Long-term follow-up of patients with idiopathic scoliosis

Listen to Andrew Duckworth, Nick Birch and Athanasios Tsirikos discuss the editorial 'Long-term follow-up of patients with idiopathic scoliosis' published in the February 2023 issue of The Bone & Joint Journal.

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Transcript

[00:00:00] Welcome everyone to one of our BJJ podcasts for the month of February. I'm Andrew Duckworth and a warm welcome from your team here at The Bone & Joint Journal. We'd like to thank you all for your continued comments and support for our journal podcast series, as well as a big thanks to our many authors and colleagues who've joined us thus far.

We also wanted to mention and hope you've had a chance to use our new and really exceptional website platform form for all our journals here at the Bone & Joint, and a big congratulations to Emma Vodden and all her team for the amazing work on it. So for today's podcast, I have the pleasure of being joined by one of my editorial board colleagues here at the BJJ and our specialty editor for spine, Mr.

Nick Birch, welcome Nick, and thank you so much for taking the time to join us. Thanks, Andrew. It's great to be here. Nick and I are delighted to be joined by one of my great colleagues here in Edinburgh and Mr. Thanos Tsirikos to discuss their editorial entitled 'Long-term follow-up of patients with idiopathic scoliosis'.

Welcome tha Thanos. It's great to have you with us. Thank you very much for this invitation. It's great to be here. That's great. So Nick, maybe if I, I kick off with yourself. The editorial, you and Thanos have written highlights of paper by Ragborg et al, that's also in this month's [00:01:00] journal that has been published and looks at the, the, the, and the long-term outcome and quality of life outcomes, in particular for patients with the idiopathic scoliosis.

So Nick I was just to start with, can you give us some insights maybe from your own clinical practice in relation to this topic along with your perspective as a spine specialty editor here at the BJJ that made this paper catch your attention and prompted you and Thanos to write this editorial?

Absolutely. When I read the paper, the length and completeness of follow up of the idiopathic scoliosis cases really grabbed my attention immediately. I mean, as time's gone on and training's become shorter. And the world's moved faster. We have seen fewer and fewer really long-term follow ups in, in clinic.

It, it's in my clinic and I've been a consultant almost 30 years, and in North Northamptonshire, I, I guess people don't move very far, but I, I'm seeing now patients who I saw in the 1990s, and I've seen them intermittently since then. So I have been seeing their long-term follow [00:02:00] up from what I did in, in 97, 98, 2000, what it was.

So I can see that, but I know that in, in, in general terms, in training, long-term follow up is no longer really available. And of course, if you can't see the long-term follow up, you can't see the natural history. And if you don't see the natural history, then the mistakes of history tend to repeat themselves.

When I was training, my, my clinical training was very much governed by cases that I saw on the wards in clinics and in clinical conferences, particularly at the RNOH. And you'd see someone who'd be coming up for years after year after years, the clinical conferences. And for that, it was, it was a bit like having a, a hanger in the, in your clinical wardrobe when I was hanging off that hanger.

A coat and that was the case. And then into the coat pockets. I put all of the learnings, the research as the years went by, and I always remember those cases and they were the long-term cases and they just stood out. And Ragborg's [00:03:00] paper really just reminded me so much of that experience. And so I was delighted when the, the reviewers came back and they, they gave it a, a green light and that we were able to publish.

And then I contacted Thanos and said, look, you know, we've got, we've gotta write something about this because it is so important in terms of modern spinal practice. So that's, that's really how the editorial came about. That's really interesting. I, I, I think you're very, very much right. I think the, the world has moved on so quickly, hasn't it?

And we, we don't follow up our patients like we used to it, not just in in spine, but in all, all walks of orthopedics now, ma and a lot related to pressure services, which will come onto, and so you lose that natural history of watching those patients as they progress and. Thanos if I maybe come to you next, you know, before we look a bit more in detail at that paper, would you have a feel about, for, for scoliosis in particular, what is the current practice with regards follow up across the UK?

Maybe your own and what you know of other peoples? Yeah, I mean, I totally agree with Nick Nick's points, I mean, the. You know, you can only learn by following the [00:04:00] patients and, you know, spinal surgery as much as any other, you know, part of orthopaedics has evolved enormously in, you know, in the last decades.

I mean, if you think you know, we started deformity surgery by doing in situ fusions. We just bone grafted until the 1970s where, you know, instrumentation sort of the very basic first generation instrumentation started. And you know, from there to where we are now, you know, there's a vast evolution.

So, you know, it would be amazing if we could. Retrieve some of these old patients and see, you know, how are they actually doing? And you know, unless they have, you know, clear complications or sort of long-term sequela, you know, from either the surgery that took place in their teens and now, you know, they're

they, they are in their sort of midlife and sometimes some of them in the senior life, you know we don't really see them, so we don't get a chance, you know, to have this benefit of, you know, the continuity of care and the long term. You know, follow up and, you know, there's no question that. [00:05:00] You know, many of these patients will have issues over time.

Now they'll have issues related to the deformity. They'll have issues related to the treatment of, of, of the condition you know, related to the surgical treatment. And, you know, coming back to, to this paper, you know, the, the, the ability to follow patients up has been you know, sort of unique if you look at the, any, anywhere across the literature and, and even more in, in our area, in the sort of Scandinavian countries because they have the national registries and they have these huge advantages that they can

always go back and look into patients. And I remember, you know, years back, I, I had a lady from Sweden who lived in, in Edinburgh at the time, who was in her mid forties. And you know, she came with an infection, she had a tooth operation and she came with a long mean, sort of really severe, you know, sort of long term deep infection following a posterior spinal fusion that she had when she was 12, but now she was [00:06:00] 45.

And I, I, you know, she told me the surgeon, I, I mean, I, I knew the surgeon, a colleague in Gothenberg. So I sent him an email and within five minutes, I got the reply with all the notes and I had, you know, the operation notes and I, I could straight away find out what was used, what instrumentation you know, we, you know, was used at the time what implants and instruments we, we needed to take it out because, you know, obviously we needed to take it out.

So, you know, this is a sort of benefit that, unfortunately, not many colleagues have, or not many countries. Not just us, but you know, around the world, you know, have the ability to, to maintain. Yeah. I mean we, we are. You know, sort of in an equal setup to Nick in the sense that, you know, Scotland is quite a close community and, you know, people don't necessarily move around a lot.

So, you know, we do try to, to chase up as many of our old patients as we can. And alongside what we've seen in, in this article and what, you know, obviously the scoliosis disease of [00:07:00] society has also advocated for longer term follow ups comes the need for long-term follow up of outcomes, not just, you know, what, you know what the degrees of the curves and we know these days that, you know, even if you end up with a 30 degree curve at the end of growth with an idiopathic scoliosis

this will tend to progress. So either we used to say to our patients that, you know, you get a 50 degree curve at the end of growth, we need to do treatment. We need to operate because the 50 degree will progress into adult life and you'll end up with a more severe medical problem. But actually that's not true.

Yeah. We know that 40 degree curves and 30 degree curves will progress. Now they won't necessarily progress to the point that they need surgery. And this has been demonstrated in this you know, Danish, you know, paper. But it doesn't mean that, you know, you can still ease them up and say, okay, well, you know, there, there won't be any, any problems in the future.

Yeah. And I think it would be great And that, that was one of the, the points I made when we were reviewing this paper [00:08:00] that, you know, it would be great if we had clinical outcomes for this group of patients. But of course, you know, it, it's difficult always to go back, you know, so many decades down the line and, and try to, to

to pinpoint all of these details, but it's one of the things that I think will be, be, will be becoming, you know, more and more useful and, and almost an obligation one to defend our practice, but also, you know, to be in a position, say, actually, you know what we are doing is really making a difference to the patients, not not just producing a better x-ray, but actually, you know, the, the, the, the way to be able to tell that, you know, you're actually making a difference is how the patient respond, you know, to the treatment.

Absolutely. I think, I think that's a really nice overview of, of that, of that paper. And like you say, the ability of the scandin, Scandinavian countries in particular now, it was 71% follow rate at four over a, a mean of 40 years is, is, is just truly remarkable, isn't it? But. As and as and as, as the [00:09:00] paper says, you know, it does have a significant impact on these patients health related quality of life.

And it's an important point, like you say, that you need to know that your intervention, if it is surgery, for example, is making a a difference to them. Maybe moving on Thanos, because you, you re, you briefly mentioned it there, you know, and you mentioned it in the editorial, the SRS has identified the importance of long-term follow up for these patients.

Yeah, yeah. Do you have any insights into the background of that or how that's sort of come about and what they may be envisage, you know, for that in terms of the research in that area? Yeah. And, and yes, and, and I think, you know, this is a very good point and it's something that we have also discussed within the, the British, you know, spine societies over the years.

But the, the Scoliosis Research Society being sort of the world leader in, in deformity surgery, you know, they, they have sort of a wider impact across different countries. But you know, there is a lot of argument around the treatment that we offer. [00:10:00] One, because it is very you know, high risk and, and there's no question that, you know, when we're talking about, you know, patients being pa paraplegic as, as a risk of surgery or becoming paraplegic or, or even, you know, having a risk of death, you know, and yes, we say that, you know, there's a very small risk, but you know, it's not negligible and it's, if it happens to that one patient, for that patient, it's a hundred percent risk.

So, you know, these. These are very, you know, major procedures that you know, what we do needs to be solidly, you know, sort of validated Need to be in a position to say that well, actually we do make a difference to the patients, not just in terms of producing a better x-ray, but producing hopefully a better quality of life and, and, you know, sort of avoiding pain in later life and, and have a sustainable result.

Not just as they move into you know, early adult life, but later on it used to be. And, and that was also a recommendation by the [00:11:00] Scoliosis Research Society that every, you know, clinical series should have a two-year follow-up. And of course, two-year follow-up for paediatric adolescent surgery doesn't mean anything.

You know, it's, it's, it's actually useless. I mean, you know, you, you operate on a, on a, on a 14 year old and you see them until they're 16. Okay? They're probably fully grown. What does that mean? You know, that doesn't tell you anything. What's gonna happen 10, 20, 30 years down the line as they progress into, you know, a, a life of more activities, you know, more career planning, you know, having a family.

You know, having a totally different demand like physically, emotionally, psychologically. So I think it is critical that, you know, we, we do follow this, this lead and you know, in, in, in whatever way it is possible, you know, trying to keep some contact with our patients. One way that helps and, and we've done that in a similar way in, in the UK as the Scoliosis Society has done [00:12:00] in the US is creating registries.

Yeah. And the British Spine Registry has helped a lot because, you know, that is a way to document, you know, results, complications, revision rates, you know, all of these things, but also hopefully go back and retrieve your data. Yeah. One of the things, I mean, I always put in my presentations, I always say produce every year a graph which comes from the registry.

So the registry gives it, you know, to you and you can go back and chase all your patients who have been on the registry have documented their outcomes. And we, you know, we use val validated questionnaires, so obviously to be able to see how their quality of life, you know, has has progressed over the years.

And you can do your pre-op, you know, immediate postop. You know, 6, 12, 24 months, but also then longer term follow up. And we, we are now looking into our results beyond 10 years and beyond 20 years. And I think that would be extremely, you know, useful. So I think this is what the SRS is [00:13:00] trying to, to pass as a message.

Again, you know, the Scandinavians are leading the way because they have you know, this ability of maintaining contact with the patients and, and having them all on a database. Yeah. A national database. But I think, you know, in, in the UK we have a, a great opportunity to, to maintain that quality of, of data collection and, and, you know, look into our outcomes.

Absolutely. And I think it's a very interesting point you may realize about the registry and how, how that can potentially help. And also your analogy of two years, you know, if you, you relate that to our arthroplasty colleagues who follow them up, you know, for 10, 20, even 30 years. You know, that's what we really yeah.

Like you suggest what, what we really should be aiming for and actually looking at the, the potential deterioration that these patients can actually, can actually have, has as has been shown in, in, in the, the Danish paper. So, Nick, Nick, if maybe I come back, back to you now, cuz you know, whilst we've, we've talked a lot about that, the Danish paper, but your editorial very nicely goes through how the, how that that, that [00:14:00] knowledge has maybe evolved over time and how the literature has evolved.

And so for our listeners, can you maybe sort of summarize that and maybe some take home points from it? Yeah, I mean, the the first thing that stands out in the literature is there aren't that many very long-term studies on idiopathic scoliosis and the ones that there are they, they come along every 10 years or so.

So interesting cuz the first one that really sticks out was in 1968, again, a Scandinavian study from Nielsen and Lundgren. And in that paper they actually stated, they said the orthopaedic surgeons should concentrate on patients whose age makes them particularly susceptible to progression of the scoliosis.

And that most attentions should then be paid to the opportunities for active therapy at the same time. Little is known about the fate of scoliotic patients after they've left the orthopaedic surgeon's immediate field of interest. That speaks exactly to what Thanos was just saying, exactly what you're saying, Andrew.

And that is that, you know, a [00:15:00] couple of years of follow up is absolutely worse than nothing. And they go on to say, an analysis of the vital prognosis in idiopathic scoliosis and an account of the social and social sociomedical functions of these patients is required. Well, this is what Ragborg's done. This is exactly the whole approach that Thanos has just been illustrating that the SRS is trying to get.

So I thought that was very interesting. So that's back in 1968 which most of our listeners, I think weren't even a glint in their parents' eyes in those days. Now by our standards, that paper was relatively low, low standard of evidence, but it was actually quite a good observational paper. The IO cohort from Stuart Weinstein's group.

And, and we, we do an apology to, to Professor Weinstein because, we, we originally had quoted that as Ponseti's group, and of course it wasn't. Ponseti was there as a if you like, a courtesy order author. It was very much Professor Weinstein who was driving that in the two papers they published back in the 1980s, et cetera.

And then they looked, phenomenal group of people. 219 patients [00:16:00] seen originally between 1932 and 1948, but they focused on back ache and curve progression. And they said there wasn't very much evidence of backache actually in this group of patients and functional loss at 39, 50 year follow up periods was, was not that great.

So they were reporting quite good outcomes. I mean, Jackson in 83 was more pessimistic. He said half of their, their 197 patients at 10 years had chronic pain. And that was related to the curve extent, particularly lumbar spine, which is what you'd expect, and their age and the older they got and the worse the lumbar spine problems became, the worse their pain became.

So Mike Edgar and Min Mheta reported the, the Stanmore results in 1988. And that was a nice study cuz what they did was they, they got everybody to skeletal maturity and then they looked at them 10 years after that. So it wasn't as though they were seeing patients who were still developing within their, their follow up time.

So they knew exactly where they were. I mean the, the cohort was split [00:17:00] roughly 50 50. It wasn't exactly and they concluded that fusion reduced the instance of long-term back pain, but not backache. I'm not quite sure what back pain and backache are, because I deal with backache and back pain all the day, every day.

And, you know, patients come along and say, my back hurts and my back aches. It's all the same. So not quite sure quite what they were saying but they did say that surgery seemed to have some benefit with that. Yeah. So that was again an optimistic view of, of the long term. And then you have to jump a couple of decades until Danielson, another Swedish paper in Nordic paper reported 2010 on the 16 year follow of patients with moderate curves not treated with surgery.

And they then they said, well, look, in the thirties, these people are the same as people who don't have scoliosis. So they. That, that's the thirties. You know, what happens to the forties, the fifties? What happens when you start to get secondary degenerative changes with mild curves and, and then you begin to get the onset of

genetic [00:18:00] influences on your discs that you know, you really know that 80% of disc degeneration is genetically determined and 20% is what you do in your life or past. That 20% is going to be scoliosis and, and you know, are these then the cases that then lead to this real tsunami of adults degenerative scoliosis cases that we're now seeing?

That is the typical. You're seeing in the supermarket who's leaning on her trolley because she can't stand straight cuz she's completely out of sagittal alignment. Yeah. Is this what these mild curves are doing? And we need to know because we need this long-term data. And really the last, last, last few papers in the, in the 2000 tens, that was last in 2019.

And, and Barshad in in, he was in 2020 I think. And they, they were looking at it, they were saying basically, there were pretty low levels of disability, low levels of back pain. So much of the, the literature, first of all, methodologically, it's difficult to make it good. So you have to say, so you have to take it as it is.

It's a, it's an [00:19:00] observational study. Yeah. But Ragborg, of course, they've got the data from early on. So, so we've got better methodology now because of the registries, as Thanos has said. And the, you know, as we're building that up, we'll, we'll, we'll continue to have better methodology. The optimism of the, the good outcomes, I think actually has been that little balloons been punctured.

And what we're seeing in this, in this, this latest paper, and I think what we are really seeing is what I see in my clinic, and that is that there are patients who've got significant rotation within the centre of a degenerate curve coming up as a, you know, is it a de novo ad- adult degenerative scoliosis?

Well, no, it probably wasn't. It was probably an AIS. That's then developed into a degenerate scoliosis so that there's then been an olius thesis at L three four or or whatever else that's then tipped it over. And so you're getting this mixed picture. And I think that that's the bit that we really need to understand from these long-term studies.

And I, I think that Ragborg's paper is contributing to that. No. [00:20:00] Absolutely. I think that's a, a lovely overview of of, of how it has evolved and like you say, the, the methodological quality. You know, you could, you know, we all look for these high levels of evidence, but that there is, that's the best that is out there.

But that, like you said, how that Ragborg paper has sort of, like you, you say painted a much less rosy picture than previous reports is, is very interesting. So maybe if we, that sort of takes us nicely, I suppose. And sort of the final sort of question I had for you, for you both really is, you know, and we've sort of touched on it a bit, but sort of.

You know, how, how do we then moving forward, you know, cause I know what people will say is that, yes, we need to follow these patients up from what we've said, but you know, we, we work in a very resource strained environment, you know? And providing or getting long term follow up is, is, is more and more difficult.

So what, how do we balance that out? Maybe Thanos, I'll start with you. What the, you know, how, how do we, how do we deliver that without, unduly burdening the, the health service that's already pretty strained. There's no question that it's challenging and, [00:21:00] and you know, we, I mean the

socioeconomical aspects of all these you know, conditions is, is, is, you know, quite sort of affecting healthcare, whichever way you look at it, in terms of initial treatment, in terms of, you know, need for support for this, you know, people later on in life in terms of, I mean, exactly as, as Nick said, you know I, I think the, the, the, the two sort of striking points that I would make is one, obviously, you know, try to keep good databases. I think that is essential. So, you know, in a prospective way, keep track of all the patients that come through the services and ideally then document, you know, these patients in a registry.

So, you know, the registry should have the ability for, you know people who say colleagues would like every you know, now and then maybe every five, 10 years to go back and retrieve the data on a national basis not just on a, on a local basis. And then go and look into different aspects [00:22:00] that you know, can sort of quantify you know, quality of, of care and how is that maintained, you know, over time.

So I think that would be very, very useful. So, you know, collect as much transparent data as possible. Hopefully motivate people, you know, to, to document, you know, these patients because that is one of the problems we've had. I mean, the level of compliance has been quite low in many services and, you know, through the societies we've tried over the years, you know, to try to make this almost mandatory.

So in other words, especially, you know, in England where you know, the, you're paid by results. You know, if you don't document the patients, you don't get paid. So there, there, there is a lot of sort of pressure, sideways pressure, you know, to try to, to make this work. But I think the more accurate the data that is collected, the, the more the results and, and the, the, the value of the results that can come outta this.

So that is the one thing. The other point, which I think is very important is that there has to be a breaching between [00:23:00] paediatric and adult services. In other words, you know, you don't want to have you know, separate services, and I'll use the example of north America where much of the deformity surgery on the paediatric and adult adolescent side is done by the paediatric orthopaedic surgeons.

And of course, they stop seeing the patients as they get in, you know, to the age of 18. Some centres you know, when I worked in Delaware and in Philadelphia, you know, they used to see patients up to the age of 21, but again, 21 is not enough to maintain follow up. And you know, the length of follow up that you need to be able to see the complications or to be able to see the problems, whether it's for untreated patients, whether it's for brace patients, whether it's for surgical patients, because all three groups should really be monitored.

You know, you, you want to have a natural history study of all three categories. Yeah. Being treated, the brace or the surgically treated. So I, I think, you know, that doesn't work. So [00:24:00] these patients then disappear from the paediatric services. They go to adult services and they, they probably get dispersed across different, you know, clinicians and different, you know, services and they're lost and there's no way to follow them up.

Iowa has always been a unique sort of setup and, you know Professor Weinstein has really motivated in a sort of personally motivated to collect data over the years. And, and he has done an amazing, you know, work not just in, in a sort of natural history studies, but also for instance in you know, brace based studies that, you know, have been landmark in how we treat these patients.

So he has to be certainly, you know, acknowledged for this. You know, in, in, in our setup, like in Europe and, and in the UK we are now moving into the model of having, you know, deformity alongside, you know, degenerative spine and alongside, you know, the acute spine work. And I think that gives the ability for this [00:25:00] bridging to occur.

Of course, and, and hopefully it'll give us the opportunity to follow patients up and you know, if you, if you have this combination of okay, good local, you know, documentation of what has been done, you know, databases at the local service basis so, you know, okay, say in Edinburgh or in or in Manchester or in Leeds or in Sheffield or in London, you know, what have you done?

What are your patients? Try to follow them up. And, and this is where again, maybe having people who have more of a research type of role, cause you know, you, you, you always find it almost impossible to retrieve patients, to come back to clinic, you know, to be seen in clinic, to have x-rays, to have, you know, tests.

That is where obviously, you know, we have huge pressure from the health service and it's impossible to do it, but to, to do like telephone type of surveys to send, you know, questionnaires out to, to try to see how they're scoring years down the line should be feasible. Yeah. With some [00:26:00] maybe, you know, non clinical and nonclinical support.

So research type of audit, type of support. And then go through the registries, try to work that on a national basis, and then use databases like the Scoliosis Research Society. Yeah. Which again, you know, they've. It looked for two year follow up, but it would be great if they could go back and try to extend this follow up to, you know, longer years and into adult life and into hopefully from decade to decade, you know, longer term.

Yeah. And see what happens. I think, I think that is the only way, you know, to be able to, you know, to validate what we're doing and, and at the end of the day, you know, for risky procedures for costly procedures, you know, to be able to offer the maximum benefit of the patients. Yeah. And accommodate problems that will come, you know, longer

term down the line. Yeah, no, absolutely Thanos. I think that's two very, two very clear points are very well made about how we can potentially do that. Maybe Nick, same question to you. I mean, I suppose the other thing I was [00:27:00] thinking of, you know, along the lines of a lot has changed in healthcare and how we, how we interact with our patients because of Covid.

Is there any sort of novel methods you think we could maybe use as well? Absolutely. I mean, the. You'll recall, of course, the article by Hansji and, and his colleagues and including our Editor-in-Chief Fares Haddad last year looking at exactly this, and they looked at all of the various techniques that we can use in arthroplasty follow up, and how we can apply some technology and, and really in spine, we are not much different.

So I think the first thing to Thanos' point is, is, is essentially to say telemedicine let's, let's, let's record PROMs over the telephone, over a video link like this. You know, it's not gonna be very long before we start to get some clinical history bots. Instead of chat bots, they'll be clinical history bots and they'll be able to have an avatar and they'll be able to inter interact with people.

And the people who've got scoliosis now have been treated in their teens, in their twenties. [00:28:00] Are going to be very familiar with these sorts of technologies and they'll be absolutely fine, and I don't think there's gonna be a problem with that. We tried it back in the 1990s for diagnostic algorithms or back pain and tried to understand patient reported outcomes

from that, it didn't work because we didn't have the computing power. We didn't have the software technology. We are developing that now, and AI is moving forward at such a, a rapid rate that I don't see it very, very long before we can actually start to do most of our routine non-urgent follow up through, through a telemedicine AI approach.

The second really then comes to the second part of the assessment. So we've got the history, which is the PROMs, the, the AI, the avatar. The second is the assessment of the examination. How do we see whether somebody's curve has progressed and now modern digital technology on our phones is such that we can use them.

We can go back to the old days when we were using Mario Fringe type approaches. We can look at that. We can put grids on on [00:29:00] our phones and we can see whether someone is 3D shape has changed from year to year to year. And because of the accuracy of digital photography, we can be pretty sure about that.

And I remember going to a 3D spinal shape conference in 1994 in Pescara in Italy was the first scoliosis conference I ever went to. And they were talking about, you know, things like Mario Fringe type technologies then, but they just didn't have the technology to make it work and I think we actually will have those in the coming years. And, then the other part is actually about the treatment of patients and actually chronic pain management.

How are we going to allow them to access good treatment to manage their pain if we know that they're getting chronic pain? And I'm involved in, in new technologies, things like home-based neurofeedback training, which is really looking at how you can alter to people's brainwaves to allow them to become more able to manage their, their chronic pain.

And this has been very successful and this is gonna be rolled out [00:30:00] in the next few years, and I think that's gonna become something that is just home-based and we can then, look at them remotely, treat them remotely, and then react as needed. So they then come into the clinic only when it's absolutely necessary for Thanos to see them or his colleagues and say, look, there is a problem now and we need to do something different.

And I think that's probably going to be the type of approach that we have in the next couple of decades. No. Absolutely. Okay. That's a really nice, nice point to finish on in terms of what, how, how it will evolve. And like you say, I don't think it will be long before for these, these these ambitions and sort of aims are, are sort of realized.

I, I totally agree. Well, both sincere thanks for joining me today and, and highlighting a really important topic and, and, and how we might move forward in this area, what we've just touched on there. And, and, and not just in, in scoliosis surgery or spine surgery, in, in several areas within our specialty where that longer term follow-up and

assessment is, is, is really still very important and, and valid. So it was really informative and, and so nice to talk to you [00:31:00] both. And to our listeners, we do hope you've enjoyed joining us and we encourage you to share your thoughts and comments through social media like about what we've discussed today and the papers we've discussed.

Feel free to tweet or post about anything. And here today, and thanks again for joining us. Take care everyone.