Ep 105: Scoliosis in children--an overview! With Michael Heffernan MD, pediatric spine surgeon,

On today's episode of Ask Dr Jessica, we discuss the topic of scoliosis.   Today's guest is Dr Michael Heffernan, pediatric spine surgeon who works at Children's hospital of Los Angeles. In this episode we talk about everything you've ever wondered about scoliosis--like, what is scoliosis exactly? is it preventable? if a child is diagnosed with scoliosis, what can be done about it?   If a child has scoliosis, will it lead to back pain? When is bracing indicated? If a child is recommended to receive surgery, what will that process and recovery look like? We discuss all of this about scoliosis and more!

Michael Heffernan, MD, is a Board-certified orthopedic surgeon who specializes in the surgical and nonsurgical management of scoliosis and other pediatric spinal conditions. He is an Associate Professor of Clinical Orthopedic Surgery at the Keck School of Medicine of USC.  He can be reached by his email Dr Heffernan's email: mheffernan@chla.usc.edu and he can be found on his instagram @drheffortho.

Before joining the Spine Program at Children’s Hospital Los Angeles, Dr. Heffernan served as the Director of the Pediatric Orthopedic & Spine Deformity Fellowship at Children’s Hospital New Orleans. 

Dr. Heffernan is active in the Pediatric Orthopaedic Society of North America, the Scoliosis Research Society and the Pediatric Spine Study Group. He is passionate about global outreach and is Chair of the Global Outreach Committee for the Pediatric Orthopaedic Society of North America. He has also served on the Scoliosis Research Society’s global outreach committee and works with surgeons at Kingston Public Hospital to advance the care of children with scoliosis in Kingston, Jamaica.

After receiving his undergraduate degree at the Pennsylvania State University, Dr. Heffernan received his medical degree from the University of Pittsburgh School of Medicine. He went on to an orthopedic surgery residency at the University of Massachusetts Medical Center. Dr. Heffernan then completed his advanced fellowship training in pediatric orthopedics and pediatric spinal deformity at Children’s Hospital Los Angeles. When Dr. Heffernan is not working, he enjoys spending time outdoors with his wife, Joanne, and their two daughters, Sophie and Riley.

He can be reached by his email: mheffernan@chla.usc.edu 

Andrew Chung, PA-C email: akchung@chla.USC.edu

CHLA phone number is: 323-361-4658

ortho website

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

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The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your child's health care provider.

Transcript

Unknown: 0:00

Hi everybody I'm Dr. Jessica Hochman, paediatrician, and mom of three. On this podcast I like to talk about various paediatric health topics, sharing my knowledge not only as a doctor but also as a parent. Ultimately, my hope is that when it comes to your children's health, you feel more confident, worry less, and enjoy your parenting experience as much as possible. On today's episode, I discuss scoliosis with Dr. Michael Heffernan. Dr. Heffernan is a paediatric spine surgeon and he works at Children's Hospital of Los Angeles. In this episode, we talk about everything you've ever wondered about scoliosis. Like, what is scoliosis? Exactly? Is it preventable, and after getting diagnosed, what can be done about it? Dr. Heffernan is knowledgeable, personable, and as a bonus, he has a great sense of humour. I learned a lot from our conversation, and I am so grateful he took time from his busy schedule to come on the podcast. Dr. Heffernan, I'm so happy you're here. Thank you so much for taking the time. I know you're a busy surgeon. Oh, well, I'm ecstatic to be here. And I really appreciate the opportunity. That tell me people always ask when they hear about a sub specialised field, how long it takes. Tell us how many years did it take for you to get to where you are today? Well, I started in kindergarten. Now it's four years of college. I totally tested out preschool and went from kindergarten straight to med school. Now that's four years of college, four years of medical school and then after med school, it's five years of orthopaedic surgery residency, and then one year of fellowship in paediatric Orthopaedics. And then you do more spine work. Correct. So at this point, essentially, I only do spine with the exception of the fact that I take call so I also do fractures when I'm on call. Wow. And do you like this niche that you're in? I do. I mean, I absolutely love it. When I came to fellowship, I thought that I was going to focus on neuromuscular patients. And and I still have neuromuscular spine patients, but I thought I was going to do a lot of foot surgery, lower extremity surgery, hip surgery, and to be honest, spine was something that I thought maybe I would do, but it was certainly not going to be the focus of what I did. And then I got to fellowship and I got exposed to spine. And I really had a fantastic experience with that. And that's how I sort of decided to slowly focus more and more and more on spine to the point where now I mean, that's literally all I do. So first, I want to ask you broadly, What should parents know about scoliosis? So scoliosis is basically just a curve in the spine. And in order to be defined as scoliosis, the curve has to be over 10 degrees. So anything under 10 degrees is called spinal asymmetry. Anything over 10 degrees, we technically call scoliosis. Now, there's a wide variety in terms of the implication of, you know, a curve. So for example, if you're 17 years old, you're totally done growing, and you have a 20 degree curve, I fully expect for that curve to be 20 degrees, when that patient is 87 years old. So if somebody is done growing, and their curve is under 30 degrees, there's essentially no chance that their curve will ever progress. So I guess the point to that is, it's not just this curve, magnitude that makes a difference. It's curved magnitude, and for kids plus remaining growth. So for example, we just covered somebody who's done growing. In order for a curve to be of significance, once you're done growing, you really need the curve to be about 40 to 50 degrees for gravity to take over and have the curve continue to progress into adulthood. If you're growing, let's say you're on the flip side, you're eight years old, and you have a 20 degree curve, you still have your entire growth spurt left, we know that curves get worse during periods of growth. And so that 20 degree curve in an eight year old, I expect to get worse over time. So I think one point of clarification is that not all 20 degree curves, for example, are the same. And it really depends on how much growth you have left. No, that makes sense to me. So you're saying that if a young child who hasn't finished their growth spurt, you see a curvature of 20 degrees, that would concern you enough to follow that patient? Correct. And that really has to do with when we start treating it. And between 20 to 25 degrees is when we start thinking about bracing. And the whole point to bracing is to try to prevent the curve from getting worse during periods of growth and Has it worked pretty well. Bracing is so it's interesting, because in I think it was 2013. That was when there was a prospective randomised controlled trial that was published that showed the bracing is certainly effective. Now the issue with bracing is that in order for it to work, you basically have to be in the brace for a minimum of 12 hours, and we really shoot for 18 hours. So based on that same research 12 hours was roughly the cut off for efficacy versus what they considered to be not sufficiently effective at preventing the curve from getting worse. And then past 12 hours per day, there was increased effect of the brace to prevent the curves from getting worse. So that's what we use, we recommend minimum of 12 hours, and we really shoot for 18 hours a day. It's a question for you. Yeah, my my brother in law, he had bracing in high school. And it was socially difficult for him. He felt like everybody noticed that he was wearing a brace, have braces improved in bulkiness and style in the last 2030 years. So hoping your answer is yes. In some ways, yes. In in some ways. No. Okay, so there was a time actually, if you go back far enough, there were braces that included the neck and basically attached to the chin and the base of the skull. Now all the braces and basically at the level of the armpit. If somebody's wearing loose fitting clothes, like a T shirt, a fleece a sweatshirt, there are many kids that will come into clinic, and they have a brace on. And I don't even know that they have a brace on. So it sort of depends on the clothes that are worn, but the braces now are less bulky than they used to be. So that's a good thing. In terms of the concept behind the brace, that part really hasn't changed. And really, the driver for bracing is the fact that each one of the vertebral bodies has a growth plate on the top and the bottom of the vertebral body. And when you have a curve, there's more pressure that's seen on the inside part of the curve relative to the outside part of the curve. growth plates grow slower when they see pressure. And so the inside part of the curve ends up growing slower, the outside part grows faster. And that's how curves get worse during growth. The point of the brace is to offload the inside part of the curve so that there's less pressure seen on that portion of the growth plate to allow it to grow more normally. And that's why we only give braces to kids who are still growing and there's absolutely no indication to wear a brace once somebody's done growing. I have a patient who had scoliosis, around 1214 degrees, let's say it was not enough curvature for her to merit wearing a brace and the mom asked me well, why not? What's the harm in just giving her a brace? And her question was, why not do this? If it's preventative? And what what would you say to a mom like that? Well, there's different things to weigh. And so by the books where we start using bracing is at 25 degrees in somebody who has significant growth. That being said, I've had a patient who had a 10 degree curve, and then came back and had an 18 degree curve six months later. So it showed signs of progression, we would initiate bracing at 18 degrees even though if you read a textbook, the recommendation is 25 degrees. So there is some leeway to when we end up recommending a brace. But that is sort of thinking about it solely from a scoliosis standpoint. First, so for that scenario, number one, not all 10 degree or 12 degree curves progress. So it's certainly possible that that child could get an x ray in six months, it still be 12 degrees a year, the curve still be 12 degrees. And so then you could make the argument that we've now socially tortured that child unnecessarily so I think that would have to be weighed. So for me, if I had somebody that came in with a 1214 degree curve, I would have to see progression. Before I would torture that child with a brace because admittedly, the hardest part of bracing, we have evidence that it's effective. The the most difficult component of it is the fact that you have to have a preteen or a teen where a piece of plastic padded but still a piece of plastic that isn't exactly the most comfortable thing for a minimum of 12 hours a day. And once we start, we're not going to recommend stopping until we You've basically got to skeletal maturity or close to skeletal maturity. So I would just have a frank conversation with the family. And I think by the time we finished discussing all the pros and the cons, we'd all be on the same page of, it's probably okay to hold off on bracing for now. I'm just thinking, what to ask to ask my teenager to do to do much is hard these days. So that would be a big ask. It's a huge ask, I would say that if you were to compare recovery from surgery, versus spending two to four years and embrace my anecdotal sense, is that kids would say that the bracing process for the majority of them was probably more difficult than actually having surgery and recovering from that. Wow, that's, that's saying a lot. Well, I mean, think about it, it's in general, you're probably fifth sixth, seventh grade. It's an awkward time, just at baseline. And now you're the one kid in your class that has to wear a piece of plastic. So yeah. So that's why the 14 degree curve is not going to get a brace unless I know that it's progressive, because, you know, it's interesting, there are plenty of kids that will have a curve that never progresses. And the interesting thing is, so what we do currently is, say, for example, we're trying to figure out, is this child progressing and need treatment? Or is this just gonna stay the same? We don't have a test, you know, when they come in, to sort of say, Oh, this is a progressive curve, we should follow it closely. Or we should start a brace now. This other child, nope, they have the same curve currently, but they're gonna stay the same forever. So we don't need to do anything. With the bigger curves. We know with these small curves in the teens, which if we knew that 14 degree curve was in fact a progressive curve, and we could identify that during the first visit, then you could really make a strong argument to start bracing at that time. But we just don't have that ability to to distinguish between who will progress if they have a 14 degree curve, and who will not at this point. Do you feel like it's getting worse? I mean, I'm just curious with all the cell phone use and the heads down and the bad posture and the heavy backpacks? No, I don't think so. So I would say paediatric back pain is getting worse. You know, back pain is not really associated with scoliosis. That's a common misconception. So a lot of people think that. For example, if a child has a curve in their back, the way that you know that the curve is getting worse is if the kid is complaining about back pain. Well, there's really not much correlation between curves in kids and back pain, especially thoracic curves. Now, some of the kids that have lumbar based curves so closer to the pelvis, if they're leaning over to the side and have a big trunk shift, that can cause back pain. And it makes sense because you're sort of like, your muscles are asymmetrically working to keep you upright. But for the curves that are up in the chest area, generally speaking, those are not painful during childhood. Glad you brought that up. Because a lot of people do worry when they hear that their kid has scoliosis or some degree of scoliosis, they are really worried that their kid will have back pain. So if you look at population that does not have scoliosis versus population that does have scoliosis long term, you're more likely to have back pain as an adult, if you have scoliosis, if it's significant, so let's say you had a 3540 degree curve, and you're shifted off to the side. Over time, you're more likely to have back pain. That's true. Okay. However, you're also more or less more likely to have back pain at 40. If you're overweight, if you smoke. There's other lifestyle things that would put you at increased risk for back pain. So scoliosis is one. Sure. But there's many other controllable factors that probably play a bigger role in the majority of people's adult back pain, and it's not solely related to scoliosis. That's good to hear. That's a good misconception to clear up. Yeah. So I guess what I'm gathering from what you said so far, it sounds like there's not much that we can do to actually prevent scoliosis. Is that right? So as of 2023, there's nothing that can be done to prevent scoliosis from a behavioural standpoint, meaning talking on the cell phone or what rather watching movies on a iPad, spending time sort of hunched over Have a backpack on one shoulder versus another different forms of sporting activities, or no sporting activities. There's nothing that can prevent a curve in the back. You know, like, say you have a straight spine, there's not some sort of like routine exercise or supplement that we know of that people should be taking or doing to prevent the onset of scoliosis. What about things like seeing a chiropractor or stretching or physical therapy with any of that prevents scoliosis. So prevention means that, you know, somebody has a straight spine, and they keep a straight spine. So none of those listed would prevent curves from starting. So bracing has the best evidence. So that's the sort of talk about like, you have a straight spine, and you're asking to prevent it from starting the process of curvature. And going to a physical therapist and or chiropractor or doing certain stretches, there's no evidence to suggest that that would keep your spine straight and prevent it from beginning the process of curvature. For kids who have curves. Another misconception is that not all curves, progressed to a significant level. So there are a lot of kids who will have a curve in their back. That's 510 15 degrees. And that's the way it will be forever. And an astute paediatrician may pick up on those. And there are plenty of kids who have those curves that weren't picked up on and they're just fine. So it's interesting that it's pretty common to have a very small asymmetry in your spine. But for the progressive curves, there's not great evidence for anything outside of bracing, that would prevent the curves from getting worse. The only other thing that's been looked at scientifically thus far are scoliosis specific exercises with physical therapy. And to date, all the research would suggest that it doesn't play a huge role, maybe an adjunct role to the brace in terms of preventing curves from getting worse, but really cannot replace the brace because it would be great to replace braces, because as we talked about, it's challenging for the kids to wear the braces for as much as we need them to wear it for, for it to be effective. But it also makes sense that if a brace in order for that to modulate growth has to be on somebody's body for 12 hours the day that if you go to physical therapy for 30 or 45 minutes and do some stretching, it does seem intuitively difficult that that would alter the way the spine is growing. It does sound intuitive, just too it's too too short of time to make a difference. Right. So we don't necessarily promote an advocate for physical therapy aggressively with our patients. But we have a list of providers in the area. And we send people for the scoliosis specific exercises, every clinic when they ask about it, because it's certainly not harmful. We just don't have great evidence that it's effective. That makes so much sense to me, why not refer them there? If they're asking for it, it's not going to hurt anything. But how great of a difference it really makes is unclear. And well, it's unclear. And the issue is that insurance doesn't necessarily cover it. So that's out of pocket, and it's actually can be quite expensive. So I certainly wouldn't want to insist that a family do something that I didn't have evidence for, if it could be a financial burden. This is speaking like a good doctor talking about this, thanks. A lot of parents will say to me, when they'll come they'll come to my office for physicals and they'll say Oh, I just want to let you know like my grandma had scoliosis. Make sure you really check my child. Does genetics play a large factor in scoliosis developing in future generations? No. So the most common kid who comes to my clinic with a significant curve, the family looks back at their extended family both sides, many generations, and they can't find anyone with a curve in their back. Now we have families Exactly. It's surprising another misconception. We do have families that there are 273 siblings in the in the family and two out of three have scoliosis. So I've operated on sisters before. So there are families that scoliosis clearly has run in the family. So there has to be some genetic component to it. But there Er, it is multifactorial and not well understood. There have been people researching the genetics of scoliosis for at least 20 years. And I would say we're no closer to understanding it in 2023 than we were when that started. That is so interesting. So I think there is a genetic component, but it is overshadowed by other factors that I we do not not just die, but we, as a profession do not fully understand yet. So, are there any risk factors involved in determining scoliosis? I know there's some genetic diseases that you'd see scoliosis more likely. But in general, for idiopathic scoliosis, are there any? Are there any risk factors, so the only risk factor for having a significant curve is being female. So the incidence, meaning the overall number of people that have scoliosis is equal in boys and girls. But the amount or the percentage of patients who have curves that are significant enough to require treatment, whether that be brace treatment, or surgery is extraordinarily higher, extraordinary, like the number is much higher in females relative to males. And the physiologic difference of why that is, is not yet understood. But that is very clear. I'm gonna call this podcast clearing up misconceptions of scoliosis. Sure. I mean, it's really interesting, though. I mean, think about that. So we have this condition that has been studied, is treated. And there is an in general, in medicine, we continue to learn more and more we understand the aetiology of different issues conditions, more now than we did 50 years ago, and scoliosis in terms of like, what is the underlying aetiology? What are the risk factors? It is poorly understood in 2023, which to me is fascinating. And hopefully, over the next 50 years, our understanding of the condition continues to improve. I get a lot of patients who will come in and say the hip is asymmetric, or when they look at the body, things are visibly asymmetric. And they went to the chiropractor to get readjusted. Do you think that's beneficial? And if it's not beneficial to you? Do you think it's harmful in any way? In other words, is it okay in your eyes to see a chiropractor for adjustments? Yeah, I mean, I think it's fine to see the chiropractor for adjustments. Interestingly enough, my great grandmother was a chiropractor. My grandpa was a chiropractor. My mom who grew up in Dayton, Ohio has 11 Brothers and sisters, six of whom were chiropractors. So when I was growing up, every time I went down to my grandma's house, whoever was at Palmer College of Chiropractic, which apparently is like the mecca of chiropractic. Whoever was in school was like trying to snap my neck, adjust my back. So I don't currently go to a chiropractor. And if you asked my family, what chiropractic like, what is their wheelhouse, it is in general, for back pain. And it works for some people, not for others. In terms of like some of these other things, scoliosis included, I certainly don't think that it would be harmful to go the chiropractor, I can also say that we don't really have evidence to date, that it would make a big difference. So if a family is asking me about chiropractic, I will certainly just let them know that it's not harmful. I just don't have any evidence that it will do anything in terms of the curve. That's quite a family history. By the way. Now, I really understand why you liked orthopaedic spine. I don't know if it's related to be honest, because as a child, having my neck snap, I'm not sure that inspired me to pursue that at all. Actually, I was a little bit afraid of going over to my grandpa's office with like one of my aunts or uncles to have them practice on me. Fair enough. Like, that's a good point you make. Yeah. Now, my mom has always been interested in me having good posture as an adult. And so when I was five years old, she actually enrolled me in ballet with the hopes that I would have good posture and never have spine issues as an adult. Was she right signing me up for ballet? Does that make a difference? Or? Well, I think it set the record straight for my family. Sure. Well, I mean, I think signing you up for ballet probably helped with grace and social interactions with your peers and a great activity to do. I would say that it probably didn't hurt. And I don't know that helped either. So in other words, exercises that improve posture or encourage better posture. In your eyes, it doesn't make a clear difference in terms of preventing scoliosis. 100% it does not make a difference in preventing scoliosis. Is there any benefit? For sure, then your mom won't be a bother. Yeah. Fair point, fair point. Now I remember because I was terrible at ballet, I was awful. And my mom said, Well, you want to have good posture as an adult. So it's good for you. You'll thank me later. Yeah, well, I mean, I don't know that has any effect in preventing scoliosis. But I mean, just observing, I think you have good postures and adult probably better than mine. So I'm maybe I should have done ballet. Thank you, doctor. So now I want to ask you about your your expertise, spine surgery, when a spine surgery actually indicated when when do you actually want to perform scoliosis surgery on patients. So we only do surgery, if we know that the curve is going to continue to get worse, as the kids are going into adulthood? Well, it depends, actually. So that's for adolescent idiopathic scoliosis. So if your curve is 50 degrees or greater, we know that even when you remove the fuel of growth from the equation, those curves based on gravity will continue to progress. Over time, the rate of change is different. So once somebody's done growing, the rate of change or progression is really only about one degree per year. But then that is additive over time. So if you're 20 years old, and you have a 50 degree curve, our expectation is that when you're 40, it would be 70 degrees, and approaching 90, when you're in your 60s, curves over about 70 degrees start interfering with lung function. And so that's what indicates surgery for thoracic base curves for lumbar based curves, once you hit about 45 or 50 degrees. And if you have enough trunk shift, your curve will continue to progress. And that can be associated with significant back pain as kids become adults. And that would be the indication for when we would operate in the lumbar spine. And do you find that most people when they have surgery, they're so happy afterwards? Like what are the what are the outcomes like after scoliosis surgery? So the interesting thing is, it depends on who you ask. So the kids are most pleased with their cosmetic improvement. So we're back to adolescent idiopathic scoliosis. Okay. So for your otherwise healthy child, the thing that they get the most out of surgery that they're happiest about is the fact that their rib hump is gone, their shoulders are level, and you know, they can wear a dress, or they can wear their clothes, they don't fit funny, and they they feel that their appearance has become much better. Which, you know, for orthopaedics, we certainly don't indicate patients for surgery based on cosmic basis. But it's interesting, as you're asking that question, one of the things that is most immediate is the fact that people feel so much better about the way they look, I don't, that's not really something that I value per se. Right? I value the fact that we're preventing pulmonary compromised later in life. We, you know, obviously value doing a fantastic job in surgery. But the kids, that is their primary concern in a lot of cases, and the thing that they are most appreciative of afterwards, I guess, for me, the thing that I can appreciate about that is that oftentimes will translate into increased self confidence. And you can see it they come back to clinic and their lay, you know, before they were this Meek child who wore big hoodies that you really couldn't see their body and they come back and like skin tight clothes with a lot of swag. And I'm like, Who is this child? No, I actually think cosmetic changes are hugely beneficial for anyone, especially a teenager because like you said, it really improved your self confidence. That's huge. I think that is that's their perspective. A parent's perspective is they're grateful that they took care of something that would have been a problem when their child was an adult. And I think they feel relieved that it's sort of taken care of, and they don't have to worry about that. So it's interesting that at least from my perspective, the kid and the parent have two very different perspectives on what a successful outcome are. You know what is great about having the surgery done, and I'm assuming it's a really long involve surgery. It depends. So for, you know, some of these kids who have 140 degree curve are medically involved with multiple things going on. Sometimes they even do those cases in a staged fashion. So part of it on one day come back a week later part of it on another day. But for the otherwise healthy child that has a curve in their back, our plan for that is that's a one day surgery, we're looking at about four to four and a half hours for surgery. So that's long, but not that long. And then in terms of recovery, we really shoot to have people home on post update to see if surgery is on Monday. The goal is to be home Wednesday afternoon, if not Thursday morning. And then by two weeks, we want them walking a mile. By two months, we clear them for all activities, with the exception of context, sports and rollercoasters, which we hold off on until four months, contact sports and roller coasters. In my mind, you could tell my kids forever, no more. I have a couple of kids playing college football after surgery right now. Really? Yeah, that's amazing. And when your patients talk to you afterwards, do you find that they're really happy that they did it? Oh, yeah. So and that's one of the things that I think special about what I get to do is because it's spine, for us, it's routine. Right? Literally, I do that every Monday and Thursday. But for the families, that's their first experience for first exposure, it's the spine, there's a lot of concern and anxiety around that. And so, you know, I kind of think it's special to be able to be the person that can kind of guide them through that process. And yeah, we do the surgery. And we love being awesome at doing surgery. But I also really value the relationship that we have with the families and the kids because they have to put so much trust in us to be able to do that. The bond that we have is pretty, pretty tight, which I like mean, that's really great. So people are both relieved, and sort of excited after surgery is done. And again, the main thing is from the parents, they sort of feel relieved that they've sort of taken care of this thing that was going to cause their kid a problem. After they were out of their house pretty much and you know, then it was going to be they were 35. And they're calling their mom up. Like why didn't you take care of this when I was a kid. And I feel like that's what the parents they have this sense of relief from that. And again, for the kids, I really think it's mostly cosmetic, you must get tremendous satisfaction from what you do. I love it. I mean, I love every bit of it. So I love being a surgeon, the technical aspect of it, the planning of it, the anatomy, we are in the operating room, and something is curved. And by the time we're done, it's straight. I mean, I love that part. I also love the depth of connection that I have with the patients and with their families. Again, because it's a bigger thing. It requires more relationship for us to all be on the same page. And so you know, I think that's special. Very and so you you literally see the spine straighten from beginning of this surgery to the end of the surgery, you see the spine straighten? Yes. And so it's very satisfying. It's incredible. For the surgery has come a long way in the last number of years. Oh, definitely. Do you ever feel like there's information you wish paediatricians knew or did better that that we should know? Like in terms of screening, for example, I screen kids yearly at their physicals, but is there anything more that I should do on my end? I think there may be some kids who, for whatever reason, don't really come to the well checks as much. And so their visit to the paediatrician is more for acute needs. So for example, they have a cold or there's something going on, so they come for that visit. But if it's a child who doesn't necessarily make it to the paediatrician otherwise, those would be the kids who may get missed for some of these screening things if they are not routinely coming to their well child check. And in 2023, for example, in California, screening at the schools is no longer mandate mandated. And so it really puts the onus on the paediatrician to pick up the curves. And from my perspective, the ideal situation is that we pick up the curves early enough that they could be treated non operatively and not with surgery. And here, I mean, we're a tertiary referral centre so we probably see, you know, the biggest curves there are, but it seems like there are plenty I mean, literally I saw two kids this morning and clinic Have Curves and this is the first time that I'm meeting them and the first time that they're accessing a paediatric orthopaedic surgeon, and their curves are in surgical range, you know, one had 70 degree curve, and one had a 65 degree curve, and this was their first visit. Now, that's actually good advice, because it sounds like what you're saying is one encourage everybody to come in and get their annual checkups. But then to if I see a patient, who I haven't seen in a few years, and they come in for another issue, and I have time, a quick look at the spine would be helpful. Yeah, I think so. To pick up on the kids that may not come back for this. Well, checks. Thank you. Now, is there anything that you want parents to know is are there any resources available that you recommend that they look out for if they're interested in learning more? So there's the scoliosis Research Society has some good information on their website? Yeah, I mean, that's, they're basically the authority of like research and or educational material for, especially for adolescent idiopathic scoliosis. I mean, their information is going to be solid, I would say. So the take home point I'm getting from you overall, is that scoliosis is something that there's nothing that we can really do up to prevent it, but we can screen for it so we can prevent it from getting worse. But back pain is a separate issue that we can make modifications to improve. beautifully put, yes, we can screen for scoliosis, and catch it early enough that it can be treated non operatively. So we have the ability to do that. We don't have the ability to prevent the initiation of scoliosis or somebody's spine being straight and initiating a curve. On the other hand, just as you said, from my back pain perspective, the vast majority of paediatric back pain is muscular in nature. It is most commonly related to having weak core and back extensor muscles, or forcing those muscles to carry too much meaning obesity, for example. So in that case, being more active, less screen time, and more play time, core exercises, and being fit would be preventative from a back pain perspective. I think this is so helpful. Thank you so much. I've had a lot of fun chatting with you. Thank you so much for coming on. I really appreciate your time. Of course, I really appreciate the opportunity. Thanks so much. Thank you for listening and I hope you enjoyed this week's episode of Ask Dr. Jessica. Also, if you could take a moment and leave a five star review wherever it is you listen to podcasts, I would greatly appreciate it. 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