Dr. Purnendu Gupta discusses the extensive spine care at Shriners Children's and serial casting for infantile scoliosis.
Melanie Cole (Host): Welcome, today we’re talking about Mehta/Cotrel castings in infantile scoliosis and my guest is Dr. Purnendu Gupta. He’s the chief of staff at Shriner’s Hospital for Children Chicago. Dr. Gupta, I’m so glad to have you with us again. Tell us a little bit about the history of body casting, what we’ve done previously and what’s different now.
Dr. Purnendu Gupta (Guest): Sure, so originally the Mehta casting or Mehta/Cotrel casting was started by a famous orthopedic surgeon in the UK, and her name was Mehta as you can imagine. In fact this lady had scoliosis, so she was very passionate about her care for children with scoliosis, and as you know, the reason for the evolution of casting is that infants with scoliosis are very small, so we don’t have the usual armamentarium of surgical techniques and instrumentation that we might need to use for a patient who’s older, so we really have to figure out ways to help direct the growth of the spine to help correct the curvature, and so the casting is in that first to mold and help shape that growth of the spine in an effort to get that curve, or the scoliosis controlled.
Host: Well then who is body casting a reasonable treatment for, and at what age are most patients treated with it?
Dr. Gupta: Sure, so it depends on the series that you look at. We have a long running series of patients who were treated for Mehta/Cotrel casting, the average age of our child that goes into a cast would be probably about 1.5 years or 18 months. What we’re looking for is children that have had progression of their curvature, their curves are 35 degrees or greater, and there’s some very fine measurements that we do to determine if they’re appropriate for casting. Those are some of the indications that we use to determine if a child would need a cast. As you know, the incidence of scoliosis in this group is less than 1% of all patients who have idiopathic scoliosis, but infantile scoliosis is the spectrum if you will with disease. So in addition to having idiopathic scoliosis, they can have other syndromes, or connective tissue disorders, or chromosomal abnormalities that can lead to the development of scoliosis.
Host: What a great description. So then tell us about the Mehta/Cotrel casting, what is its growth guidance casting? How does it work?
Dr. Gupta: So let me tell you a little bit about how we apply the cast, and you’ll get a sense of how we guide the growth. So the neat thing about the Mehta/Cotrel cast is it helps to de-rotate the spine. As the curvature develops, the spine tends to rotate. So what we do is we apply the cast on a very special frame called a Risser table and we apply gentle traction to the infants. Our preference is to do it under a general anesthetic, and as we apply the casts, what we do is we put a de-rotational force on the spine. It’s not just about pushing the spine over, it’s actually about de-rotating the spinal elements. We found that the cast is the most effective way to apply that de-rotation to the spine where a brace cannot put that kind of force and in that direction. So once you have the child in traction and you apply the cast and de-rotate the spine, that helps to hold the spine in a straighter position. Once we have held the spine in a straighter position, it gives an opportunity for the growth on the two sides of the vertebral to equalize because as the scoliosis develops, the vertebral bodies, which are rectangular, start to become trapezoidal. So when we de-rotate them, and correct the curvature, it gives those bodies that are misshapen and are smaller in length to start to grow and to reshape.
Host: It sounds complicated, but the way you explain it, I do understand it and I can picture it in my head while you explain it Dr. Gupta. So tell us a little bit about the length of time it takes to see results. I imagine that’s one of the questions most parents have.
Dr. Gupta: That’s a great question. So for every child, it’s somewhat unique depending on the parameters that we start with, but as you know when the kids are younger, these infants they grow faster. So if they’re less than 35 months, or less than 3, which is typically the case, we will apply the cast every 2 months and that helps us to keep up with their growth and also to better reshape the spine. If they’re older than that, then we do casting just every 3 months. Now it can take as little as 5 casts or it could take as much as 15. We’re very thoughtful because what we typically do is try to see if there is a response and improvement of the curvature. If there is an improvement, then we have to sort of understand why and also look for other reasons why if that’s the case. If there is an improvement, what we see is there will be potentially 5 or 10 degrees of improvement between castings, and while that’s not always the case, the first landmark is that we’re preventing the curvature from getting worse. So that’s how we sort of assess how kids are doing and how they’re improving, and that’s how we determine if the cast is effective.
Host: Is it uncomfortable? What’s it like for the child?
Dr. Gupta: So it’s fascinating. We as adults are not very adaptive [laughter]. Kids on the other hand –
Host: No certainly not.
Dr. Gupta: Kids on the other hand adapt very readily. It’s interesting we have videos with these kids playing Legos on the floor, doing different activities. Believe it or not, even trying to tumble in the cast, which you can imagine could be a little bit of an adventure, but the reality of it is, is I think the parents can facilitate the activities of these kids, and once they’re in the cast we let them do pretty much what they reasonably can with the exception of getting the cast wet.
Host: Oh that’s interesting, so what happens then? You take it off so the kids can shower or swim or do therapy or any of those things? How does that work?
Dr. Gupta: Yeah no if the cast is wet then it would have to be changed, but our usual plan, at least in Chicago at our hospital, is to have them out of the cast for a week before the next cast application. So many times either they’ll have the cast removed locally or we’ll have them come to the hospital, they’ll remove the cast, and they get a little cast holiday, and then the next week the cast is applied.
Host: I love how you said a little cast holiday because I’m sure they feel that movement when it’s removed for just a little while. Would you use some other adjuvant therapies along with the casting, or if the cast is off are they then doing physical therapy? What else goes along with it?
Dr. Gupta: So typically we don’t do any fancy physical therapy when they’re out of the cast. We just let them play and be kids, and I think right now there’s not a lot of data on physical therapy or those types of modalities in infantile castings that I can really refer to or quote and it’s not part of our routine practice.
Host: So what would you like parents to take away from this episode, Dr. Gupta, about the Mehta/Cotrel casting if their child does have infantile scoliosis and the treatment options that you have at Shriner’s Hospital for Children in Chicago?
Dr. Gupta: I think that this is a very effective method of helping to control the curvature of infants with scoliosis, meeting the right criteria, and many times we can sort of help them to improve the curvature for the right indications, and so it’s a really fantastic way to treat them, and I think it’s most effective with children who have the idiopathic infantile scoliosis. It’s harder to predict on children who may have a syndromic reason for the scoliosis or potentially genetic reason if you will, but none the less, I even find in those cases that many times the cast is the best alternative we have to help prevent curve progression. So it can really be a win-win.
Host: Well it certainly sounds like that, and what an interesting topic we were discussing today. Dr. Gupta, thank you so much for taking the time and coming on with us to explain this type of body casting and who it might be beneficial for. This is Pediatric Specialty Care Spotlight with Shriner’s Hospitals for Children Chicago. For more information, please visit shrinerschicago.org, that’s shrinerschicago.org. This is Melanie Cole, thanks so much for tuning in.
About the Speaker
Purnendu Gupta, M.D.
Purnendu Gupta, M.D., is an orthopedic spine surgeon and chief of staff of Shriners Children's Chicago.
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