Thank you very much. It's an honor to be here today. My name is Dr. Michael Bohl. I'll be presenting on spinal deformity. I'm a neurosurgeon practicing in Charlotte, North Carolina, and my practice is in both adult and pediatric spine deformity, and that's what we'll be reviewing today. Adult and pediatric spine deformity diagnosis, conservative treatment, and surgical treatment options. Here are my disclosures. So the term spine deformity is a real broad umbrella term that describes a very large heterogeneous group of disorders. There are a lot of terms that get thrown around when talking about spine deformity, but I think it's just important to recognize that the term spine deformity is really the umbrella term that describes any disease or pathology that results in a problem with the shape of somebody's spine. There are a lot of terms that are used to describe that shape, things like scoliosis, kyphosis, sagittal imbalance, coronal imbalance. We'll get into all of those things, but an equally if not more productive and useful way of describing a spine deformity is to talk about what causes it, and that's what's shown here on this slide. We're going to touch on both adult and pediatric deformities, but we'll spend most of our time on adult deformities. These are certainly something that anybody in a neurosurgery practice seeing any spine will come across, and there are a large number, as you can see, of different types of adult spine deformity, the most common of which would be degenerative deformity. These are problems with the shapes of people's spines due to degenerative disc disease, facet disease, spondylolisthesis, or slipped discs. Those things can all become severe enough that it starts to create a misshapen spine, and the more misshapen it gets, the more quickly it gets misshapen, and you can end up with curves like that shown here. There are also certainly plenty of iatrogenic spine deformities out there. These are problems that we, as physicians, that we in healthcare create, like this patient here with iatrogenic flat back syndrome and hardware failure, resulting in this global spine imbalance. There are idiopathic curves. These are likely patients who developed scoliosis when they were teens, never had them treated, and now that they're adults have progressive debilitating spine deformities with no structural underlying cause, hence the term idiopathic. Then, of course, you can combine these and end up with really complex stuff like this patient shown here. All of these different classifications are very helpful to us in terms of knowing, one, what we're dealing with, two, what we should be looking out for and what the workup is, and three, what the best way to go about treating these deformities is. Why is it important that we understand something about adult spine deformity? Well, for one thing, it's becoming increasingly prevalent. This Lancet review article published five years ago showed that all the demographic studies out there show that among patients age 65 and older, as many as 32 to 68 percent of people have a spine deformity. Now, obviously, the majority of those are not symptomatic. Predominantly, the moderate and severe ones that are very symptomatic are the ones we end up treating, but whether they have a symptomatic deformity or not, as neurosurgeons and as neurosurgery care providers, we still have to take into account the presence of these deformities even if we're treating one or two level disease, surgically or conservatively. This is becoming increasingly prevalent. It's already highly prevalent. Another reason it's important for us to know about these disorders is that the symptomatic ones are not just mildly symptomatic. These tend to be among the most severe and debilitating conditions that we see. This is a study that showed that health-related quality of life scores in patients with symptomatic adult spine deformity, the quality of life was affected more negatively for the adult deformity than arthritic conditions, chronic lung disease, diabetes, and congestive heart failure. These are not just mildly or subtly debilitating conditions. These are severely debilitating disorders. Another study here looking at the physical and mental impact of an adult deformity showed no difference between the impact of the spine disease and that of cancer, limited use of arms and legs, or in other words, paralysis of varying degrees, and again, heart disease and lung disease. These are really terrible conditions. It's very important that we not only be aware of them, but that we understand correct treatment algorithms and best practices for treating these conditions. In the same Lancet article, I'm reviewing the modern literature on this. They looked at all the non-operative and operative literature on this and concluded that non-operative management of adult spine deformity is demonstrably ineffective. Anybody who commonly treats patients debilitated by spine deformity know this, but I think it's important to point out that this is what our literature shows us. It's also been very well shown in peer-reviewed studies that when it comes to moderate to severe deformities that are symptomatic, non-operative treatment, although it's worth trying, is typically very ineffective at treating these disorders. We in the neurosurgery community very much are responsible for owning and treating these. Non-operative treatment, conservative treatment mostly benefits people with milder deformities who are already happy with their spine-related health. In other words, if you don't really have much of a deformity and you're not really symptomatic, conservative treatment is reasonable for you. For everyone else, surgery offers very clinically important improvements in their quality of life. A large number of published studies show that not only is surgery effective, but it's also cost-efficient over non-operative management. We in neurosurgery absolutely play the primary role in managing and treating these conditions. That's a very important thing to remember. Getting into how we diagnose these conditions, first and foremost, if we're going to identify problems with the shapes of people's spines, first we have to know what a normal spine looks like. When you're looking at a spine from the front, as shown over here, any curve that you can measure, a Cobb angle greater than 10 degrees is scoliosis. Anything less than 10 degrees is normal. Looking at it from the front, it should be pretty straight, nothing more than 10 degrees. When you're looking at it from the side, there should be these natural curves in the spine. Over here, you can see ranges of normal for these curves. Backwards-shaped curves are called lordosis. The cervical spine should have a lordosis of 20 to 40 degrees. A forward-sloping curve is called kyphosis. The thoracic spine should have kyphosis that measures around 30 to 50 degrees. The lumbar spine should be lordotic or have lordosis, and that should be 40 to 70 degrees. The junctions between the cervical and thoracic spine and the thoracic and lumbar spine, these are the transition points from lordosis to kyphosis and kyphosis to lordosis, respectively. Those should measure about zero degrees. If you have a large amount of kyphosis, for example, between T10 and L2, that is pathological. That should be about zero degrees. One way we can globally assess whether or not a spine is normally shaped or not, or whether a spine has some kind of deformity or not, is to just look at the global balance. In other words, is the base of the patient's neck over their pelvis or is it not? We can do this looking at the spine from the side and the sagittal axis. The measurement we use for that is called the SVA or sagittal vertical axis. This is the distance between the center of the C7 vertebral body and the back of the S1 superior end plate. That distance, shown here by this X, that distance should be less than five centimeters. That would mean that your head, looking at you from the side, is relatively over your pelvis and not too far out in front or behind. Similarly, if you look at the spine from the front, the base of the C7 vertebral body should be less than four centimeters away from the center of the sacrum. This measurement is called the CSVL, the central sacral vertical line. It's shown here by this X measurement. Similarly, if somebody's head is too far off to the side, one side or the other, that is defined as globally imbalanced in the coronal plane. That should be less than four centimeters. If you combine these two measurements together, that creates an oval or a cone of balance, often called the cone of economy. Inside this cone, a human body is able to support itself and maintain an upright posture. Once you get beyond five centimeters in the sagittal plane or beyond four centimeters in a coronal plane, the biomechanics of a human body standing upright start to fail. The human body will not be able to support itself for long in an upright posture, and you'll eventually have to sit down or lay down due to fatigue or pain. That is global spine balance. This is a very important measure when looking at whether or not somebody has a deformity, but it doesn't tell the whole story. Patients are able to compensate for global imbalance through a number of measures. For example, you can bend your knees. That will oftentimes bring somebody's head, if it's too far forward, bring it back over their pelvis. The most common way that people compensate for a spine deformity is to create imbalances in their spinopelvic parameters. The spinopelvic parameters, those are important to know how to measure and evaluate when looking at somebody and trying to determine, do they have a spine deformity or don't they? This is an example of what somebody may do intuitively if they have, for example, not enough lumbar lordosis, and their spine is shaped in such a way that puts their head way out in front of their pelvis. This circle here is the femoral head. This is a misshapen spine with their head sticking way out in front of them here. If the spine cannot compensate for itself, what most people will do is they'll retrovert their pelvis. As you can see with each subsequent picture, the pelvis is getting further and further retroverted. This measurement here, we'll get into this, this is the pelvic tilt. That measurement gets greater and greater, and the effect is it brings the head back over the pelvis. It brings them back into global balance. The spine, the shape of the spine has not changed. It's still a deformed spine. So how do we measure whether or not that's going on? We do that with spinopelvic parameters. The first and one of the most important measurements to know about is the pelvic incidence. There's a geometric proof over here that if you're into geometry, you're more than welcome to go through this to prove to yourself that this equation is true, or you can take my word for it, but pelvic incidence equals the sum of the pelvic tilt and the sacral slope. So the pelvic incidence is constant. This is something that we're born with. This is a number that we have when we reach skeletal maturity that does not significantly change over time. We are able, however, to change our pelvic tilt and sacral slope in order to bring our head into or out of global balance. And so the pelvic incidence also defines, and this is very important, the pelvic incidence also defines the amount of lumbar lordosis that we need to have in order to maintain balance. So for example, if your pelvic incidence is, let's just say, 40, you should have a lumbar lordosis that is no more than 10 degrees away from 40. So it should be 30 to 50. Your lumbar lordosis should equal your pelvic incidence plus or minus, the literature says nine degrees, most of us just say 10 degrees because it's easier to remember. So if your pelvic incidence to lumbar lordosis mismatch is greater than 10 degrees, that would suggest there is some kind of deformity present resulting in a mismatch between how much lumbar lordosis you should have and how much you actually have. The other measures that correlate very well to patient disability are pelvic tilt. This is a measure of how much compensating somebody is doing. 20 degrees or less is normal. More than 20 degrees would suggest that somebody is compensating pretty hard for a deformity. And then finally, the global spine balance measures also correlate very strongly with patient spine-related quality of life. The CSVL is not up here, but that's equally important. People who are globally imbalanced are very unhappy people. And typically, those are people who are already doing their best to compensate, but their deformity is so great that even their compensation measures are inadequate, and they are still imbalanced despite that. If there are three numbers you know about spinal pelvic measurements and overall global spine balance, these are the ones that correlate most strongly with debilitation. Okay. So we know what normal looks like. We know what abnormal looks like. And we have a way of recognizing if somebody has an abnormal spine that they are compensating for. The next question to ask, and this may seem like a no-brainer, but it can actually be somewhat difficult in some cases, is to ask, where is the spine deformity? Okay. In many cases, it's very obvious where the deformity is, but not in all cases. And if you see a lot of deformity, there'll certainly be cases where you see it, and you have to stop and ask yourself that question. And it's obviously important to know because where the deformity is defines where we do our surgeries. You don't want to operate on non-deformed parts of the spine if you're doing a deformity correction, generally speaking. So here's a case example. This is an adult patient. The SVA, the measure of their global balance in the sagittal plane is shown here. It's two and a half centimeters, which is normal. It's less than five. But as you see down here, their pelvic incidence is 55, but they only have 35 degrees of lumbar lordosis. So they have a 20 degree mismatch. Also, their pelvic tilt is 26 degrees, so more than 20. So even though they're globally balanced, they're retroverting their pelvis pretty significantly. 26 degrees is a lot. And they have a 20 degree mismatch between their pelvic incidence and lumbar lordosis. That should be 10 or less. And so this would tell us that there is some spine deformity present, which is causing a mismatch in this patient's spinal pelvic parameters. And the patient is successfully compensating for it in their global balance. And sure enough, if you look at their AP x-ray, they have this 60 degree degenerative curve here. Now, if you look at both of these x-rays together, you're not going to have a hard time telling where the deformity is. But there are some cases, like this one, for example, where it's not always as clear. So this is a younger adult patient who comes in with back pain. And the back pain is all over her back. It's in her thoracic, lumbar spine, middle of the back, low back. And as you're looking at this, it may not necessarily be intuitive where the problem is. If we look at the measurements, this patient's thoracic typhosis is 80 degrees. The lumbar lordosis is 52. Pelvic incidence is 27. So here we have a very large, a 24 degree mismatch between the pelvic incidence and lumbar lordosis. But it's important to note that it's in the other direction. This patient has much more lumbar lordosis than she needs. She's not retroverting her pelvis, and she maintains good balance. The number that really sticks out as abnormal here, if you remember what a normal thoracic typhosis is, that should be about 30 to 50 degrees. So an 80 degree thoracic typhosis, that's pretty abnormal. And that is, in fact, where the deformity is here. What's going on here is that this patient has a thoracic spine deformity, leading to thoracic hypertyphosis. 80 degrees is too much. And she's compensating for that typhosis by hyperlordosing her lumbar spine. So normally, she should have within 10 degrees of 27 degrees lordosis. She should have probably no more than 37 degrees of lumbar lordosis. But she's cranking her lower back back to 52 degrees just to keep her head over her pelvis. So she doesn't have to retrovert her pelvis. She's young. She has a flexible lumbar spine. And the deformity is in her thoracic spine. Her lumbar spine is normal. So you want to be careful. If you see numbers like this, that you don't think that this patient needs a T10 to pelvis. The T10 to pelvis, that just takes away the normal part of the spine and the part that she's using to compensate. The problem is in the thoracic spine. And sure enough, if we go back two years and look at her standing x-rays from two years ago, she had a thoracic typhosis of 52 degrees, much closer to normal. And two years later, it's 80 degrees. So this is where this patient's deformity is. This patient needs a thoracic surgery, not a lumbar surgery. This is another very similar example to the case I just showed you. Only difference is that it's very obvious where the deformity is because it's right where all this failed hardware is. So this patient has much more lumbar lordosis than they need. The PIL mismatch is 20 degrees, but the lumbar lordosis is greater than what it should be. And that's because she's compensating for this focal typhotic problem here where her screws pulled out and rods broke and all this stuff failed in here. And sure enough, when you fix that problem with a thoracic, not a lumbar surgery, all the spinal pelvic parameters normalize. So her lumbar lordosis goes from 83 to 68 because she doesn't have to hyper lordos anymore to keep her head upright. Her PIL mismatch goes from 19 to 4, and her pelvic tilt goes from 23 to 14. And we stayed out of the lumbar spine entirely. Because now she doesn't have to compensate for this focal exotic problem. So in review, does the patient have a deformity? Is the spine shaped normal or is it abnormal? And if the patient does have a deformity, are they compensating for it by imbalancing their spinal pelvic parameters? If they do have a deformity, where is the deformity? Okay. You know, here are three different examples of different types of adult deformities that we commonly see. Identifying where the deformity is in these patients. In some that's easy, in some it's not as easy. And it's real important when coming up with a treatment plan for all three of these patients to ask yourself, where's the problem? Because that's where we need to go in our surgery. And finally, just to review here, how do we go about treating these spinal deformities? It is absolutely appropriate to attempt conservative treatment for anybody. However, it is also very important for us to recognize that in moderate to severe deformities, like those that you've seen so far, in patients who are unhappy with their spine-related health, non-surgical treatment, non-operative management has been demonstrably ineffective. And the literature shows that over and over again. So surgery is the standard of care. It's very important to remember that. Surgery is the standard of care for these patients. So how do we go about coming up with a surgery plan for these patients? This can be very confusing. And I'll jump ahead just by saying, there are a lot of right answers. There is not just one correct way to fix these kinds of problems. There are a lot of different ways to get there. That can create quite a bit of confusion. The world of spine deformity surgery can feel a little bit like alphabet soup. We tend to talk in abbreviations, and the abbreviations, they tend to get overused and used differently, and it can all become very confusing. In addition to that, there are a lot of different ways to get to the spine. And for every 10 surgeons out there, there's 12 different preferred ways to do it, it seems. The important thing is not to think about this in terms of there being one right or wrong way to do this. The reality is the best way to fix the spine deformity is whatever the treating surgeon feels they are best at, that is the best way to do it. In other words, in the world of adult spine deformity surgery, it's very important that we all have a big toolbox. It's very important we all be comfortable with all these different treatment strategies. But it's also very important that surgeons and their mid-level providers have their favorite tools, that they have the things that they are not just proficient at, but excellent at, because that is how we take very complex, potentially morbid surgeries, and make them very safe and very effective for patients. So as you see me going through cases here, you'll probably get an idea of what my own preferred treatment approach is. That does not mean that that's the only right way to do it. There are a lot of right ways to do it. In my practice, in my hands, this is the right way for me to do it, but that does not mean I argue it's the right way for everyone to do it. So when we're looking at planning an adult spine deformity surgery or an adult spine reconstruction, one of the most important things for us to recognize is whether or not we are dealing with a flexible, a stiff, or a rigid curve, because the surgical plan will change significantly depending on what kind of curve it is. Is it really floppy? Is it going to move wherever we want to put it? Or is it like a rock? It's not going to want to move. We can identify that with preoperative imaging. Standing scoliosis x-rays are helpful. Comparing standing films to supine films, for example, scout views on CT scans or MRIs, that's a very easy way to take a standing film and compare it to supine film. Personally, I like doing maximum traction films. So when they're getting their standing x-rays, they'll lay down and the radiology techs will pull on their arms and legs. And that will oftentimes help us see how flexible a curve is. There are a number of ways to evaluate that. Side bending films are another way. Flexion extension films are a common way. But with preoperative imaging, you want to have an idea. CT scans are also helpful because you can just look and see, is it fused or not? But it's important to look at that ahead of time to give yourself an idea of how flexible or rigid is this spine deformity. The plan that you go into with surgery directly results from how rigid or flexible that curve is. Flexible curves are much easier to fix. They're much safer to fix than rigid curves. And so the strategy for fixing any spine deformity is to make all the deformities, make all the curves flexible. And the way that we do that is going through stepwise approach, successive osteotomies. So basically osteotomies are what we do to make the spine less stable, to make it more flexible, and to make it easier for us to move it into the shape we want it to be. My approach, the approach I like using is a stepwise approach. This picture you see over here, this is the Schwab osteotomy grading scale. The reason I like this scale is because it cuts through a lot of the alphabet soup of osteotomies. We all talk about Ponte's and Smith-Pete's and PSO's and SPO's, and it can be confusing what those things mean because a lot of people use them differently. This grading scale goes from one through six. In order to do a two, you have to do a one. In order to do a three, you have to do a one and two. So you move successively through these osteotomies. And the higher you get, the more destabilizing of an osteotomy that is. And so I take a stepwise approach to this. And here are some examples. This is an adult idiopathic scoliosis. This is a very flexible curve. This is going to be sufficiently treated with grade one, maybe grade two osteotomies. Okay, this is grade one and two are posterior column osteotomies only. You're just cutting variable amounts of the facet off. At grade one, you're just cutting the inferior facet off. Grade two, you cut the whole facet out from pedicle to pedicle. Grade one, maybe grade twos are all you need to take this curve and make it real straight, okay? If we take this curve, for example, this is not gonna be flexible, but it's also not gonna be rigid. This is more of a stiff deformity. Anytime you're looking at a CT or MRI and you see the air in the disc spaces, those vacuum discs, those are very floppy discs. And so these are gonna move just fine. However, this disc, which is where the most focal part of the deformity is, this part of the disc is open, but this part appears to have fused. So parts of this are gonna be very flexible. Parts are gonna be very rigid. Overall creating a stiff deformity. And it's important to recognize that going in. The way that I would treat this, the way I did treat this is with something called a disc space osteotomy, okay? Posterior column work alone is not going to make this flexible because two vertebral bodies have fused together at that point in the disc space. So we have to get into the disc space and do three column work, a three column osteotomy. However, this doesn't really require a pedicle subtraction. It doesn't really require cutting a whole wedge of bone out. All we really need to do is send an osteotome or a bone scalpel or something across this disc to crack that open and separate these two vertebral bodies. And so that's what we did here. Once we got through that disc, it cracked open. Everything became flexible at that point. It wasn't a stiff deformity anymore at that point. It's a very flexible deformity and you can easily realign the person into the shape that you want them to be. And then finally we have rigid or fixed deformities. These are spines that are just fused in the shape that they're in. This is one example of a case that we saw that was fixed. This is going to require three column osteotomies. This is going to require some amount of bone resection. In her case, due to the severity of the curve here, we ended up having to do multiple grade five osteotomies. These are basically vertebral column resections. We did one, saw the correction we were gonna get and it wasn't adequate. So we skipped a level and did another grade five osteotomy. And sometimes if it's a very rigid, very fixed spine, that's really the only option. And so you can see here, one of our osteotomies was here, the other one was here, and that enabled us to get her back into global balance and also a normal physiological shape here for her spine. Now, as you can imagine, spine deformity surgeries like the ones I'm showing you here are big surgeries. They carry some risk. When you're doing big surgeries like this, it's very important to recognize the impact that one, surgical volume, and two, standardizing your workflow can have on outcomes and the overall safety of that procedure. It's been very well shown in the literature and it's just intuitive that the more of something you do, the better you get at it. And spine deformity surgery is definitely true, definitely consistent with that. The more of it you do, the better you get at it. And so if you're doing spine deformity, it's important to try and make it a part of your regular practice, because the more you do of it, the better you'll get at it, obviously. The other real important thing is to try and standardize your workflows around these cases. If you're doing these cases differently every time, if sometimes you're doing it like this, and then the other time it's totally different, and then the next time it's totally different, it can just become very chaotic and you never really know what is working and what's not. So I think it's very important when doing spine deformity surgery to standardize your work process. Try and make every case standard. You do it as close to the same way every time as possible. At that point, you get a handle on what your outcomes are, what your efficiencies and deficiencies are, and then you can implement continuous process improvement where you change one thing at a time and see does it improve or worsen your outcomes. And you have a much better idea of recognizing that because you're doing it the same way every time. We've been doing this in my practice for a few years. I'm showing you here kind of my standard workflow. I'm not showing you this because I expect anybody to remember it, but just to say that this is kind of the same way we do it every time approach that I take in my practice. And we change this every once in a while. Sometimes we'll make a change to see does it help or does it make it worse? And anything that helps, we keep, and that becomes the new standard. Anything that doesn't help gets thrown away and we move past it. It's important to approach this this way because these are very complex procedures and they can be very safe and effective, but they can also be dangerous. And the way we make them safe and effective is by standardizing them. As an example of the impact of this, I've been doing this now for two, three years, the standard work process. What you see here is blood loss data. All of these blood losses are measured from the cell saver. So it's a objective measurement of blood loss. It's not my estimate or the anesthesiologist's estimate. And these six groups here are groups of 23 consecutive patients who had surgery. Group one had surgery the longest time ago and group six is the most recently treated group in this series. And these are the objectively measured blood losses. And you can see that going through this process of standardization and continuous process improvement, you can go from over a liter average blood loss on these cases to what our most recent was, is less than 400 milliliters of blood loss, which is a really big deal for big cases like this. Over that same time period, we also saw a decrease in our albumin transfusions, a decrease in blood transfusions, both measured as blood transfusion volume in the OR, number of intra-op blood transfusions and number of length of stay blood transfusions. So that's all consistent with less blood loss. Patients are not getting younger. In fact, they're getting older over that same time period. We're not treating fewer levels. If anything, we're treating more levels. Patients are staying as healthy, relatively healthy or sick. ASA score is not significantly changing. And our MRSA surgical invasiveness score is effectively not changing. And those scores are higher than what's reported in the literature and other studies looking at blood loss. So this is an effective way to do this. It's an effective way to take what traditionally were thought of as one to two liter blood loss cases and make them less than 500 milliliter blood loss cases. We also keep track of how well patients feel they're doing. We ask all of our patients, what percent better or worse do you feel now compared to before surgery at their three, six and 12 month visits? And these are the scores over the last 240 consecutive adult spine deformity cases. So in the last 240 cases with a response rate of 89%, on average, people feel at three months post-op, 81% better than they did before surgery. And then at the six and 12 month marks, it's 83 and 88, 89% respectively, which are big numbers. These are very debilitated people who feel much, much better, 80 to 90% better three to 12 months after surgery. So in summary for adult spine deformity, adult deformity is an increasingly common disease that has a tremendously negative impact on people's health-related quality of life. These are among the most debilitating conditions that we see, not only in neurosurgery, but in healthcare generally, as debilitating as paralysis, as cancer, as heart failure, et cetera. Surgical treatment is the standard of care. It's not wrong. In fact, it's right to offer non-surgical treatment, to have people do physical therapy, to offer those things. But it's also very important for us to recognize and to be honest with our patients that those modalities have a very, very poor track record. And the literature is very clear on that track record. Those things, those non-surgical treatment pathways are demonstrably ineffective for the treatment of moderate to severe spine deformity in patients who are symptomatic. Finally, taking a standardized systematic approach to these surgeries is a powerful way to minimize blood loss, morbidity, all of those negative things that we can associate with these surgeries, to make these surgeries not only very safe, but very reproducible, and result in very good outcomes for our patients so that they go from highly debilitated back to a very good quality of life. Okay, we'll take a little breather there as we transition to pediatric spine deformity. This is gonna be a more brief review. Pediatric spine deformity is in some ways similar, but in many ways very different. And it's something that we in neurosurgery are taking on more and more. So it's something that many of us and many mid-level providers will start seeing increasingly more as the years go on. So pediatric spine deformity similarly is a very heterogeneous group of diseases. The most common pediatric deformity that we see is adolescent idiopathic scoliosis, like the case shown here. Idiopathic scoliosis usually presents during early adolescence, during somebody's kind of growth spurt, and there is no structural underlying cause for it, hence the term idiopathic, okay? There are also many other types of scoliosis that occurs in kids. There are congenital deformities. This is when bones don't properly shape. People develop hemivertebra. Kids develop hemivertebra, things like that that can lead to deformities like the one you see here. There are neuromuscular disorders. This young girl suffered a gunshot wound to the spine years before and developed this neuromuscular scoliosis. And there are many other more complex combination types, just like in adults. Things like this young patient who is a syndromic patient who had a myelomeningocele repaired shortly after birth and has now developed this effectively 180 degree lumbar curve, okay? The approaches to treating all of these things are very different, and so it's important to kind of keep in mind these classifications because we need to know are we going down this pathway or this pathway with this patient? And the surgical strategies for these treatments, like for this one example, sometimes have to get very creative. As you can see here, we effectively had to do a kyphectomy in this patient, just cut out that kyphotic segment, that 180 degree curve. Believe it or not, the screws that you see there, this patient weighed 35 pounds. The screws that you're seeing there on that postoperative CT scan, those are cervical screws. They're three and a half millimeter diameter by 15 to 20 millimeter length screws. So those are the kind of screws you'd normally see as a lateral mass screw in somebody's neck. So sometimes you need to be creative with these. This screw right here just crosses the osteotomy. It just goes straight through the canal. This patient doesn't have any neurological function below this level, and so we're able to do things like this to get good fixation across. So some of these pediatric deformities do require a very different surgical approach than what many of us are used to seeing, for example, in adult degenerative spine disease. Okay. Adolescent idiopathic scoliosis, there's a lot of data on this, and treatment algorithms have been studied very well and are very well defined. Bracing is the most important thing to know about this for kids with moderate curves who are skeletally immature, bracing is the standard of care. Bracing works. The braced trial from 2013 pretty definitively showed this, and more importantly, the more you wear the brace, the less likely you are to progress to needing surgery. So bracing is standard of care for skeletally immature patients with moderate curves. That's 25 to 45 degree curves. The Lanke classification system defines for us where the deformity is, okay? It's important to know where the deformity is. That's what the Lanke classification system does. So once we know where the deformity is, then we know where to do the surgery. And then we have all the non-idiopathic cases, okay? And those are very different diseases that require very different surgical approaches. We try not to fuse spines before the age of 10. Sometimes our hands are forced, especially in very severe deformities like this. Even in cases like this, we can significantly improve these patients' qualities of life with surgeries. This patient, for example, underwent this correction with me. This was the office note from the pulmonologist six months later. This patient was declining in terms of her pulmonary function. After surgery, she's moving away from needing any further invention, and her ability to breathe has significantly improved. So even in very severe cases like this, we still can significantly improve people's quality of life. Overall, just like adults, pediatric spine deformity is a very heterogeneous group of diseases. At AIS, adolescent idiopathic is the most studied of these with high-quality evidence backing standard treatment algorithms. Non-idiopathic scoliosis is more complex and takes a more nuanced approach. And so it's important to know whether you're dealing with one or the other. All right. Thank you very much. We'll wrap it up there. Just under the buzzer. Or over the buzzer. Thank you, Dr. Ball.

spinal deformity

scoliosis

kyphosis

adult spinal deformities

surgical intervention

pediatric spine deformities

adolescent idiopathic scoliosis

Dr. Michael Bohl