Adult Idiopathic Scoliosis

Podcast Transcript

Neuro Pathways Podcast Series

Release Date: November 1, 2024

Expiration Date: November 1, 2025

Estimated Time of Completion: 28 minutes

Adult Idiopathic Scoliosis

William Clifton, MD

Description

Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases
• Describe options for the treatment and care of various neurological disease

Target Audience

Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

ACCREDITATION

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CREDIT DESIGNATION

• American Medical Association (AMA)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  
  Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

• Certificate of Participation
  A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

• American Board of Surgery (ABS)
  Successful completion of this CME activity enables the learner to earn credit toward the CME requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Credit will be reported within 30 days of claiming credit.

Podcast Series Director

Imad Najm, MD
Epilepsy Center

Additional Planner/Reviewer

Cindy Willis, DNP

Faculty

William Clifton, MD
Center For Spine Health

Host

Glen Stevens, DO, PhD
Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

Adult Idiopathic Scoliosis

William Clifton, MD

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

William Clifton, MD	Symgery Intellectual property rights (Royalties or patent sales)
Imad Najm, MD	Eisai Advisor or review panel participant NIH Other activities from which remuneration is received or expected: Research Funding LivaNova, PLC Advisor or review panel participant SK Life Science Inc Advisor or review panel participant Teaching and Speaking
Glen Stevens, DO, PhD	DynaMed Consulting

The following faculty have indicated they have no relationship which, in the context of their presentation(s), could be perceived as a potential conflict of interest: Cindy Willis, DNP.

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: Neuro Pathways Podcast November 1, 2024 to log into myCME and begin the activity evaluation and print your certificate If you need assistance, contact the CME office at myCME@ccf.org

Copyright © 2024 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research, discoveries and clinical advances in the fields of neurology, neurosurgery, neuro-rehab, and psychiatry.

Glen Stevens, DO, PhD: When diagnosed and managed early, adult idiopathic scoliosis can result in fewer complications later in life. But the reality is more than 50% of patients receive late-age surgery suffering with larger deformities and enduring more complex surgical procedures. In today's episode of Neuro Pathways, we're discussing our evolving understanding of idiopathic scoliosis and the value of surgical intervention in adolescents.

I'm your host, Glen Stevens, neurologist/neuro-oncologist in Cleveland Clinic's Neurological Institute. I'm very pleased to be joined by Dr. Bill Clifton. Dr. Clifton is a dual orthopedic and neurosurgery trained spine surgeon in Cleveland Clinic's Center for Spine Health. Bill, welcome to Neuro Pathways.

Bill Clifton, MD: Thanks Glen. Thanks for having me today.

Glen Stevens, DO, PhD: So Bill, before we get started, introduce yourself to our audience out there. Tell us where you trained, where you came from, what you do on a daily basis.

Bill Clifton, MD: Yeah, I did neurosurgery residency at the Mayo Clinic both in Jacksonville, Florida and Rochester, Minnesota. And then I did an orthopedic spine surgery fellowship in adult and pediatric scoliosis and complex spine deformity at the Columbia University in New York City.

Glen Stevens, DO, PhD: So, I'm going to take a little detour here. I'm going to just tell you a little story. So back probably almost 30 years ago, I was seeing patients over in the Mellen Center and the Mellen Center is the Center for multiple sclerosis. And I see a young man come in to see me and I said, "Go through the story and what you're here for." He says, "Well, I have MS. And I'm going through the history." And I'm listening to his history and I'm thinking, "I'm not really hearing anything that sounds like MS to me." And they always teach you that if you get the history and you're not sure what you're doing, you better go back and get some more history. So I get some more history and I'm still a little bit confused.

So, then I examine him and when I do the exam, I know exactly what he has, which is just the opposite of what they always teach you with studying. And I said to him, "Do you have a MRI of your brain?" And he goes, "Yes, it's right out there." And this of course was back in the days where it was just the hard copy films. So I go out there and I look at the films that he brought, and of course there's no brain MRI scan at all. The only scan he has is a spine plain film X-ray. And I look at it and he has a huge curvature of his spine. And I came back in and I said, "Sir, you have a very bad case of scoliosis." He says, "That's right, doc, multiple scoliosis." The internet was fairly new at that time and his medical knowledge base wasn't that new. And he got a little confused on the spelling and I think he put in scoliosis but spelled it incorrectly as sclerosis. So he thought he was at the right place. So I said, "We can fix you. I know exactly who you need to see." So we sent him over to the scoliosis folks and they looked after them and fixed him.

Bill Clifton, MD: Down the hall to the left.

Glen Stevens, DO, PhD: Down the hall to the left. So that's my some total of interaction with scoliosis patients. And of course, I remember in the old days, and I'm not sure if they even do it anymore, but when we used to do a lot of sports physicals on kids, everybody would have to stand, bend forward and you'd look to see if they have scoliosis. Do they still teach that? Do people still do that today?

Bill Clifton, MD: Yeah, it's called the Adams Forward Bending Test. And it's still pretty routine, not so much in schools nowadays, but more of a pediatric well visit.

Glen Stevens, DO, PhD: And I think it was more in the sports physicals. So we used to refer a lot of people.

So we're going to talk about adult idiopathic scoliosis and excuse me if I say sclerosis, because now I'm the wrong way for our listeners. So how do we diagnose it? My understanding is idiopathic always means you don't really know what causes it. But what is the cause of idiopathic scoliosis?

Bill Clifton, MD: I always make a joke about that to my patients. I say it comes from the Latin word idiot, meaning we are not sure, but we actually do know, Glen, that it's a very specific type of scoliosis that's been studied for the last 20 years. And it's a type of scoliosis that starts to develop as patients hit adolescence. And so once they start to reach skeletal maturity, they develop these conditions. So it's not something that they're born with, that would be congenital scoliosis. And it's not something they develop because of the effects of gravity, which would be something like a degenerative scoliosis. And it's not something that they would get from a surgery that didn't go the way that you'd want it to and that's called an iatrogenic scoliosis. So those are really the four main domains. But today we're going to focus on the idiopathic.

So this is a curve pattern that's really characterized by having what's called a main thoracic curve. So it's a curve that starts in the chest spine, in the middle of your back, and then from there can develop more curves depending on which curves are creating the scoliosis and which ones are compensating for the scoliosis to try to keep the person's head over their pelvis.

Glen Stevens, DO, PhD: We mentioned it just a little bit at the start. Obviously you can do the forward bending test, but how do we diagnose it?

Bill Clifton, MD: So one of the first symptoms that kids have is pain. And you can see this in children that are very active, and this mostly occurs in females. So a lot of these kids are active soccer players or gymnasts, and then they notice that their clothes aren't fitting themselves the way they used to, or they start to notice some breast asymmetry that they didn't have before, or they start to complain of shoulder pain or mid thoracic pain or even some low back pain. So if children start to complain of those things, that's one of the first diagnoses that we look for.

Glen Stevens, DO, PhD: And why women more than males?

Bill Clifton, MD: It has to do with the genes, and it also has to do with ligamentous laxity of the ligaments that are holding the bones together. So it just tends to develop more in women.

Glen Stevens, DO, PhD: They come to see you, they have this typical pain. What's the workup?

Bill Clifton, MD: We have to characterize... An adolescent idiopathic scoliosis is different from an adult idiopathic scoliosis only by the age 18. So it's the same curve pattern, same curve type. So if you're seeing someone that's not skeletally mature, it's a very different workup than if you're seeing someone that is skeletally mature. So we're going to focus on the patients that come in our office that are skeletally mature, and usually for females that's around 15, 16 and up. So the first thing to do is actually to examine the patient, look at them. And you can tell a lot about a curve pattern just by physical examination. So we would have the patient either remove their shirt or come and get in a gown, and then we'd perform Adam's Forward Bending Test.

We can measure degrees of rotation on a device called a scoliometer, which we're able to place on the patient's back. And that helps us determine which of these curves, even before we look at the films, are going to be the important ones to fix. Because not every type of scoliosis needs both curves fixed or your three curves fixed. Some of them only need one curve fixed. So if you can diagnose these curves and catch them early, oftentimes you can save patients pretty big operations.

Glen Stevens, DO, PhD: Now do you see more curves left or right? Does it have anything to do with handedness or dominance with people?

Bill Clifton, MD: So about 90% of these curves are to the right. It's a right main thoracic curve. Left main thoracic curves are typically congenital, but we can see them in atypical cases of idiopathic scoliosis.

Glen Stevens, DO, PhD: And why is that?

Bill Clifton, MD: It has to do with the genetics and how this developed.

Glen Stevens, DO, PhD: Interesting. Everybody gets plain film X-rays or do you go to CT or CT is not necessary? Plain film's good enough.

Bill Clifton, MD: We always start with a plain film. And one of the awesome things about the Cleveland Clinic is we have new technology here for X-rays, especially for our young patients who you know they're going to get X-rays over their life, especially if you're following a scoliosis patient. So we have a machine here called an EOS x-ray. And what that is, it's a 10th of the dose of a normal X-ray, and it gives us the entire patient's body. Because the more that we're finding out about this type of scoliosis, the more we realize that it's really the pelvis and the limbs that are really important in the development of this type of scoliosis and also how it's going to continue to progress. So that is one thing that we start with here. It's a low dose X-ray but it gives us 10 times more information.

Glen Stevens, DO, PhD: Do you do any dynamic imaging?

Bill Clifton, MD: So no, we've actually gotten away from doing side-bending X-rays, and if you're thinking about intervening on a patient, for young patients, I typically don't get CTs in my practice for idiopathic scoliosis because I don't like to radiate my young patients, especially with young females. But we do get an MRI. And on the MRI you can measure the curves when you're supine compared to standing up and that gives you an idea of the flexibility of the curves.

Glen Stevens, DO, PhD: So let's say I'm a general practitioner, have a young patient come in, I check the... Was it the Adam's test?

Bill Clifton, MD: Mm-hm. (affirmative)

Glen Stevens, DO, PhD: I see a little bit of stuff there. I don't have the fancy machine to put on their back to look at it, but I look at it. And I go, "Well, with my years of experience it doesn't look that bad." And I don't refer anybody, which I guess becomes then a problem. But let's say what happens to these people that I just kind of go, "Oh, it's a little bit there," and I didn't refer them. Is that a bad thing? What percentage of them will become a problem?

Bill Clifton, MD: That's a great question. If the patient's asymptomatic and it's something that's incidentally found, it typically doesn't require further workup in a case like you had mentioned, that may just be something clinically insignificant but does need to be documented in case the curve does progress. If a child or a young adult is complaining of pain, no matter what the degree of curvature that you think it might be, it's always good to get some sort of X-ray so we can document.

Glen Stevens, DO, PhD: So where are patients typically when you see them? Who are you seeing?

Bill Clifton, MD: So just going back and I'm going to tell you a neurology story now. So if you look, and I'm going to answer your question kind of the long way. But if you look at epilepsy surgery and how epilepsy surgery has been pushed forward in the last 20 years, sort of dogma back in the nineties and eighties was never get epilepsy surgery, bad outcomes, we’re going to medicate these people until they're blue in the face. And then what we realized was that the more seizures these patients have, the worse they do long-term. And then it was really the epilepsy surgeons that turned around and said, "No, these are the techniques that we have to get Engel 1 outcomes and help these patients be seizure free."

And they were very aggressive with their management of these seizures. And even though that was kind of taboo at the time, now it's one of the first line managements of seizures. And so we're kind of at the cusp of where that is with this type of scoliosis. So there's a stigma around spine surgery that is a negative for the most part. And what I think a lot of practitioners and a lot of even patients and some surgeons don't even realize is that early intervention in a lot of these cases can prevent these curves from getting to the point where these patients are going to need a massive surgery and some of them even require vertebrae removal, like basically sawing the person in half to try to fix this.

So when I'm seeing these patients, and especially at a tertiary referral center like the Cleveland Clinic, usually this person's been seen, documented scoliosis and has been told, "Oh, don't let anyone even look at you or touch this until it gets to the point where you can't walk anymore." Well, at that point, it's too late. If you're starting to get neurologic dysfunction from the deformity, that's something that may not be reversible. So even if a practitioner has a patient that they say, "Well, maybe this is inoperative." It's important to send them to somebody who really can tell if an early intervention would be warranted or not.

Glen Stevens, DO, PhD: I like the analogy with the epilepsy because I think that's really been a big problem. Right, that instead of just doing two medicines and then referring, people are on 16 different medications over time, and it's just if you're a kindling theorist, seizures beget seizures, there's nothing good about waiting. So before we get into the surgical, what about non-surgical approaches, can you brace me up and fix me that way? Or is it just symptom control?

Bill Clifton, MD: So like we said, we're going to focus on skeletally mature kids or adults. And at that point, it depends on the degree of curvature and then the type of scoliosis. So there's six types of idiopathic scoliosis, and this is all put forward by Dr. Larry Lenke, who was my mentor. So he was the one that really took this and made it into a three-dimensional problem. And over the last 20 years, they've shown the outcomes of treating these disorders in this way. And there's a type of physical therapy called Schroth physical therapy, which actually can reverse some curves. So not every curve needs a surgery. And if you can catch this early and get them into the right type of physical therapy, not just spine, but this specific method, even some chiropractic manipulation can be very helpful for a chiropractor that is very familiar with scoliosis.

So I have had patients that have come to me for surgery, I've measured their curves and said, "Listen, try this. It's awesome." And their curves have actually regressed. So that is one option for non-surgical management. Other things like injections can be of benefit if there's a focal area that's causing pain. And then of course there's certain things like lifestyle modifications, smoking cessation, weight loss and diabetes control, things like that.

Glen Stevens, DO, PhD: I know my grandkids carry around bookbags that are way too heavy. Worsen the problem, not worsen it, it causes back pain and that's the extent of what it does.

Bill Clifton, MD: There really hasn't been great evidence for the whole tech neck or that sort of thing to really push this forward. It's an instability problem of the ligaments that are holding the spine together. And so I get a lot of patients that say, "Do I have Ehlers-Danlos? Do I have a connective..." Well, it's a spectrum. Every patient with a scoliosis has some sort of connective tissue disorder and they fall under that umbrella. So it's not more of an external factor as it is more of their internal genetics that are causing this to progress.

Glen Stevens, DO, PhD: So they come see you, you mentioned a couple of things. Do you do any other testing with your surgical evaluation, let's say you think that the degree of... because there's so many variants…but you feel the degree of abnormality as such should have surgery, other tests that need to be done, maybe MRI you say?

Bill Clifton, MD: Exactly. So all these patients once, if they have any neurologic symptoms whatsoever, should have advanced imaging like an MRI. Pre-surgery, I get MRIs on patients because it depends on the position of the spinal cord to plan the correction to prevent neurologic issues during the operation.

Glen Stevens, DO, PhD: Is there an ideal age for surgery?

Bill Clifton, MD: So, it depends on curve magnitude and then skeletal maturity. Anytime you talk about fusion, you always want to wait until a child is pretty close or completely skeletally mature so that they don't grow through their fusion. And then if they do that, that can cause the scoliosis to actually progress through the previous fusion. And that's called a crankshaft phenomenon and that can lead to really significant problems. And that is one of the conditions that I treat in kids that have had that done.

Glen Stevens, DO, PhD: So let's talk surgical approaches and procedures. What kind of things do you offer?

Bill Clifton, MD: So there's something called a selective thoracic fusion, and basically what that means is that if a patient comes in and they have two or more curves, but only one or two of the curves is what we call structural or the main curve, then just by correcting that curve with physical therapy after the surgery, we don't have to fuse the person's entire spine. And so if we can catch patients early, a lot of them are candidates for this selective fusion, which is less surgery, less operative time and less blood loss than doing a massive spinal reconstruction if you wait until the patient's 60 or 70.

Glen Stevens, DO, PhD: And rod placement, all patients. So I guess nothing's ever all patients but common to have to place rods. And if you place them, do they come out later or they stay in?

Bill Clifton, MD: No, we hope they stay in forever. And there is a procedure called vertebral body tethering, and then that is a procedure that can reduce the degree of scoliosis that's not a fusion. And for kids that are on the border of being skeletally mature, but you want to reduce their curve to keep it from progressing, but you don't want to fuse them yet, that's a great procedure.

Glen Stevens, DO, PhD: So I come in to see you, I've got some curvature. You think, "Boy, this is beyond anything that any therapy would help. I tried it. It didn't help me. I'm going to have to have something done surgical." What's the success? What's the likelihood that I'm going to need additional surgery down the line? Those types of things.

Bill Clifton, MD: That's probably the most common question that I get asked. And that really depends on the age of the patient and the degree of the curvature and how early you catch it.

Glen Stevens, DO, PhD: And how well can you say those things to people? I mean quite well or not so well? Can you look at my spine and the other attributes about me and tell me I would have a 10% likelihood of requiring additional surgery, or I got a 90% likelihood somewhere down the line, I'm going to get something else done.

Bill Clifton, MD: It's really hard.

Glen Stevens, DO, PhD: Can you tell that type of stuff?

Bill Clifton, MD: No, that's a great question. There's certain factors that you could say, "Well, if we don't fix this now, then this may become an issue." But there's so many factors at play when you have so many different mobile parts to the spine. It's not just one joint. It's really hard to predict.

What we do know is that in patients that you perform selective fusions for is that the technique you use in the operation is the most important prognostic factor, meaning planning the surgery as an individualized medicine for that particular person. So it's not a one-size fits all, it's not everyone gets the same correction. So having these X-rays, looking at these pelvic parameters, understanding just the right amount of curve that that particular person needs, that's what we do in my practice. To make sure that they get a good result and that is what has been shown to decrease the need for surgery later down in life.

Glen Stevens, DO, PhD: So if you fuse me, obviously there's going to be a point at the top that interfaces with non-fused, a point at the bottom that interface with non-fused that I would suspect would be risk areas for movement.

Bill Clifton, MD: That's absolutely correct.

Glen Stevens, DO, PhD: Or motion, right. What can we do to help that? Or lots of physical therapy, strengthen everything, don't do silly things, or just your genetics and what's going to happen?

Bill Clifton, MD: No, that's a great question. So obviously there are lifestyle modifications like the things we mentioned before that could prevent that from happening. But really it's about what happens in the operating room. So taking care to horizontalize the disc spaces to de-rotate the vertebral bodies to the point where they're physiologic actually will affect the vertebrae below where you're fusing and correct them. So there's very subtle things that we do in the operating room to get people perfect to try to prevent them from having another surgery. So really it's about a surgical technique and less about external factors, actually even less so than what we used to think.

Glen Stevens, DO, PhD: So if I'm somebody out here, a physician out there listening to this, how do I know who's doing that?

Bill Clifton, MD: So obviously with any referral there's word of mouth, but it's also about how many of these are people doing a year? What is the bulk of their practice? So I think looking up the physicians as a referral and not just referring to centers is very important because especially at the Center for Spine Health, we all do spine surgery, but we all have our niches as well. And so when you have these operations, you want someone that's doing them two to three times a week and not two to three times a year. So just like if you had a vascular surgeon that's doing endarterectomies two to three times a year, you might want to get it stented.

Glen Stevens, DO, PhD: So spine fusion surgery today versus 20 years ago, a lot of change, not that much changed?

Bill Clifton, MD: So two things have changed. One, the information that we have about the spine's relationship to the pelvis and the limbs has dramatically improved our outcomes and the way that we go about planning our surgeries. 90% of what happens to a patient after surgery is what the surgeon planned before the operation. It's the game plan. So that's one thing that's changed that's improved our outcomes.

And then the second thing is that the types of screws that we use and the types of instrumentation that we've used have better biomechanical purchase and better fusion rates than instrumentation 20 years ago. And that's something that might be a little controversial to say, but I do think that there's good evidence to support that.

Glen Stevens, DO, PhD: I like what you say about the pre-plan because I hear this all the time, more surgically, right? It's almost as much time outside of the OR as in the OR.

Bill Clifton, MD: Absolutely.

Glen Stevens, DO, PhD: That needs to be done. Do you guys run a spine board for these cases?

Bill Clifton, MD: We do.

Glen Stevens, DO, PhD: Or scoliosis board?

Bill Clifton, MD: We do. We have a deformity conference in our center once a month where we all get together and we talk about some of these challenging cases and we get everybody's input and even on a multidisciplinary level about things that might be able to be done. And especially in patients that are older that have had this neglected for a while, that have lots of medical comorbidities, there's big risk factors for these patients after an operation like this. And so we like to have a lot of the medical doctors on board and things like that to make sure that we can ensure that they're optimized to have a good outcome.

Glen Stevens, DO, PhD: And you're interesting in that you're a neurosurgeon with ortho training. Are scoliosis surgeries done more by neurosurgeons, orthopedic surgeons, it's equal? Do you know what's going on?

Bill Clifton, MD: That's a great question. The history of this has been intertwined for a really long time in different ways. And now we're kind of moving away from are you neurosurgery or orthopedic surgery? And what are you doing in spine? So are you minimally invasive? Are you scoliosis trained? Are you tumor? And that sort of thing. So we're more focusing on subspecialty. So traditionally, orthopedic surgeons have a better biomechanical understanding of bones, instrumentation and fusion and things like that. And the neurosurgeons obviously have a little bit more intimate understanding of the dural, the thecal sac and the nerve contents.

When I looked at my training and I wanted to do these types of operations, especially for revision deformity, for patients that have had a surgery and didn't go well and they want it fixed. I really wanted both aspects and going to Columbia and learning from people like Larry Lenke who basically invented this classification system and has completely revolutionized the way that we treat these patients. And folks like Ron Lehman and Dan Riew who are both orthopedic surgeons, they've taught me just as much if not more in as my seven years of training in neurosurgery. So I think we need to blend these two things together and talk more about spine surgery and your particular subspecialty rather than neurosurgery or orthopedic surgery.

Glen Stevens, DO, PhD: Which I think is one of the nice things here, right? The spine program is an integrated program.

Bill Clifton, MD: And that was one of the very appealing things to me about coming to a place like this and working with a whole host of people with different training experiences and different perspectives. And it really is amazing for our patients to have that.

Glen Stevens, DO, PhD: What's the average length of your surgeries?

Bill Clifton, MD: So for a selective thoracic fusion, that's usually somewhere between 3-3.5 hours, could be up to four hours depending on how many bone cuts that we do to loosen up the spine. For a total spine reconstruction, if you have an upper thoracic, so that'd be T3 or T4 instrumented vertebrae, if it requires a vertebral osteotomy, that could be somewhere between six and nine hours.

Glen Stevens, DO, PhD: So you mentioned bone maturity and growth. How do we determine that?

Bill Clifton, MD: So there's a few different ways that we can do that. We can do it through Sanders scoring, we can do it through the Risser index, and basically we can look at the patient's bones and joints and look at their cartilage and determine whether or not that they're skeletally immature. So there's a pretty standardized way that we do that.

Glen Stevens, DO, PhD: Unfortunately, I drug my feet, I didn't come see you when I should have when was young and now I'm older and I've got it. The difficulty of treating me as an older person.

Bill Clifton, MD: So there's been a lot of literature on this, and we were kind of asking ourselves if someone came in and they're over 65, what's their complication rate? And we found that it's about 20-30% for major medical morbidity for these surgeries. And then they did an interesting study and they looked at, "Okay, I have a person with a significant deformity with decline in neurologic function, decline in ADLs, activities of daily living. And I take someone else that has this very similar deformity and I follow them for a year. One person had a surgery (and they did this study) and had a bad complication, life-threatening complication, but got over it. And at a year, what were their quality of life scores compared to someone who did not have the surgery at a year?”

And they found that even if you have a significant complication, if you survive it and you can recover from it, the patients who had the operation had better quality of life scores than the patients who didn't. And I think the only thing that that tells us is that these are really bad problems, and if you can't move, then that's when patient's life expectancy starts to decline. So what I tell my patients when I counsel them, I say, "Look, you're between a rock and a hard place. You're between a really aggressive invasive surgery and just continued decline in function." And we have an honest conversation about that.

So I think one of the big things is about just developing a relationship with the person, getting to know them, getting to know their family, understanding what do they want out of this, not just making their X-ray look good or treating an MRI, but really treating a human being. And that's one of the wonderful things about the Cleveland Clinic is that being a salaried, non-for-profit surgeon, I can sit for as long as I want with my patients. I don't have anywhere else to be except for that person in that room at that time. And I think that's one of the awesome things about my practice and working here.

Glen Stevens, DO, PhD: Well, good. Where's the field going? What's the next revolutionary thing that's going to develop that's going to help you?

Bill Clifton, MD: So it's less of the technology, which is definitely there and it's being researched, but it's more of our continued biomechanical understanding of not just the spine as one structure, but the individual vertebral relationships where they are in space? How do they relate to each other? And I think once we understand more of that, which we have been doing a lot of research on the last four years, and we've discovered a lot. We'll be able to do exactly what you said, which is predict. If we get this at this point and at this angle, how is this going to help you later down the line? So I think as we push the field forward and we're doing more research in that aspect, we're going to learn a lot more.

Glen Stevens, DO, PhD: Good. Well, I've learned a lot and I'm sure the audience has as well. Anything we haven't touched on that you think is important?

Bill Clifton, MD: No, I think that any referring provider that has a patient with scoliosis that has any doubt of a clinical symptom, I think you should send to a scoliosis surgeon. And for the consortium of scoliosis surgeons, we're pretty conservative. We're not going to jump the gun. We understand, we do this every day, we know how big these surgeries are for our patients, but it's something that we can at least follow.

And I think coming to a place like the Clinic where you're actually able to be sort of a primary care doctor for these scoliosis patients, they may not need a surgery now, but you definitely can help them in the long run by keeping a close eye on this. So I think having a good referral network and having a good relationship with your providers that you're referring to is really important.

Glen Stevens, DO, PhD: It clearly sounds like sooner is better than later.

Bill Clifton, MD: Correct.

Glen Stevens, DO, PhD: For many, many reasons. Well, Bill, I really appreciate your taking the time to join us today.

Bill Clifton, MD: Thanks, Glen.

Glen Stevens, DO, PhD: And getting the chance to meet you and appreciate all you're doing for our patients that are out there, and I look forward to chatting with you down the line.

Bill Clifton, MD: Thanks, Glen. This has been great.

Closing: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's @CleClinicMD, all one word. And thank you for listening.