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Interviewer: Your child's been diagnosed with scoliosis, and you're a little worried about what their future looks like. Today we're going to talk about what to do after a scoliosis diagnosis, what you should know, and what are the next steps.
Dr. Joshua Speirs is a fellowship-trained pediatric orthopedic surgeon at University of Utah Health, and he specializes in scoliosis treatment.
What Is Scoliosis?
And I'd like to start with, for somebody who's unfamiliar with scoliosis, how would you describe that condition to them? I understand it has something to do with the curvature of the spine, but how would you explain it to a patient?
Dr. Speirs: Yeah, that's exactly right. The most basic explanation is a curvature of the spine where the spine is no longer straight on the front and back view, and it's deviating to the side.
Interviewer: All right. So it's a side-to-side curvature. Because our spine naturally kind of curves from front to back. That's normal.
Dr. Speirs: Exactly. The more detailed way to think about it is it is a three-dimensional deformity, where it rotates a little and deviates to the side. And that does cause some rotation of the ribs, and sometimes it actually even makes the shoulders a little bit unlevel. But the, you know, basic front and back view is it's a side curvature.
How Scoliosis Is Detected?
Interviewer: And you usually see referrals, right? Generally, I'd imagine, from what I understand, patients get the initial scoliosis diagnosis in, like, a wellness check or a pediatric visit. I mean, it used to be in some places, I remember when I was in school, they would check your spine. I don't think they do that as much anymore. But when a patient comes into your office with that diagnosis, what are you seeing?
Dr. Speirs: Yeah, great question. It's most often picked up by the pediatrician. Usually what they have the child do is lean forward, like they're trying to stretch their hamstrings and touch their toes, and they're looking for the ribs to be asymmetric or one being more prominent than the other. That usually triggers an X-ray. Sometimes the pediatricians will order it prior to referring, or sometimes we get it in our clinic when you come. But really, the diagnosis is confirmed by getting an X-ray to evaluate the spinal shape.
Mild vs Severe Scoliosis
Interviewer: All right. And generally, the pediatrician does that first step, and then is that kind of the end of their involvement? Is that when they would normally recommend that the patient go to see a specialist such as yourself?
Dr. Speirs: Yeah. And that depends on the result of that X-ray, right? So a very small curve, so if you have a very mild scoliosis or something less than 10 degrees when we start doing measurements on the X-ray, that we don't even call scoliosis. They normally call it spinal asymmetry, and often the pediatrician will take note of that and will often watch it themselves because it's not something that needs to be followed. One in 10 people have a very small, less than 10-degree curve of their spine. So it's exceptionally common and doesn't require treatment. Bigger curves, where we're now getting into the true definition of scoliosis, get referred to us.
Interviewer: All right. So, generally, that's who you see, somebody who has a curvature of the spine that's more than 10 degrees.
Dr. Speirs: Yeah. Exactly.
Interviewer: Yeah. Okay. And then when a patient comes into your office beyond that 10-degree curvature, generally how severe is the case that you're seeing? Are they generally pretty severe, not too severe? Like what's the range there?
Dr. Speirs: Yeah. I mean, we see everything from 11, 12 degrees to 100 degrees. Most of them are small. Like 2% of the population has a curve between 11 and 20 degrees, so a fairly small curve that usually doesn't require treatment and doesn't really have any long-term effects. But there are definitely some kids and some adolescents who have curvatures much larger.
Interviewer: Okay. So it is possible you might see somebody that has a curvature of 10 to 20 degrees, and even that, then you would say, "This is something we'll just keep an eye on. It's nothing to be concerned about at this point." Is that true?
Dr. Speirs: Yeah. Exactly. Like the treatment in scoliosis, or our way of looking at it, is really trying to decide how big the curve is and what is the risk that the curve could get bigger with time.
Consequences of Untreated Scoliosis
Interviewer: We'll get to some of the treatment options and some common questions people might have about that in a second. But at this point, I'd like to know if you do diagnose a curvature that is something that you think needs treatment, what are the potential repercussions of not treating that scoliosis?
Dr. Speirs: There have been a lot of long-term studies looking at this, kind of looking at the natural history of scoliosis. We know that there are small curves that stay small throughout your whole life and have little to no effect. We know there are some curves that tend to get bigger throughout your life and can go on to have some effect as they continue to create more and more curving of the spine or more and more deformity. So it kind of depends on which camp you're in. If you have a small curve and it's unlikely to progress, it may not go anywhere, and you may just have a small little curve of your spine your whole life and it has very little effect.
Interviewer: That's reassuring, I'm sure, for a patient who maybe just received that diagnosis. For the curves that are more substantial, what is the potential repercussion of not treating that?
Dr. Speirs: The concern is that it continues to get bigger throughout your life. And I think the more and more research we do, we know that curves, as they get into the 40s- and 50-degree range, seem to get bigger throughout your whole life. There are kids with a 40-degree curve that, if it continues to progress throughout your life, can add a degree or two every year, and in your teens and 20s, it may stay pretty small. But by the time you're an adult, it could potentially be a fairly sizable curve. Those are the curves that end up requiring further surgical intervention.
Interviewer: How does that impact somebody's life, that curve?
Dr. Speirs: Partly depends on the location of the curve, if it's in the thoracic spine, the mid-back, the lumbar spine, or the low back. But it can create some deformity of the chest wall, and some asymmetry of your shoulders. If it gets really big, it does start to impact your heart and lungs. That's usually much bigger curves, you know, in the 75-plus range. But it is possible if the curve gets big, that it can start to affect other things.
Interviewer: Do you ever have patients that come in that have children who have a substantial curve that choose not to do treatment? And what are their reasonings for that?
Dr. Speirs: It happens occasionally. It can be multifactorial. There are different types of scoliosis. Right now, we're mostly talking about what we would call adolescent idiopathic scoliosis, so scoliosis that happens in your pre-adolescent, in teen years for an unknown reason. That's what idiopathic means is we don't know exactly what causes it. There are other types of scoliosis that maybe if you've had a neuromuscular disease, like cerebral palsy and other things. And sometimes we have big curves, and the child has other medical problems that may not make the risk of a procedure, you know, something we want to do at that time. I feel like the majority of otherwise healthy people, kids with no other medical problems than just a curved spine, most people recommend and proceed with surgery just because the long-term risks of avoiding it can become more severe.
Treating Scoliosis
Interviewer: What is your scoliosis treatment philosophy? So a patient comes in, it looks like some sort of treatment is going to be necessary. How do you approach that?
Dr. Speirs: Yeah. Well, first we try and make sure everyone understands what scoliosis is. I really sit down, and I review the X-rays with the patient and the family. I show them the X-rays, I show them how we do the measurements so they kind of see what I'm seeing. And then once we decide that this is a bigger curve and that the curve's likely to get bigger, then we talk about different treatment options, kind of go through all the options, kind of weigh the risks and benefits of all of them, and then come to a mutual, you know, group decision on, "Hey, at this time, we think this is the best option." And that's the direction we go.
Non-surgical Treatment Options: Bracing and Physical Therapy
Interviewer: Yeah. I understand some of the options could include physical therapy, bracing, or maybe even surgery. Did I include all the possibilities? And then how do you kind of systematically go through which one is going to apply to a particular patient?
Dr. Speirs: Yeah. The choice comes down to curve magnitude, size of the curve, and how much growth the child has left, because we know that one of the main risk factors for a curve getting bigger is residual growth, so how much more is a kid going to grow? The more growth they have remaining, the more likely the curve is to get bigger. And kind of those two factors, how big it is and how much more growth they have. How we decide what we do really depends on that.
Smaller curves, you know, 25 to 40 degrees with a child still having growth, our goal is to stop the curve from getting bigger. And that's when we consider bracing and physical therapy.
Surgical Options for Severe Cases
For larger curves over 45 to 50 degrees, bracing hasn't been shown to be as effective. And if the kid still has a lot of growth, then we start to talk about procedures and surgical interventions, whether that's a fusion-sparing procedure, like an anterior vertebral body tethering or a fusion to correct the deformity and prevent it from worsening.
Interviewer: And then how long does treatment take? I'm going to assume that it depends, again, on the curvature of the spine, but give me that range.
Duration and Commitment to Treatment
Dr. Speirs: Totally. If we're doing nonoperative treatment, we go until they're done growing because that's when the risk of it continuing to worsen kind of decreases. So it kind of depends on when you start, right? If I have an 11-year-old boy and we're trying to brace, that may be a longer course of bracing. Whereas, you know, if you have a 13-year-old girl, then maybe a shorter course of bracing.
Supporting Your Child Through a Scoliosis Diagnosis
Interviewer: What are the types of reactions that the children and their parents have when you do tell them about their diagnosis?
Dr. Speirs: Oh, it's very variable. There are families that have multiple people in their family who have scoliosis. They kind of know the drill already, and they're prepared for it.
The hardest ones are the families who show up, and have a more sizable curve, 30, 40, 50 degrees. They didn't know it was there two weeks ago. They just got an X-ray. Now they're looking at this X-ray, and there's a big curve, and there's a little bit of a shock factor, which I think is completely understandable and even kind of expected, you know, to be like, "Man, two weeks ago I thought I was a totally normal 11-year-old. And now you're telling me my spine is all twisty."
Interviewer: Right. And I might have to wear braces.
Dr. Speirs: And I might have to wear a brace. And definitely the brace response is its own thing, right? Wearing braces on teeth in society is very normal for preadolescents and teenagers, the preteens. Everyone wears braces. That's normal. But now someone showing up to school potentially wearing a brace under their clothes is a little more scary for kids, and I think that's also very reasonable, and we kind of expect it.
Common Misconceptions About Scoliosis
Interviewer: Yeah. What are some of the common misconceptions that you find that people have when it comes to scoliosis, either the condition or the treatment?
Dr. Speirs: Yeah. Many people have specific concerns regardless of the treatment. When it comes to bracing, you know, is the child going to wear the brace? How much does the brace cost? How much do I have to wear the brace for it to be effective? And then the other one is, what if the curve keeps getting worse even though I'm wearing the brace? Concerns for surgery, obviously, are, "You're doing surgery on my teenage child's back. I know my friend down the road had back surgery, and they're having tons of pain. Is my daughter or son going to be in pain for the rest of their life? Is all their motion going to be taken away, and they're going to be stiff as a board?" Those are the kinds of very common reactions we get.
Interviewer: What is the most important thing that you would like listeners to know about this condition or the scoliosis treatment and take away from our conversation?
Dr. Speirs: I try to emphasize to families and to patients that most of the time we can avoid surgery, that we can get your child to be able to live a very normal and functional life in the long run. And even if they're in the rare category that needs surgery, it is not life-ending. You know, I have patients who still ride rodeos, and compete in competitive sports. And this is something that we can get your child through, and they can still live a very normal life.