Today, we have a very special guest here on the blog, Dr. Marcelo Risso, who is a Professor and Coordinator of the Spinal Surgery Group at UNICAMP in Campinas and the Coordinator of the Spinal Surgery Group at Hospital Alemão Oswaldo Cruz in São Paulo. I spoke with him in recently, mainly about adolescent idiopathic scoliosis, the use of braces, and early detection, but we also talked about what lies ahead for the future of this condition. Check out our conversation below:
1- Dr. Marcelo, welcome to the blog, and thank you for being here with us. To start our conversation, could you please explain what adolescent idiopathic scoliosis is?
It's a great pleasure to speak with you, who has turned your life story into an opportunity to educate and guide people who have experienced or are experiencing scoliosis.
Scoliosis is a spinal deformity that causes the vertebrae to deviate from the body's midline, producing an abnormal curve. Medical conditions labeled as idiopathic are those that do not have a known cause. Thus, adolescent idiopathic scoliosis is a deformity that deviates the spine from the midline without a defined cause. It is the most common type of scoliosis and becomes clinically significant when it has an angular value greater than 10 degrees in radiographic measurements. Approximately 80% of scoliosis cases are idiopathic. Mild curves, generally between 10 and 20 degrees, have a prevalence in the population of approximately 20 to 30 individuals per 1000. On the other hand, severe curves, those above 40 degrees, have a prevalence of less than 1 person per 1000. Idiopathic scoliosis affects healthy and normal children and has the potential to be more severe when it starts in younger individuals.
2- At what age should parents start paying attention to the spine to notice quickly any abnormal deviations?
In general, the first visible manifestations usually occur in early adolescence, around the age of 10. It's common for parents not to notice these signs, but rather for them to be observed by people who have less frequent contact with the child, such as aunts, friends, and teachers. The first visible manifestation is an asymmetry in the contour of the trunk compared to the arms. As the curve progresses, it can lead to deformity of the ribs, resulting in a hump that becomes visible when the trunk is flexed. However, many times parents only have doubts and cannot conclusively determine whether there is a deformity or not.
3- If they notice something different, what should they do?
In the presence of any doubt, the first action is to ask a doctor, usually a pediatrician, if there is any abnormality. After the pediatrician's examination, they may request an imaging test and refer you to a specialist evaluation with an orthopedic doctor.
4- Early detection of scoliosis can prevent surgery?
This is a very important point. The earlier the diagnosis, the better the effect of non-surgical treatments. Therefore, if well indicated, well performed, and at the right time, conservative treatment with modern braces and specific physiotherapy exercises can prevent the progression of scoliosis and even achieve some improvement. In many cases, it can avoid the need for surgical treatment.
5- At the last International Scoliosis Symposium of AACD, you spoke about assessing skeletal maturity in adolescent idiopathic scoliosis patients. What is the importance of this process for the treatment of adolescent idiopathic scoliosis?
This is a very important variable in the monitoring and treatment of scoliosis. Skeletal maturity is the point at which the skeleton transitions from an immature, or child-like, skeleton to a mature, or adult, skeleton. The adult skeleton no longer has the potential to grow. We know that all types of scoliosis, not just idiopathic ones, progress with growth. Therefore, knowing the level of skeletal maturity is important for estimating how much scoliosis can worsen and also for determining if conservative treatments like bracing and physiotherapy will be effective. Assessing skeletal maturity is challenging for those treating scoliosis and is important for decision-making.
6- In case the use of a brace is recommended, and considering the difficulty that children and adolescents have in accepting this condition, what are the main tips you could give to make the use less distressing?
Currently, the available braces are more discreet than those used years ago. The old braces, while effective, had inconsistent usage as their main failure point. For a brace to be effective, it should be worn for many hours a day. Initially, it was recommended to wear it for 23 hours a day, then it was reduced to 16 hours a day. However, issues related to appearance, negative body image, pain, and the fact that our country has a hot climate can lead to irregular brace usage, rendering it ineffective. Braces that extend up to the cervical spine are not widely accepted in our population. The more modern braces, known as 3D braces, have proven to be effective and do not require cervical extension, allowing them to be worn under clothing. However, even with these advancements, it can still be challenging for adolescents to accept the brace. It is necessary to have one or more conversations with the patient and parents - some together, others separately - explaining the need and importance of wearing the brace, and the potential benefits it can bring, while also motivating and agreeing to some moments and situations where it use could be more flexible. Nevertheless, it is quite challenging, and these conversations need to be revisited periodically throughout the treatment. A good partnership and alignment with the physiotherapist are crucial. At the end of a successful treatment with a brace and physiotherapy, the sense of achievement brings a significant boost in self-esteem.
7- What are the most common complaints from patients that you hear in your office? And how do you usually address them?
In general, idiopathic scoliosis is asymptomatic. Occasionally, there may be pain that improves with common painkillers and physical therapy. The most common complaints are related to wearing the brace and adherence to physical therapy. Regular conversations, brace adjustments, and periodic clinical and radiographic follow-ups are very important.
8- What have been the main medical advances in relation to scoliosis in recent years?
The main advances in relation to scoliosis have occurred in three areas: the first is related to conservative treatment, which is more efficient and based on better evidence, using 3D braces associated with specific exercises. This has brought about better treatment adherence and improved effectiveness. The second advance relates to surgical treatment. Today, we can perform surgeries that provide better correction, are less invasive, and, primarily, safer. This is due to better techniques, equipment, and more modern implants, along with intraoperative neurophysiological monitoring. Finally, advances in the assessment of skeletal maturity, using more precise and reproducible radiological methods, make us more assertive in recommending each type of treatment and ensure that decisions are made at the most appropriate time.
9- Thinking about the future, do you believe that it will be possible to identify scoliosis early with genetic tests?
There are genetic tests in development, some already in use, that identify the risk of developing scoliosis. They are performed using blood or saliva samples. However, they are still not widely adopted, and their effectiveness in broader populations has not been confirmed. Nevertheless, I believe that in the near future, this will become a readily available reality.
10- And robot-assisted surgery, will it be a reality in the long term?
Robotic surgery is a reality in various fields of medicine. It won't be different in spinal surgery. However, the operation of these robots depends on a surgeon. As advanced as they are, they still don't have the autonomy to perform the procedure or parts of it. The first step in using robotics, which is already very close to becoming a reality, will be the use of robotic assistance to position implants more accurately and safely. Let's stay tuned for updates!
Dr. Marcelo, thank you so much for providing such valuable information! I'm sure this interview will help many people in need.
Excellent interview!!! A lot of important information about idiopathic scoliosis