thorough clinical examination and included in that is a good neurologic examination. Those are key in terms of our initial evaluation. To make the diagnosis, then we end up doing X-rays. Here at Shriner’s, we have EOS Technology, which is a way to do X-rays with less radiation for out kids. I’m pretty excited about that in our system, but yes, X-ray is the key way to make that diagnosis finally.
Melanie: And then what factors might influence your recommendation that the child needs surgery or casting or bracing? Speak about some of those different interventions you might consider.
Dr. Gupta: There is a whole spectrum of treatment that we have, and it all depends on the age of onset, on the type of scoliosis, and the potential the child has for growth. Let me start in the infant group. When infants have scoliosis, and we notice that it’s progressive, we typically look at a very specific measure called the Meta Angle, which helps us to determine if scoliosis may be progressive in addition to looking at multiple X-rays in sequence to see the progression.
In infants, at Shriner’s hospital, we do Mehta Casting – Mehta-Cotral Casting. That involves helping to straighten out the spine by holding it in a cast, and usually, that helps the spine to grow straighter. That’s one great way to help children, and we have a big Mehta-Cotral Casting Program here at Shriner’s Hospital, in Chicago.
As we go to the next age-group, as these kids get bigger, they’re really not amenable to being in a cast and usually, that’s when we consider bracing. Bracing is probably one of the mainstays of treatment for scoliosis in almost all age-groups from juvenile to adolescents. It has a wonderful track record, and here at Shriner’s, we’ve been in a multicenter national trial to help prove the efficacy of bracing. As the curve grows and if the child has a significant potential for growth, one of the mechanisms we have of treating the growing child, is to place rods that can grow with the child by adjustments that we do in the rod.
Years ago, we had to take children back to surgery once, maybe twice a year to lengthen the rods. Currently, we have a new device, which is a magnetic growing rod. We are able to have the child come back to the clinic, and we have a special magnet machine called the ERC, which helps to lengthen the rods when the child is in the office, simply laying on the exam table. It’s a phenomenal way to help the growing children with scoliosis and avoiding multiple surgeries. They may need other surgeries too -- once the rod is long enough and they’ve grown past the potential of the rod or if there is some problem with it -- but this, I think, has been one of the greatest advancements that we have had in the field of treating growing children with scoliosis.
And then ultimately, down the road as children grow and get closer to being completed with their growth, that’s when we offer them surgical fusion in which we try to correct the amount of deformity, and we’re able to prevent further progression and also correct the deformity on a more permanent or long-term basis. That would be spinal fusion with the instrumentation.
Melanie: Dr. Gupta, as children grow we can explain a little bit about procedures, interventions that we do for them, but like for the babies with casting – what do you tell parents? How difficult is this to raise a child that’s going through some of these procedures? Are they amenable? Do the children just sort of take to these things? What do you tell parents about dealing with those kinds of things?
Dr. Gupta: Sure. I think that at first, it’s very daunting for patients – for families and parents to think about having an infant in a cast. The surprising thing is that kids are very resilient and once they’re in the cast, they recognize this is what they have, and they kind of continue on and continue to develop. It’s hard on the parents. I think in some ways it’s harder on the parents than the children, but they adapt beautifully and do respond fairly well. Obviously, as they grow older, they’re not as – they’re a little more resistant to casting, but they continue to develop, and grow, and learn to crawl and walk. Although, it does offer some setbacks, but I think a big advantage is that many times, we’re able to treat these infantile curves, get them to remodel and grow straighter. Sometimes, in a lot of cases, we have casting successes with those children that eventually go on to have a brace or maybe be out of a brace. It depends on the curve and the patient.
That would be the infantile group. When it comes to the bracing, which is the next step of treatment again, kids do adapt to bracing. One of the things that we encourage the parents to do and the child is to be active in some type of activity, and we encourage the patient to be out of the brace for those activities, so they can continue to grow and develop physically as well as psychosocially be out of the brace for special events. It’s a give and take, and I think we have to be very thoughtful as we do the treatment.
When it comes to the growing rods or the magnetic rods as we often use nowadays, we initially have a time period where we want them not to be active while the spine is healing from the initial procedure. Once that initial healing takes place, then we encourage them to be active, but we don’t allow them to do any contact sports, tumbling, gymnastics, or use of a trampoline, for example. I think down the road, when and if the child needs a fusion, those restrictions are similar, but as soon as they heal from the fusion, we try to get them back to their activities so they can participate and again, grow, and develop physically and psychosocially.
Melanie: What a great answer because that was going to be my next question was about activity, and exercise, and the psychosocial aspects of going through these treatments as they grow. What about physical therapy and scoliosis-specific exercises? Can they do those? Are there some that they can do at home? Do they work with a physical therapist at Shriner’s?
Dr. Gupta: We do have a 3D Scoliosis Exercise Program, and I think it’s a wonderful adjunct to the bracing – I think the bracing is still necessary, but I found it to be very helpful. What it does is it helps to encourage the child to strengthen their trunk musculature, be more aware of their posture, and also, to strengthen those postural muscles. I have found it incredibly helpful and particularly helpful when children are weaning out of the brace because it gets them to be more aware of their posture and their position and keep their muscles stronger for a lifetime. I think it’s very helpful for them to work with a physical therapist. It’s not one of those things that I would recommend giving a sheet of exercises. I think working with the therapist actively is really helpful for them to learn these scoliosis-specific exercises. We do have a nice program here at Shriner’s, for those 3D Scoliosis Exercises.
Melanie: Wrap it up for us, Dr. Gupta. In summary, what would you like parents to know about scoliosis, getting their child screened, what they should do if they notice some of the symptoms that you’ve discussed, and tell us about your team approach at Shriner’s Hospital for Children, Chicago?
Dr. Gupta: First and foremost, I would always encourage patients once they’ve recognized that there is a concern to bring it to the attention to the pediatrician and then seek opinions from a specialist is the scoliosis is significant. I know it’s overwhelming, but they should remember that there is a host of people out there that can help them. At Shriner’s, we do have a team approach. We have a group of spine surgeons; we have wonderful physical therapists, occupational therapists, and our team approach extends to the social service aspect of this too because there are other issues that come up with children who have surgery or need braces and different things that we can really embrace the child and try to help the child and the family to go through this experience. The good news is that we have treated scoliosis for a long time and have had this program at Shriner’s for a long time and can give some depth of experience and outcomes to those families and also give them people to talk to as a network as parents so they can cope with this all better.
Melanie: Thank you so much, for being with us today, Dr. Gupta. It’s great information. This is Pediatric Specialty Care Spotlight with Shriner’s Hospital for Children, Chicago. For more information, please visit ShrinersChicago.org, that’s ShrinersChicago.org. This is Melanie Cole. Thanks for listening.
About the Speaker
Dr. Purnendu Gupta
Purnendu Gupta, M.D., is chief of staff and a pediatric spine surgeon at Shriners Children's Chicago. He is experienced treating scoliosis in children of all ages using the latest surgical and non-surgical techniques.
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