Melanie Cole (Host): Scoliosis is a pretty common condition that affects many children and adolescents too; however, if it’s left untreated it can get worse and may cause chronic back pain and other issues down the line. My guest today is Dr. Michelle Welborn. She’s a pediatric orthopedic surgeon with Shriner’s Hospitals for Children in Portland. Dr. Welborn, I’m so glad that you could join us today. Tell us a little bit about spinal deformities, scoliosis, and a little bit more about the spine team that you have at Shriner’s Portland.
Dr. Michelle Welborn (Guest): Sure, so we actually have an incredible team of 11 surgeons here at the Shriner’s Hospital in Portland, four of which are pediatric spine surgeons. We cover the whole breadth of spinal deformity from the youngest kids, all the way up until skeletal maturity, and that includes a lot of things like scoliosis, which is defined as a curve over 10 degrees, as well as disk herniations, people who have an abnormal curvature from front to back, which is called kyphosis, so we cover a lot of different types of spinal deformity.
Host: Then tell us about scoliosis. We’ve heard this term. People don’t really know what it means. What is it and when would you see it in a child?
Dr. Welborn: Yeah so scoliosis is a curve of over 10 degrees, and this can actually happen at any time. There are some children that are born with scoliosis, but most commonly this develops kind of around that peri-pubescent growth spurt, just kind of right when they’re growing fastest right before puberty hits.
Host: Tell us what it looks like in a child, and if we know what causes it. Does it run in families?
Dr. Welborn: Yeah, so we’ve identified over 3,000 genes that are associated with this. So we don’t have an exact diagnosis yet, but they’re getting closer every day. We do know that about a third of people with what we call idiopathic scoliosis, which is scoliosis with no identifiable cause, do have a close family member with scoliosis. In terms of what that can look like, in fact parents are often the first to notice this, and what they may see is there’s a little bit of shoulder asymmetry in their child, waist asymmetry, or they may notice the actual curvature itself, and that could be simply because the curve of the spine, or they may notice an increased prominence of the ribs on one side.
Host: Why is early detection so important for treating scoliosis, and is there a screening, like at their pediatric well visit or preparticipation sports physicals, is there a screening tool that you use?
Dr. Welborn: Yeah so screening is not mandatory, and there is a lot throughout the country, so depending on where our listeners are today, there may or may not be screening programs in their area. As far as screening is concerned, it can be done on sports physicals. It can also be done in your pediatrician’s office, but again it varies quite a bit. So some kids do get screened and screened regularly and other kids not as much. As far as early detection is concerned, that’s important because scoliosis tends to progress when we’re growing and the more quickly we’re growing, the more rapidly it can progress. Now there are some wonderful nonoperative options such as bracing that can be used to slow or even stop the progression of scoliosis, but again that has to be done when a child is growing, and unfortunately they don’t typically turn back the clock. So they don’t make a spine straighter, they simply prevent it from getting worse.
Host: So tell us about some of those treatment options, both nonsurgical and surgical. You mentioned bracing, what does that look like for a child, and if scoliosis is found in their teenage years, is bracing still an effective tool? Are they even willing to wear it?
Dr. Welborn: For infants, we’ll actually often instead of doing a brace, use a cast. For children that are a little bit older, bracing is an option, but once you’re done growing, actually bracing no longer helps you and actually it’s just kind of torture. So it’s really reserved for the child that has growth remaining, especially significant growth. Other forms of treatment really depend upon how much growth you have left and how big that curve is.
Host: So what does the discussion look like when you have to proceed onto maybe a more complicated treatment plan or even surgery? How do you get that discussion with the parents going?
Dr. Welborn: Well one thing that’s nice is when you’ve met them before, and so if you know the family you can often have that discussion slowly over time and build trust and rapport. So for the families that you’ve built that rapport with, you generally know that this is a possibility long before it happens. For those families where maybe it’s unfortunately the first time you’ve met, you know there’s some kind of general guidelines that we look at. So in general curves under 40 degrees where kids are still growing are excellent candidates for bracing. Again, this can help slow or stop the progression altogether depending upon the patient’s age. You can use that in conjunction with nonoperative treatment such as schroth therapy, which is a great way to strength the core and may also help slow the progression of scoliosis. For those kids with curvatures over 40 degrees, that really depends upon how much growth they have left. So if they’re 16 or 17 years old and they’re not growing anymore, we would probably watch that for a while and see if it’s going to get worse. If it’s not getting worse, then you don’t need to do anything surgically and simply encourage them to work on core and back strength to help minimize back pain in the future. For those kids where you see that it’s going to continue to get worse, then you do have the discussion about surgery, and that really depends again on their age. So if they’re very young and they haven’t gone through puberty yet, those are kids where you may try to brace it for a while to control the curve, to slow that progression, and to buy yourself time. If the curve has gotten out of control, and say it’s progressed more than about 20 degrees in a year and they have a lot of growth left, or it’s over about 60 degrees, and again these are rough numbers because it depends on each child and their families, that’s when you may consider something that is growing with them or a growing construct such as a Magec rod. These are only utilized in children who have a significant amount of remaining growth where a brace can no longer control that curvature. They’re an incredible advancement in the technology but unfortunately do require at least two surgeries so whenever we can avoid them, we do. For those kids who have a moderate amount of growth remaining, there are guided growth surgeries that we do perform here that are newer technologies. And then for those kids who don’t have much growth left, they don’t have to be done growing, they just have to be getting close to done, that’s when you may consider a fusion, and for those children, that’s a single stage surgery and can really help improve their quality of life down the road.
Host: What a great educator you are Dr. Welborn. That was really comprehensive. Such great information, which leads me perfectly to my next question. You were recently awarded an honor of Top Doc by Portland Monthly. What does that mean for you and your patients and I can see why they did it?
Dr. Welborn: And actually it wasn’t the patients that voted for me, which would’ve been an incredible honor, it was actually nurses and physicians in the community that voted for this award. So it was an incredible honor, and I actually think it reflects on our team here rather than me. We have an incredibly dedicated team of physicians, nurses, and support staff, and so from start to finish we really work hard to try to make this a positive experience. Scoliosis can be really stressful for families, and especially at a time of life where there’s already a lot of stresses and hormones. Anything that we can do to try and make that a positive experience, and a source of strength I think is really important. It’s easy for these to become a crutch or a burden to a family, but I think that if you work together and you support kids physically and emotionally, then you can really help to, again make this a positive experience, and I’ve been lucky enough to have some of my former patients tell me that they hope to someday become an orthopedic surgeon and some of them have actually started volunteering here. So I think again it just reflects that start to finish we’ve got just a wonderful group of people, and they’re all kind of dedicated to our patients.
Host: That is great information, and if you could give parents listening one last piece of advice about scoliosis specific exercises that physical therapists at Shriner’s can work with their children on, or what they should look for as far as red flag symptoms, what they should notice. Just tell them what you think are the most important bits of information about spinal deformities and scoliosis and what you’re doing there at Shriner’s Hospitals for Children in Portland.
Dr. Welborn: Sure, so I always joke about springtime and sweater weather, so we tend to see a lot of scoliosis diagnosed in spring because all winter long kids have been wearing thick clothes and then all of a sudden they wear a T-shirt and people notice the deformity. I think the big thing is, is that not to panic, that we are a team, and we’re going to help support you through the whole process. That our amazing therapists can really work with you guys to help – to maximize strength, minimize discomfort, and they are an incredible, incredible resource. As far as the team here goes, it’s just an incredibly dedicated team and what we will do is again help support you and either young child or teen to make sure that this has as little impact as possible on their life and the future, and that they have a healthy brain, heart, and spine.
Host: For more information, please visit portlandshrinershospital.org, that’s portlandshrinershospital.org. This is Melanie Cole, thanks so much for tuning in.
