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A is, but I think they're supposed to talk about early onset as well. Although I think Ris has talked a lot about, you know, muscular and syndromic curves which form the subset of those as well. So I apologize if there is a gap there in my confusion. Um So I think you've probably covered this already. Scoliosis comes from the Greek word for a bent back. Um, and it's been described in prehistory quite a long time and, er, you know, you see people, there's a scoliotic curve and people trying to do traction for it, which is kind of almost not dissimilar and you can see where the Tree of Andre uh comes from that we will talk about um for as a, for the Cambridge orthopedic Club. Um, some of you may have the tie with it on there and um, it scoliosis really describes a spec spectrum of disorders. Um, and I think you've heard a lot about them this afternoon, it's congenital all the way through to degenerate. Um, so it affects people from in the womb until the day they die. And so, uh idiopathic scoliosis is something that basically has an unknown etiology and um oh, sorry, that's not what I wanted to do. Um Yeah, and um no, stop doing that. Sorry. Uh And it's pretty much describes sort of the switch is between about 10 when it goes from early onset scoliosis to uh late onset. And, and this is essentially what we're talking about. We're talking about a deformity in the Sagittal and the coronal plane that also has a, a rotation uh affecting and it can affect anywhere from the um cercle down to the lumbar spine. Um It is an imbalance and it can be uh uh the, the imbalance can be the whole spine. So you can get the trunk shift when the whole body is shifted over to one side, or you can get AAA balance of the spine um where the head remains in the middle and the curves compensate them out and you have then a structural curve and a um a um my brain's gone blank that um and then you've got uh the uh lower curve which is just helping it come back into the reactive curve and then it's also a three dimensional deformity. So you've got the rotation of it as well as the spine is crank shafting around as it's growing. And uh we started to really know why uh this happens. Um There is for sort of minor curves, ones that don't require any treatment. The male to female, male to female ratio is 1 to 1 but if you look at curves that require intervention, obviously, it's far more common in young ladies than in young men. Um There is a genetic component to it in that, you know, there is a 27% prevalence of scoliotic curves in daughters of scoliotic mothers. And if you have identical twins, then if one of them have a scoliosis, there's a 60% chance that the other will, but it's not 100%. So it's not just genetics. Um The majority of these curves are right sided thoracic. Um And there's a query as to, you know, left sided thoracic means possible spinal abnormalities. But why is it right sided and there's something thought to be doing to the growth pattern as well. Um We know that tissue that may be involved because if you have connective tissue disorder such as Duchenne's or Marfan's, then you're more likely to get a scoliosis. And we also know that girls who uh a sort of age 12 to 14 have a slightly lowered bone density when they have a scoliosis compared to age matched controls, but it's very difficult to actually control for reduced activity that's often associated with this. Um And so whether that is a true factor or not, is not clear, um what is a big factor in it is the heter volt effect. And in this, what I mean is that when you have a curve, if the curve starts off, then you know, that if you distract a growth plate, it'll grow. And if you compress a growth plate, it won't. So if around the apex of a curve, you have got compression on the con cavity and you've got a stretch on the convexity, then you the growth plates on the convex side will continue to grow and the growth plates on the concave side won't. So you can see how probably the most important thing when it comes to an idiopathic scoliosis is the amount of growth that remains because that is how the huge development effect will take a very minor curve. And if someone's growing rapidly, it will turn that minor curve into something far more significant. Um There is a theory about Melatonin, you can take the, the pineal gland out of a chick embryo and it will develop a s a scoliosis. But when you then look at Melatonin in um humans, there's no difference whatsoever and Japanese have looked at that very extensively. So the prevalence of this, it varies very much on the the size of the curve. Um The sort of true ones that cause a problem are the ones over 30 30 degrees and that is 1.5 to 3 per 1000 compared to the ones over 10 degrees, which are very, very common. Um And the natural history of this, this is, as I said, this is the key to it is is whether they get their curve before skeletal maturity or after skeletal maturity. And in there, if you look at this little curve on the bottom left, you've got the crank shaft versus the no crank shaft. And this is re referring to the fact that the spine will continue to grow and it will push and it will twist. Um And so you've got your peak height velocity. Um And then as you get older, you get less of that effect. Um So progression progression before skeletal maturity, there are lots of unknown factors about this. But there's some things we may, we know and that is the fact that the amount of growth remaining the size of the curve. And if they're a lady and it's a slightly complex picture, but this is from the original paper about it by Lonstein. And what essentially it says is that if somebody, if you, you look at the bottom left, if their risks are naught or one, so they've got lots of um growth remaining. If they've got a small curve, then 22% of those curves are likely to get worse. But if they've got a medium size curve with a cob angle of say 20 to 29 degrees, then nearly 70% of them will progress. Whereas if they are risk of 23 or four, when they, and they've got a 5 to 20 degree curve, then only 1.6% of those curves are gonna get worse. Whereas if they've got a larger than then 23% of them are going to get worse. So it's all about the size of the curve and how much, how much growth they've got to go. And you can see that if someone, if you look at the age of it, which probably relates to the risk of sign, but it again, peak velocity, um if they're 10 or younger, then they've got a 20 degree curve, then 100% of them are gonna get worse. Whereas if they're 15 and older then it's only 16% of them are going to get worse. And this is really what guides us when we're thinking about how we're going to treat them and what our goals are. Um, and so the risks a sign, I hopefully, I don't need to tell you guys about that, but it is something to look at. The only time. I sort of, it, normally it's pretty easy to pick up. The only time you sort of look at it is when you see a 16 year old and you think to yourself, is she risk a naught or is she, er, risk a five? Um, but then you have in girls, you have the marker of menarche, which is always very useful. Um, because you know that they're sort of growing for a year and a, a year before menarche, a year and a half, a half after menarche. Whereas in boys, you don't have that nice marker And so what happens to a scoliosis if you leave it untreated? Um So you, there's been a lot of long sort of longitudinal studies looking at this, particularly in Ohio, in the States, looking at thousands of patients. It's, it's not been repeated for a number of years and it probably does need to be repeated. But the simple fact is that we now intervene surgically, um there's no increased rate of mortality, so it doesn't kill you, but you do develop a respiratory problem, but only when a curve is really, really big when it's over 100 and 10 degrees. Um uh particularly if your thoracic curve is over 80 degrees. Um and people, you know, they do have a slightly increased incidence of back pain. Um It doesn't seem to be related, it doesn't, you know, doing, having a scoliosis doesn't seem to impact on the type of job you do or your ability to do that job. But there is a slight increase in um chronic back pain. And also, um people have a slightly increased d uh body dysmorphia. And I'd say that if you repeated that study in today's era, you would see a much bigger impact of the er, scoliosis on body dysmorphia. But that would be, you'd have to control for how it's changed with society, with social media. Um So once somebody has reached a skeletal maturity, the huge evolvement effect is kind of removed from it because you've no longer got that growth plate um element to it. So then it becomes about the magnitude of the curve and it becomes about the pull of the muscles and gravity as to whether something is going to progress. So if someone's got a neuromuscular curve, which I think you guys have already heard about, then you have a very abnormal muscle pull. You've got loss of your junk control. And so your curve's going to progress even if it's a 20 degree curve where we, whereas when you've got skeletal maturity, the longitudinal data that we've got suggests that if a curve is less than 30 degrees, it's really not gonna get worse. But if a curve measures over 50 degrees, what I tell my patients is that it's going to get worse, probably get worse by about half a degree to a degree per year. And so it means that you're not gonna see much difference from 1 to 2 years, but over 10 years, you will see a difference and that can continue going and at some point, it will start to cause problems. And lumbar curves, it says 30 degrees here, I've actually changed that to about 30 to 40 degrees. They progress by about half a degree a year. So that's because of the pull of gravity in the pool of muscle. And that's why these are the sorts of numbers that determine what we're going to do treatment wise. Um If you look at the adults with untreated, er, er, a is the demographics are very similar to those without, they have the same level of education, marriage Children. Um, and as I've said, they have that body dis Sais, um, they do however, have a limitation that comes from the fact that they've been given a diagnosis of scoliosis. They, which I think is a psychosomatic issue. Um, and it's very important to dem medicalize things as quickly as you can with Children because they're in hospital an awful lot. They're coming to clinics, they're seeing doctors, they're being told they've got a problem, but at the same time, we want them to be completely normal. So my goal when I'm seeing someone who doesn't need any treatment beyond when they finished growing is that I want them to forget they've ever heard the word scoliosis. And I want them to go off and lead a life where they don't have the problems that you get when you're given a label, when you're given a diagnosis. Um So classifying a scoliosis. So why do we classify? I'm sure you all know this. It's to facilitate the research. It's to make sure you can set up different groups of patients and tell the difference between them so that we can all have a common vocabulary when we're discussing things that it helps us from a prognostic point of view. And it gives us an idea of how we're going to treat people. So, historically, I think you need to have heard of King Mo, which is basically looking at the type of curve. Um And the majority of those are the type two and the type three curves. Um But then that got superseded because this was only looking at it in the Coronal plane. It wasn't looking at it in the Sagittal plane. And that was um it was designed for when we were using the Harrington rods. We weren't trying to correct rotation. All we were doing is putting a rod in to fuse it and try and correct it a little bit. And so it was only based on the coronal plane. So, Le Lei is the Lawrence Lei is the sort of father of classification of scoliosis and he classified them according to the curve type. I don't think you need to know the classification, but suffice to say that it's a curve type that's based on the Coronal appearance. Um And then it has a lumbar spine modifier, which is when you draw the central sacral vertical line and I'll show you a picture in a moment um up to the lumbar apex as to where that, that line touches um the apex of the curve, whether it's in the pedicles in the middle, whether it's touching the body or whether the body has moved lateral to that central c uh uh sacral vertical line. And then you have a lateral modifier as to whether there is um a significant kyphosis. Um So if you look at the bottom here, you can see the modifier. Um I don't know if my mouse will work. So you're looking at where the apex of the curve is, whether it's come over and it gives you an idea as to whether um the lumbar curve is uh structural or whether it's compensatory. But so you just need to know the lengthy classification is based on the coronal view with a lumbar modifier and a sagittal modifier. Um And so you can see you've got the NKY, so the most common curve is a lei one a um that's what we tend to deal with the most. Um uh But you can have a double major curve with a significant shift. So like a, a sort of the, the double measures of the 33 C. Um So the other variables that you need to think about being able to describe. So then, you know, I'm sure you know about cob ale I don't need to do that. You can talk about apical vertical translation, which is this how far the apical vertex is away from the CV SL? And you can talk about rotation. So how do you measure rotation on um a sort of a PN natural films? You look at the pedicles and you look at how much of the pedicle is vis visible. So at this level here, you can say there's a sorry, this level here, you can say there's rotation because your pedicles are no longer facing you. And you can imagine that this is rotated this way. So you're not seeing so much this pedicle and you're seeing this pedicle end on compared to the equal ped placement of the pedicles here. Um The flexibility of the curve. And then what's the stable vertebra? What's the neutral vertebra in the middle of the curve? And what's the end vertebra which is before the neutral vertebra? Um, how do we evaluate the scoliosis? So this is as all things are orthopedic. Well, anything medical, you do the history. So you want to find out why they're coming to you. Um, often it's something that the parents have just noticed and we have this weird thing that when our Children also sort of turn 12, 13, you no longer, well earlier than that, you don't see them in the bath, you don't see them in the shower the way you do when they're six or seven years old. And so parents will see their Children on holiday on their summer holiday and that will be the first time that they'll notice there's something bad going on in their back and then they get, they blame themselves for the fact that they haven't noticed it. But in reality, unless you're seeing someone in something tight, you won't notice the rotation that comes with it because you, and also you don't tend to notice it from the front. It's only when you're looking at the back, some people do have pain and when you're doing the history, you're looking out for any of the classic red flags such as night pain and non activity related pain. You want, obviously the age of the patient, you need to go through a pediatric type history from a family perspective. You want to know, uh, where they are from a meal status and how quickly things have been getting worse. And also you're also doing a sort of screening for any uh neurological type symptoms with the obvious ones about bowel and bladder um clinical examination. So the Adams forward bend test is the, is the crux of it. Um You don't have to say Adams, you could just see the forward bend test and what you're looking for is rotation. Um in the middle on the right, you've got a scoliometer. If you're in your exam and you see a scoliometer, then there's a reason for it and you need to know how to use it. And you can see that basically, you put it on the spine, there's an arch, little arch bit that goes over the spinous process and it allows you to quantify the degree of rotation. Um And uh and that's probably the biggest marker of the rotation of the spine. And so you, you'll see that the scapula gets pushed back by the ribs as they're coming out. Um And in the lumbar spine, you don't have something so obvious, but it's because there's the ribs, but you've got the paraspinal muscles, you know, you've got your, um your filet stake there, your um sirloin and that's rotated round. So one set of paraspinal muscles will be deep, the other set will be prominent. And so you'll often get a compensatory lumbar uh rotation going the other way. Um If there is rotation though, it means it's structural. And so you're thinking about a different type of curve. The other thing is to look for the um low increase abnormality that comes with the scoliosis. Um And you need to be able to comment on that in the exam. You need to say there is a low increase abnormality or there is a trunk shift to the left. You also want to measure their pelvic um uh look for any pelvic tilt and uh by doing so you should all be measuring, also be measuring their leg length once they're either standing or lying down, whichever one you're more comfortable with. Your neurological exam is the same screening as part of the history. You're looking for any markers that there may be an underlying cause to the scoliosis such as spinal cord tethering or neurofibromatosis or any of the other syndromic type conditions that can cause a scoliosis. Um Don't forget that it's a normal neurological examination of the legs. You should also do the abdominal reflexes and also have a look in the axilla, look on the skin for any neur, uh, any, um, uh, caff a spots, things like that. Um, MRI scans, I mean, really you do an MRI scan in anyone that's going to be considered for surgery, but also anyone that, where there's any sort of hint of something abnormal. So pain, typically anything that's come up in the history or the examination if they've got a, a left curve which is, uh, abnormal or a rapidly progressive curve at a young age. Um, and in boys also, so we tend to actually scan the majority of curves, um, if they're over about 20 degrees, but it's based on the history. So, treatment, moving on to treatment for idiopathic scoliosis, there's an awful lot of, uh, stuff out there on the internet, which is a real pain. Um, some of it's helpful, some of it's absolutely disastrous. There are clinics that can promise to treat a scoliosis. Um, if you go to them for nine hours of physio every day of the week, um, there are people giving really sound advice. Um, but the three main ways that we treat this are just to watch and wait. Um, and then to brace and surgery and the goal of it is to get to know a patient's curve, to know how it's going to behave. And some of that you can base on the factors that I've just been talking about. How much growth do they have left to go. Um, and, er, you know, um, what degree is their curve and, um, you know how much they're struggling with it. Um, but some of, of it is curves don't always be, you're going to expect them to. So some curves are going to never get worse. Some curves were always going to get worse, irrespective of whether we brace them or not. And there is a small subset in the middle where you can influence that curve with bracing. So, bracing at the moment, we always talk about full time bracing and that's probably still the gold standard using a Boston brace. The Milwaukee brace. I don't think you have to describe that. It goes right up to the neck and I'll show you a picture of that. I've never seen that used. I have to say, I think it's historical now, um, nighttime bending brace less common. There is the spine cord brace, which I'll show you a picture of which is an overcorrection type brace. We are currently the, the Boston brace is the most typical one. That's what we use here. Um And the gold gold standards for it to be worn as much as possible. They can take it off for sport, but you're really looking for, uh, a 90 90% compliance 23 hours a day, 22 hours a day. Um And when you, the brace is on, you want to get a minimum of a 50% correction of the curve. We're currently part of a trial though to see whether, excuse me, I'm going to sneeze whether there is a, um, whether we can do night time bracing only. Um, because it would be lovely not to inflict this punishment on Children. Milwaukee Curves, as I said, that's for very high Curves. It's historical if you get shown it, that's what it is. But I wouldn't worry too much about it. Um, the Sky Bid Court over Correction Braces. Um, it's, there's a question about how effective they are. Um, so the, when we look at the results of bracing, um, there's a lot of, uh, an awful lot of studies about it. Um, and some of it, as I said, some of it seems to work and so girls with a 25 to 35 degree curve, um, seems to help and stop, stop patients going on to surgery. And you can see that compliance is a factor. Um, you know, those who didn't go to surgery, 42% were compliant and those who went on to surgery were 24% compliant. But what we're really saying is that bracing isn't perfect for everybody. So they're better in flexible curves, patients who have a lower BM I and younger patients. So it's really the only tool at the moment we have to prevent progression apart from, um, tethering, which I'll come on to. Um, it never corrects the curve. The goal is to get someone to skeletal maturity with a curve in the thoracic region that measures less than 50 degrees and in the lumbar region that measures uh less than 40 degrees. So, when do we operate? Um, and this is sort of a bit of an idea of how I'm, how I'm thinking about it, Cookie's model. So, if they've got a curve of sort of 11 to 25 degrees and they're skeletally mature, you can follow them up if you need to. But if they're not SCLE mature, er, and you're considering a brace or not, then you need to follow them up until they are scal mature. If they've got an intermediate type curve, again, if they've reached Gle maturity, you might want to follow them up once just to make sure that they're not in the small subset that do progress. Um, if they are not slightly mature, you can consider bracing. But if they've got a curve of over 40 to 50 degrees and that's when you're really, uh, considering operations. Um, so indications, I guess that's what you guys want to know. Thoracic curve over 40 45 degrees in someone who isn't, uh, skeletally mature, um, or a th or a thoracic curve of over 50 degrees in someone who is gly mature. You can look at kids sometimes and you can say this curve is going to get worse. And so sometimes your indication for surgery is that if someone's got a 40 degree curve and it's thoracic only, so if you imagine this picture on the bottom, right, if someone had a thoracic curve with, without that double major and you could treat it at that point, you would then stop the lower curve becoming a structural curve and requiring instrumentation all the way down to the pelvis. Um People tend to tolerate the double curve a little bit more because they don't get the trunk shift. Um The goal of the surgery is to achieve surgery, sorry, sorry to achieve fusion. So number one is to stop the spine getting worse. It's not, it used to be historically just about that. But now with the instrumentation, we've got, we're able to deliver a much better correction and that's a correction both in the Sagittal and the Coronal plane and also with rotation to try and reduce uh the rib prominence. And whilst we're doing that, we're also thinking about trying to make sure that the shoulders are nice and equal um, surgical planning. Obviously, you've got the full history examination, you've done an MRI scan to make sure there's no underlying cause because the last thing you wanna do is operate on someone who's got a tether, try and straighten them up and then, and then have a result in cord injury, you make sure they've been photographed clinically beforehand. If necessary, they've had lung function tests done at the Norfolk and Norwich. We have a pediatrician who reviews them to make sure that he's happy that no further investigations need to be done. They have a neurophysiology assessment for the spinal cord monitoring done by Helen who's talked to you and they have lateral flexion films which help us plan where we're going to go. So we're looking at this x, these x-rays at the bottom and we're looking at how this bit corrects when the patient leans over because that tells us how far down the spine we need to come to achieve the correction. We want to stop the, the scoliosis getting worse. The goal is always to try and avoid as much as possible as fusing as many as little levels of the lumbar spine. And the theory behind this is that the more levels you fuse at the lumbar spine, the more work, the fewer the the few segment motions at the bottom are gonna have to do. So you're going to get, there is a price to pay. Uh later on the patients will get increased degenerate, change their L4 5 there, L5 S one level. If you fused all the way down to L4, you'll have a massive long lever of solid spine above. And the work that was being done by the L1, 2, L2, 3, L4, 5, L3, 4 L4, you know, discs are going to be transferred onto those bottom two discs and they're gonna wear out sooner. So we're always keen to try and cut it as close as we can to avoid instrumenting any excess lumbar levels. And so sometimes we get it wrong and, and um, and it requires further surgery. The other thing about a lateral flexion film is it will tell you how stiff a curve is and that'll tell you how much of a release you need to do in surgery to achieve the correction that you want to. So fusion levels need to be planned and so you need to plan your levels so that you can, this is what you need to say, maintain Saru Coronal balance um as minimal as possible and preserving motion and that's it. So typically, we tend to fuse from the proximal end vertebra to one or two levels ke to the stable vertebra, going back to that diagram. Um And so going back to that diagram, that's what we're talking about. So if you're not worried about this lumbar curve here, you don't need to instrument this, you'd want to stop somewhere up here. You don't want to stop in the middle of another curve. You'd need to know from your bending films that this bit corrects very nicely. So when you instrument the curve above this, which is the compensatory curve is going to straighten up um the major. So what are our surgical options? The majority are posteriors spinal fusion. And it's the, it's the gold standard. I have to say we do very little Antero spinal fusion at the Norfolk and Norwich. Um the benefits of an Antero spinal fusion is sometimes you can instrument less levels. Um and you can improve the sagittal profile, but it's a much bigger operation. It's much riskier. Very occasionally, patients need uh an anterior release and a spo posterior spinal fusion. Again, that's not something that we do very much of here. Um uh And in fact, it's sort of fallen out of vogue, I think uh in a lot of places. Um So the standard posterior approach, the patient's position prone, they've got the neuro monitoring. Um and you do a standard midline approach from the top to the bottom um and then screw placement. So we're using pedicle screws and that on this lovely picture on the right there, you've got big fat pedicles. The reality is that the pedicles are dysplastic are re uh especially on the con cavity of the apex of the curve. They're horribly thin and small. So just placing them free hand, it depends on how it feels. People will use ac arm, people will use. Um So using an x-ray to, to help you guide you with a, with a, with a guide wire or navigation. And once the pedicle screws are in place, we're really looking for a correction in three planes. You're looking for the coronal collect correction, the axial correction by the derotation and then the shape of the rod that you put into the back, we have different types of screws. And for those who've been in a spinal theater, you'd have seen this. So mono axial screws are used. Uh I that's what it was always, historically, we now have the benefit of uni planar screws which allow the rod to be put on slightly easier. But then for you to achieve a rotational correction, and then you've got polyaxial screws which make it very easy to put the rod on, but don't give you as much of a correction. We've also got reduction screws and reduction tools. And all these essentially are is ways of extending the sides of the screws up. So you can put a rod in up here and then gradually reduce it down to the screw or depending on how, you know, cup half full, cup, half empty, you're pulling the spine up onto the rod. Um We sometimes need to the, to do releases. So when you're doing a fusion, you need to make sure that you're gonna achieve a fusion. Now in kids back, you only really have to scratch the back to achieve the fusion. And when, um I think you're talking about D gen curves when they, when they are uh done, you, you really aim you, you need to work hard to get them to fuse, but even in kids, you don't take your chances. So you do do decorticate, you do do the facetectomies and then you lose use graft. Now you can use local autograft. So from the crest or from the spinous process, which is what most people do from the spinous processes when I was in Australia. Uh Jeff Askin used to put lots of allograft in there. Closure is pretty normal. Now, the bit that I haven't talked about is what sort of rod you use. So we would use titanium screws and then you can use a co work chrome or you can use a titanium rod. A titanium rod is softer um and it's more flexible. So it's less, it's more forgiving on the screws that you've put into the spine and that typically tends to be enough. But if you're going for a big correction, uh and you need to put in a really stiff rod, then you put in a Carbot chrome rod, but you need to know your screws are completely secure before you, if you're going to use a Carbot chrome rod, um lowest involved vertebra, I've just been talking to you guys about this, the extension to L4 or not. Um What you want at the bottom is a balanced vertebra. But the cost of extending down to L4 is that, is that increased degenerate change um at the lower levels. So, selective fusions are when we're trying to minimize the uh the, the involvement and they are good, but you do have this revision rate if you do a selective fusion of a curve. Um and you hope that the compensatory curve is going to correct the risk is that you're going to have to add on. Um, this is a rubbish picture. I'm sorry about that. I should have a better one in there. But we watch these girls. Yep. Oh, yeah, we watch these girls and, um, sometimes you have to add on a level. So it's always a choice that you have to make and if it was my daughter and somebody thought, do you know what I can stop my fusion at T at L1 rather than going down to L3. But the chance she may then have to have a second operation. If the lower curve progresses, then I would go for the stopper L1 knowing that in two years, she might have to have an of another operation. But if she got away with the stopper L1, then she's far less likely to have back problems in the future from a longer fixation. Um Complications of surgery. I think these are the same as uh you would expect in most orthopedics, there is an infection rate, it's higher in the neuromuscular. I think as you've already heard, uh pseudarthrosis rates, a failure to fuse varies. You, you don't see it very often in idiopathic curves that have been fused posteriorly. We do see them in the ones that have been done. Um Thor scop physically anteriorly. And so you do have a pseudarthrosis rate of, you know, between 2 to 7% and the reoperation rate is similarly, um the biggest possibility that we worry about is the risk of uh permanent spinal cord damage, which I think has been covered already in terms of the neuromonitoring. Um, but it is devastating when it happens and when you're talking to the parents and the family about it, you have to be very clear about that and you have to be very clear that you can't give them a guarantee that it's not going to happen. Um We still don't know what, whether we're doing the right thing, which is a weird thing to say. But if you think about the techniques that we're using at the moment, those techniques have been around for 2025 years, we don't really know what those patients are gonna be like when they're 80. We are seeing the patients that had Harrington Rods done 40 years ago ago coming through and when I see them, I, I put my hands, I, I can't do anything for them. They have back pain, a lot of them, um, down in the lumbar spine, but you don't really have much that you can offer them apart from extending their fusion, but that just creates problems in the hips. We believe we're doing the right thing. Um, but I think time will tell. Um, certainly, yeah, I, I believe in it, but that's pretty obvious because I do this sort of surgery, um, what's going to be coming in the future. So, as well near future. The sco score was developed in the States. It's a saliva test. It looks at 53 genetic markers, which gives you an idea of the complexity of scoliosis. Um and it gives you a scale from naught to 200. It's not very widely used, it's very expensive. And I think that it's main use is in, if you look at a curve that's likely to progress. So if you got G A girl that you're going to brace and her sc score is high, then the bracing is going to be a waste of time. Don't put her through it and just wait to fuse her at the right point. The other thing and again, it's the wrong picture. Sorry is the idea of using tethers to achieve a fusion, this correction. So the idea is that if you get a girl who is wri er naught or one or two who has got sufficient remaining growth, you can harness the Hua Volkman effect to try and correct the curve. So if you imagine that you're putting a tether down the convexity of the curve, you're effectively squeezing the endplates on that side. So you're trying to do a reverse huk the concave side will then continue to grow and the curve will correct. And it's a, it's a lovely theory and I think it's incredibly elegant and I think it's fantastic. You can put tethers in Thos cop, you're not fusing them, the levels are minimum. The problem is that we don't know when to do it and who to do it for. So, identifying the correct patients in the correct time is the biggest problem this, as always in the States, they've taken this on, they're doing huge numbers of operations because they, you know, they, you know, they're making a lot of money out of it because everybody wants to fu in this technique, but they're doing this in 15 year old girls who've only got six months of growth left. There's no way it's going to come to uh go on. The tethers are breaking because the spine is so incredibly strong as it's growing. And so the reoperation rate is between 10 to 20% which is massive compared to doing a selective posterior thoracic correction and fusion. So when we don't know which ones to do it on the, the problems they're getting is they're getting over correction where they've put the tether on and the spine start winds up bending the other way they're getting under correction. So patients are winding up needing a fusion anyway. And then you've messed up a little bit. Somebody's lung function because you've gone through their thoracic cavity and then they're going to need a posterior operation anyway. So you're doubling the risk, um which I just wouldn't, you know, that's not something that I would want to go through. However, I think that if we do get it right there are girls and boys who could be treated with a spinal tether to stop uh so that they achieve a correction by the time they finish growing, they've got a nicely balanced spine. We've just got to work out the, the finer details of it. OK. So yeah. Um any questions on what I've shared with you today guys? Uh Mr Kirk, there's one question from the audience. Um I just go to just go to that. Um Hold on. Um Yeah. Uh It's uh from uh Doctor Addie. Um So does Coronal Y shaped osteotomies in the apical vertebra uh to treat complex congenital, rigid scoliosis, give good clinical and radiological results. I a complex Y shaped osteotomy, a verte, I mean, that's not really what I was talking about today. Um um at all. Um And it's not something that I'm familiar with doing a Y shaped osteotomy. I think that we do asymmetric osteotomies. Yes, you can do an asymmetric osteotomy, but that's a massive procedure and you have to have a very clear reason to do that in the thoracic spine because of the risks involved. Um But you, yes, so osteotomies are sometimes necessary to correct very angular deformities and they do achieve a good result, but they, there is a huge risk associated with it. Yeah. Do you normally use the classification as management? Um I think that it, it's always there in the back of my mind when I'm thinking about it. Um I think it's a very good way for, it's a very good tool from a research perspective and I think it should be done. However, for me, it's the magnitude of the curve um and the degree of flexibility and what the um compensatory, how the compensatory curve behaves that we'll decide which levels I'll go to in terms of management. If you're deciding about operations or not, then no, the classification doesn't help in that regard. It's about the magnitude of the curve and the um and the remaining growth. So if you use a brace for a moderate curve, when do you decide to stop the bracing application when they're reaching skeletal maturity, it would be, oh no, no, no, don't, don't worry about asking. It's fine. I'm really not worried at all. Um It, it just, yeah, it just, it's more from the congenital point of view. Girish might throw something in about that later on. Um When, if we're using the brace for a moderate curve, when do you decide to stop the brace? A application? Um You stop when they've reached gluing maturity. And the, and the reason for that is that if you've put someone through 12, 18 months of wearing a brace and you take it off four months early and their curve goes past the tipping point and they need surgery, then it's a waste of those previous 18 months. Little more detail on the level, lower level of fusion based on the bending films. So it's about how much the, the, the compensatory curve corrects on the bending film. Because if it corrects to less than 20 degrees, then by definition, it's nonstructural. But what you don't want to do is to. But if you've still got a structural curve in the lumbar spine, then you'll need to include it in your construct. Um And if there is significant rotation even on the bending films, then you don't want to stop at that level, you want to stop at a vertebra there that is um U neutral from a rotational perspective and you don't want to stop at AAA vertebra that's in the apex of another curve. Uh Severe scoles is greater than 60 degrees. You aim for a straight spine. No, you're not. I mean, you aim for as straight as possible. But what you want is a balance spine. You want their head and shoulders above their pelvis and you want a spine that's not going to get worse. Um And you want to achieve that. Um some people, some surgeons will put two screws in at every level. Um and, and really crank it around to try and achieve a perfectly straight spine. There is no evidence that that produces a better outcome if you look at their SRS scores um or their later life, as long as they've got a well-balanced spine, you want to improve cosmesis as much as possible, but that comes from the rotation. Um When you've got a severe scoliosis. You need to do bigger releases, you need to take out more of the facet joints release as much as you can. And in extreme cases, you do need to do an anterior release because there's only so much you can achieve without releasing the uh anterior longitudinal ligament, which is a massively strong structure. And you can only do that from the front. Uh easiest way to explain suprapelvic, intrapelvic causes of scoliosis. Um I think uh by that, what do you mean by that as in terms of whether they've got a leg length inequality or whether they've, which can be the driver for it, but sometimes it's the, the leg length inequality produces asymmetry to the pelvis and that asymmetry of the pelvis is what is just the, the sort of almost the start of it for the curve to kick off. You do want to differentiate between a postural curve and a structural curve. And that's part of your examination. If somebody's stand, you can have kids that sometimes come in standing with a massive list over to one side. That can be because they've got a leg length inequality. Um It can be because they've got um er because they're standing in a funny way and sometimes it can be because of pain. But if, when a child is bending forward, there's no rotation, they're very unlikely to have a structural deformity in their spine and you don't have to do the ab for bend test, you can just sit them down on the edge of the bed because that will square the pelvis off. And if once this pelvis is squared, the curve disappears, then you don't have, um, then it's not a structural cause and the cause of their scoliosis is their leg length and equality. So centering evening out the pelvis, either if you use blocks under the feet, sitting them down or bending them forward will tell you whether their scoliosis is ST a structural spine problem or whether it's a compensation for a severe leg length or pelvic abnormality, um tethering. So yeah, if they've got a tether and you straighten out their spine, they're not going to the spinal cord is not going to like it and they're going to get an injury. So, in that scenario, we refer them to the neurosurgeons to a pediatric neurosurgeon and typically they will either say no, you can just fuse it in situ. So you don't go for any correction or they will do a, a release of the tether, which will then hopefully enable you to do the correction. But when you're doing this surgery, you are hoping that the spinal cord is just going to slide up nicely within the canal and that when you push the curve over the spinal cord isn't going to is going to be ok. But some spinal cords can be very, very fragile and they cannot like that movement. I have had cases where I've done a, a huge correction and 10 minutes after the correction, the signals, uh the cord monitoring started to go off and I think Helen may well have mentioned this at that point. You release the correction so that um, the, and you allow and you see what happens to the spinal cord, you have to have a sort of process of, there is a loss of cord signal monitoring protocol that every hospital that's doing. I scoliosis surgery should have. So you take the correction off completely and you see what happens to the spinal cord. If it still doesn't come back, you have to take all the screws out and if it still doesn't come back at that point, you just close up and you wake the patient up, you see what their neurological function is and you see, um uh uh you know, and then if necessary, you get an MRI scan, but so sometimes they don't like it. And so I've done it where this cord monitoring started to go off because you've pushed it. And then we think it's probably down to the microvascular supply of the cord in that you're changing the profile of the spinal cord within the canal and sometimes the microvascular arrangements don't like it. Um And so then in those situations, you have to go for less of a correction to protect the spinal cord. No, I wish you could just tethering. Yes. Tethering, not clinically, but that's the whole point of doing an MRI scan. If you're going to operate on anybody, you have to do an MRI scan and that will tell you whether they're tethered the flexibility of the spinal cord. There's no way of telling. No. Um, it is, that's the whole reason that you need a really good neuromonitoring team. And, you know, we're massively lucky to have Helen and then the, and her team at the Norfolk and Norwich, they're absolutely fantastic. Um But you want people who are really clued in to what they're doing. Yes. Again, similar thing. It's about the magnitude. It's about why is there a Syrinx? Is it just a widened canal or is there something more going on because often it's a problem at the top of the spine. So if somebody's got AAA sort of chiari type deformity, then a similar thing, if you, you're pulling on, you'll then be pulling on that when you're correcting the spinal cord and it can be, you can have a devastating complication. So again, when you have the MRI scan, it's the whole spine and it has to include the base of the skull. If you don't include the base of the skull, then you're not going to know if there's a chiari malformation. Um And, and then you won't know whether you're, you know, effectively giving them a brainstem issue. So if there is a Syrinx, again, you need to make sure they've had MRI scans done and you need to make sure they've had a pediatric neurosurgical review because sometimes they may need a foramen magnum decompression before you can go ahead with your surgical correction. And it also will somewhat temper your approach. You will be far less aggressive in your curve correction that you're go aiming for to try and reduce the strain on the spinal cord and also knowledge, you, you're pre armed with the knowledge so that you can then have that discussion with the family about the risks involved. I think that might be all the questions, Mr Oh no, no it's not. Is the scoliosis still a surgeon to surgeon operation? Depends on the unit. Um I think you should always have two surgeons available. Um I think that uh two consultants. Um it, it depends on your unit. It depends on your, on the, on how you practice. Um I think that if you're in a, a big specialist center, you're gonna have people around all the time doing them. So it's not a problem, but if you're doing it in most tertiary centers, um then you may not have, you may be, you may not have someone there, but actually having someone there, if there is a problem is very useful and there are some curves you look at and you go. No, that's fine. I can, I'll, I'll do that, you know, as long as you know, there's someone available. If there is a problem. There are other curves you look at and you go yeah, 100% that is a two surgeon operation. Um But you know, it does vary from center to center, but the gold standard is 22 surgeons. And so it my basic level is that there is a second surgeon available if need, if needs be any other questions. All right.