Bob Underwood, MD (Host): Welcome to Pediatric Frontlines from Shriners Children's. I'm Dr. Bob Underwood, and today we are discussing cutting edge innovations in scoliosis care with Neurosurgeon and Chief of Staff from Shriners Children's, Philadelphia. Dr. Amer Samdani welcome. Thank you for being here today.

Amer Samdani, MD: Thank you for having me.

Host: So I'm really excited to talk about the treatment and research for scoliosis and exploring how advancements are revolutionizing spine treatment for young patients today.

Amer Samdani, MD: And I'm certainly very excited to relay my understanding of these advancements.

Host: You're quite the expert for sure. So what are the latest innovations in surgical techniques for scoliosis treatment? How do these improve patient outcomes compared to some of the traditional methods?

Amer Samdani, MD: Absolutely. Traditionally, for the past 50 years, the standard of care for scoliosis treatment has been a spinal fusion, and spinal fusion works very well for correcting the spine. Essentially, you're using pedicle screws and a variety of different rods to correct and straighten the spine. The downside is, as you can imagine, those rods being stiff, you're going to have some loss of mobility. So the biggest advancement for children with scoliosis with respect to treatment has been vertebral body tethering, where rather than relying on a rod to correct the spine, we rely on a rope, a flexible rope, a tether that will allow the spine to correct as the child grows.

Host: So you and Shriner's Children's were integral in the development and FDA approval of the vertebral body tethering or VBT. Can you describe the origin's fundamental principles of this procedure and in which types of scoliosis cases is it a treatment option?

Amer Samdani, MD: I can tell you the driving force for us were parents of children that we were seeing that had scoliosis. They would come into us, as adolescent idiopathic scoliosis, the most common type of scoliosis seen in children has a very strong genetic predisposition, and they can be passed on from mothers to their daughters. And these mothers would come in and they'd say, we need an alternative. I had a spinal fusion done 20 years ago, but I want something different for my daughter. And that was really the driving force. And there was plenty of translational research that had been conducted in the laboratory that showed that if you take the convexity of a curvature ie, the side of the curvature, that has grown more than the contralateral or the concavity side; and according to Hueter-Volkmann principles, if you put compression on that convex side, you can inhibit growth and allow the other side to catch up. So that was really the genesis of vertebral body tethering.

Today, we have really evolved it. And learned a ton about where it works and where it doesn't work. I would say that the area that it works the best in is a child that has growth remaining. So this would be a young girl anywhere between 10 to 13 years of age. Boys, as we know, can grow up to 15 or 16 years of age, that have a flexible curvature, because if you have a very stiff curvature, it's not going to be amenable to having a tether hold its correction.

So ideal candidate, child that has growth remaining with a flexible curvature.

Host: So given your expertise and your extensive experience, what does current research suggest about the long-term effectiveness, durability, and potential complications that are associated with VBT.

Amer Samdani, MD: Absolutely, and there's a few things that we absolutely know. We know that anytime that a child grows, whether you do a spinal fusion or you do VBT, there's going to be a higher reoperation rate. It's because we can't control, we don't have a great understanding of how much a child is going to grow, and more specifically, how much of that region of the spine that we're treating is going to grow.

In an ideal world, and this is coming down the line, we're going to be able to use predictive analytics and AI to really help us determine individually for each child as to how much they're going to grow in a specific region and how much tension we need to apply to allow them to grow. So the latest research suggests re-operation rates are going to be higher than posterior spinal fusion, but motion without a doubt. We've done studies at our hospital where we put children through a motion analysis laboratory, and we've clearly shown that rather than a fusion, particularly in the lumbar spine, a tether is going to preserve motion to a much larger extent than if those children had actually had a fusion done.

Host: That's fascinating. We're going to talk about this motion analysis here in a little bit because I think that's really fascinating stuff. So what are some of the recent advancements in non-surgical scoliosis treatment? What are these options and when should they be considered?

Amer Samdani, MD: Dr. Underwood, that is a fantastic question because the best surgery is no surgery. Our job is to do everything we can at the Shriners Hospitals for children to try to avoid surgery, and I'd say the vast majority of patients we're successful in. So if you're able to catch a curve early. So the first thing is early detection, really raising awareness amongst pediatricians and parents who may have scoliosis to watch their children. The second option is early bracing. We know our government did a study. We spent $10 billion. We published it in the New England Journal of Medicine in 2014, that if we can get the child to wear a brace, they're going to have a very good chance that that curve's not going to progress.

So aggressive bracing. And then secondly, if we can combine that with scoliosis specific exercises, which again, research has shown if a curve is small enough, if you combine that with bracing, you'll have a good chance of at least halting progression. So those two areas need to be really looked at hard prior to even considering anything surgical.

Host: Wow. And so when patients and families are discussing these options with their healthcare providers, how can they evaluate the potential benefits or risks of these emerging scoliosis treatments?

Amer Samdani, MD: Yeah. So I would say the first and foremost is we have to consider what the risks of our intervention is. So the risks of scoliosis specific exercises, other than the time commitment is low. So even if we can't find level one data to support scoliosis specific exercises for a spectrum of curvatures; I highly encourage our parents and patients to participate because you can only get a benefit.

Similarly with bracing. Now bracing studies have shown does have a psychosocial negative impact on patients, but perhaps we can start with nighttime only to really make sure that a child, to get them more accustomed to it. So again, non-surgical options. Now as we start getting into these newer technologies such as vertebral body tethering; the most important information that I would tell parents is firstly to get multiple opinions. You want to get opinions from surgeons or caregivers that are offering not just one option, but the whole spectrum of options. And then secondly, we have to objectively look at the data. And fortunately, there've been over 250 publications on VBT in the last four years or so.

So there's enough data out there where we can decide if it would be ideal for a particular patient.

Host: So there's really a patient participation in the choices that are out there. And so let's talk about teamwork. In what ways are interdisciplinary teams of various healthcare specialists improving scoliosis treatment and patient care?

Amer Samdani, MD: Yes, absolutely. It has to be an interdisciplinary approach, ideally under one roof. So there's great communication, and again, I'm very proud that at our Shriners hospitals, we do have that within one roof where we have the surgeon. But I'd say the surgeon, especially early on, is going to play less of a role.

You're going to have the orthotist. The person that's going to be making the braces for our patients. You're going to have our physical therapists really developing a good relationship with them. You're going to have our advanced care professionals who are going to provide care on a very regular basis to patients, our nursing staff, who are going to really try to make sure that we optimize non-operative care.

As we move into the operative realm, then of course that's where we'll have, intensivists and anesthesiologists and neuromonitoring professionals, if you are one of those small percentage of patients that does need surgery, to make sure that surgery is done in the most efficacious and safe manner.

Host: And that's awesome. It's really patient-centered, when you get that interdisciplinary team who's working with the patient and the family, they really get to know each other at that point, which also makes it much more comfortable for the patient going through the process. So how do primary care physicians best coordinate care with orthopedic specialists and other interdisciplinary teams for the best outcomes?

Amer Samdani, MD: Yes. So communication is going to be first and foremost, and I would say that error on the side of referral, because nowadays we have such low dose radiation options. In the past, these children were getting multiple x-rays over years for follow up. Now there's multiple x-ray modalities and algorithms and machines that can really decrease the amount of radiation that a child receives.

So I generally tend to send patients, especially if there's any discrepancy that's seen on a physical examination. Typically, our primary care physicians are going to be alerted for potential scoliosis from either seeing uneven shoulders, hip asymmetry, or during the Adams forward bending test where a child is asked to lean towards the floor, and you'll see the rotation in the spine that's measured through a scoliometer greater than seven on that measurement. I would say that have a low threshold for an early referral. Sometimes it may not even be scoliosis, which is great, but if it ends up being scoliosis, we can initiate some of the non-operative therapies early and that's when they are most beneficial.

Host: So I said we were going to get around to this motion analysis, and so Shriners Children's has established the largest global network of pediatric motion analysis centers. How does the data gathered through this network influence clinical decision making for research initiatives for scoliosis? But I think first what is a motion analysis center?

Amer Samdani, MD: Yes. So essentially it helps us to understand functionally what we are doing to our patients. We can look at health related quality of life measures. I think that's a reasonable assessment, but they're not granular enough to give us an assessment of how a child is participating, let's say, in their sporting activities or their daily activities.

These health related quality of life measures are going to be just higher level measurements that have ceiling effects. So we need to be more granular. I would say the x-ray, something that as a surgeon we focus perhaps the most on, may even be the least actually valuable piece of information because that doesn't necessarily correlate with how a patient is functioning or how a patient is feeling.

And that's where motion analysis comes in, where we're able to place markers or go markerless and have the patient do a variety of different activities and be able to assess how they did them before surgery and how they did them after surgery. What we've done is we put all of our patients, whether they're getting a spinal fusion or whether they're getting a vertebral body tether through a motion analysis center, and a motion analysis laboratory and assessment because then they can see unique to themselves, as to how they were doing before surgery, and perhaps they need to work harder on being able to flex at the hips or being able to rotate and we can prescribe different therapies and exercises for them to overcome some of the limitations that they have. Of course we've gone a step further where we've been able to now analyze that data in aggregate and understand how spinal fusion at certain levels will compare with the vertebral body tethering, and there's no doubt about it in the motion realm, as you would expect when you've got a flexible tether, patients retain a vast majority of their motion after surgery.

Host: Yeah. And so let's move on to the hot topic I think everywhere. Artificial or augmented intelligence, it's rapidly emerging in healthcare. So how is AI specifically contributing to scoliosis diagnosis, predicting progression, and helping us plan treatment at Shriners Children's.

Amer Samdani, MD: So there's several different areas. Firstly, right now, when we think about the patient in the preoperative side, right now, we take our measurements for Cobb angles and for classification, and with respect to growth plates being opened or closed, we do that manually, individually. We are rapidly developing ways where this will become automated.

We're just looking at an x-ray. Measurements will pop up or an assessment is going to pop up. And then secondly, taking a look at large data sets and understanding that if you put an x-ray, and not only do you get the measurements where you can start getting output that tells you, Hey, listen, these are the two or three different ways that a patient with this exact demographics and x-rays was treated. And now you can decide and discuss with the patient, do a shared decision making model as to which one is going to be best for them. So that's how we're really utilizing AI currently. And I'm super excited because just like elsewhere, we're going to see some true leaps in how we take care of our children.

Host: Huge amounts of data can be analyzed and predictive analytics are becoming a reality, which is kind of cool. So you mentioned it before, in terms of radiation, but given the need for frequent medical imaging in scoliosis treatment plans, what innovations are being developed to reduce the potential risks or side effects associated with repeated exposure?

Amer Samdani, MD: Yes. So a big leap was made with the EOS machine back in 2014. This was developed out in Europe, France, specifically, and then brought over to North America. Where it was really placed early in 2013, 14 time range, and now it is widespread and that machine, depending on the physicist you'd speak to, decreases the amount of radiation per x-ray by about one 10th to one 15th of a standard x-ray.

So that has been an improvement. But the next step that we're finding is rather than an x-ray using surface topography, using your iPhone to really take a picture that can assess the surface morphology of a child, compare it to what they were previously, and then help predict what their Cobb angle is. And this is really being worked on from several different companies, several different study groups, and I know you're going to see it in clinical use over the next two or three years.

What I love about that is it puts and empowers the patient and the family because this is something that they can do at home. They don't necessarily need to come in and spend that time coming in for a visit. They can accomplish this or perform this at home. The data gets shared with us, and then we can together make the best clinical decision.

Host: Wow. That's just impressive and great for patients again. So speaking about the future what emerging areas in scoliosis research do you feel are particularly promising, say for med students and or young researchers who are looking to specialize in pediatric spinal conditions?

Amer Samdani, MD: There are so many different areas that we need to do better in. We've been speaking a lot about non fusion vertebral body tethering. That space will continue to expand as material technology catches up with our clinical need, meaning right now, one of the downsides of vertebral body tethering is the tether over time can break, which is okay because it means that you're able to restore even the limited amount of motion you may have lost. But as that technology improves, the patients that are eligible for vertebral body tethering is going to expand dramatically. You will no longer just be limited to patients that have significant growth. You may be able to treat patients that are slightly older.

So that's one big area. The next big area, which is something we're all becoming more aware of, but which hasn't really taken off in pediatrics, is robotics. I've been very interested in robotics for the past 10 or 15 years. There are a few centers that have been performing pediatric patients with the robotics, but that's an area without a doubt, even though surgeons, especially with experience, are able to accomplish these surgeries efficaciously and in a very safe manner; what our goal should be that someone who's been in practice for two or three years is able to perform that procedure at a similar level as to someone who's been in practice for 20 years.

So that's where robotics and augmented reality are going to be coming down to help bring the level of care that we provide to really equalize that across the country for sure.

Host: Yeah, absolutely. That is so cool. Is there anything we didn't touch on that you'd like to bring up, particularly about your research and the latest that you feel is coming up in Scoliosis Care?

Amer Samdani, MD: You know, I'd say the other big things it's interesting because, we're part of these different study groups. One of the study groups we're part of is Setting Scoliosis Straight Foundation, which is a conglomeration of about 20 centers around the US, over 50 surgeons. And the topics that we're most interested in studying as part of a larger group are long-term follow up. We want to see these, how patients are doing 10, 20, 30 years down the line. And we've gotten a good hold of how patients are doing 20 years with modern techniques, but with 10 years. I'm sorry. We really want to see how they're doing 20 and 30 years down the line. But it's interesting when we ask patients, because what we have to start realizing is we have to really go to our patients to understand what do they want to know? What are the areas that they're most interested in? And as it turns out, the areas that they're most interested in is they want to understand if I have a procedure, as an adolescent, what will my life look like later? If I choose to have a family and have a pregnancy? What will that look like? And we've started doing research into those realms. They want to understand the non-operative piece. So what I feel is, I feel the future is really going to the research, should be defined by not only as surgeons, what we think is important, but also really having active family advocacy groups to really combine and understand and push the field forward.

Host: That is absolutely huge. The shared decision making and understanding all of those components for the patient and the patient's family. I think it's great. Dr. Samdani, thank you for being on. I've learned a ton. I think everybody else has too. Thank you for being on.

Amer Samdani, MD: It's my pleasure and thank you for having me.

Host: And for our audience, if you'd like more information about scoliosis treatment from Shriners Children's, visit www.Shrinerschildren's.org/scoliosis. Thanks for tuning in to Pediatric Frontlines from Shriners Children's. If you enjoyed this podcast, please share it on your social channels and explore our entire podcast library for more topics of interest.