[MUSIC] Uneven shoulders and hips and even a slight curvature of the spine may be innocuous, but also may be indicators of later potential problems.

[MUSIC] Stay with us as we talk to pediatric orthopedic surgeon Doctor Kelly Jenkins about common and not so common spinal conditions in children.

Next on Kentucky Health.

>> Kentucky Health is funded in part by a grant from the Foundation for a healthy Kentucky.

>> Hello and welcome to Kentucky Health.

I'm your host, doctor Wayne Tuckson.

Today we're going to be talking about common and not so common spinal conditions in children.

Pediatric spinal conditions consist of structural abnormalities.

Think scoliosis and kyphosis.

Congenital defects, spina bifida or could be a consequence of infections, tumors, fractures or breaks.

The presentations may be as obvious as uneven shoulders and or hips.

Back or neck pain balance issues, or subtle as changes in skin color or lump in the back and pain or loss of sensation.

As is true for most conditions, early diagnosis can either prevent or minimize later complications.

Some conditions can be observed to see if they progress and others may respond to measures such as bracing or physical therapy.

However, when surgery is required, good functional results and correction of the underlying problem are achieved with multispecialty teams consisting of pediatric spine surgeons, neurosurgeons, therapists and other health care professionals to discuss pediatric spinal conditions and their treatment.

We have, as our guest today, Doctor Kelly, a Jenkins doctor Jenkins graduated from the Vanderbilt University School of Medicine in Nashville, Tennessee, and completed a residency in orthopedic surgery at Western Michigan University.

Homer Stryker School of Medicine in Kalamazoo, Michigan.

She then completed a fellowship in pediatric orthopedic surgery at the Combined Cleveland Clinic and Akron Children's Hospital in Akron, Ohio.

Doctor Jenkins is now in practice as a pediatric orthopedic spine surgeon with Norton Children's Leatherman spine doctor.

Jenkins Kelly, thank you for being with us today.

>> Thank you for having me.

>> So how does a person decide to waste their time doing orthopedic surgery and not something like colorectal surgery?

And then specifically get into kids?

Tell me.

>> About it.

We chose to be happy.

>> Tell me about but tell me about this journey.

So right out there right now, there's another little girl other than the one that you're carrying who says, I want to be like this lady?

>> Yeah.

>> What's she going to do?

>> You know, I have the wonderful privilege of treating children.

Orthopedics is an amazing career because we can diagnose problems and treat those problems.

And there's functional and real outcomes that we get to see on a daily basis.

So I think that's the most rewarding part of my job.

>> When did you decide to be a doc?

>> Oh, I decided I wanted to be a doctor.

I was probably middle school, early high school.

I knew I liked science, I knew I liked interacting with people, and that seemed like a natural career choice for me.

But I didn't decide on orthopedics, actually, until probably third year of medical school.

>> So we used to have this idea that pediatric surgeons, sorry, that orthopedic surgeons were men and big people.

Obviously, this is not the case.

>> Yes.

I am not a man or I'm not big, but but yes, I think that's an old misconception that you have to be big and strong to do something like orthopedics.

You know, we're blessed with great teaching and opportunity to learn how to do these procedures and not have to be the strongest person in the room.

>> But now tell me what is so special about the Norton Children's Leatherman Spine Group down there?

>> Yeah.

So it's a unique group.

We have adult surgeons and pediatric surgeons who now work all together to treat children, but also adults that have spinal issues.

So it's nice we have multidisciplinary approach specifically in our clinics.

We have other people that work with us, such as Orthotists, who help make braces and things that we treat spine conditions for.

We have connections with people like physical therapists.

We have nurses and nurse navigators who really help simplify the system and make it as streamlined as possible for our patients.

>> So it isn't just what you yourself are doing, but it's a whole team effort.

And does that allow you to get results that say, if you go to some place where there may be just the one doc who's taking care of everything, you get a little bit better job?

>> I like to think so.

I think what's really nice and unique about our group specifically, specifically for Kentucky, is that we're all specialists, so we have extra training.

Okay.

Specifically for spine conditions.

And so that gets you a unique perspective and people who really care about children and how children do not everywhere that you go, especially even for spine surgery alone, do they have specialized training in treating pediatrics or children.

So that's what's really unique about us.

>> So tell me, what are some of the common pediatric spinal conditions that you tend to run into?

>> Yeah.

So our most common things that we see are scoliosis.

And then kyphosis and lordosis.

Those are the three main ones that we see with abnormal curvature of the spine.

Scoliosis is the most common of those.

That's probably what most people are familiar with.

>> And tell us a little bit about scoliosis.

What is it?

>> Yeah.

So the definition of scoliosis is an abnormal curvature of the spine.

Anything more than ten degrees of curvature.

So when you look at a spine, especially looking straight on, it should be fairly straight.

Okay.

So if you were to look at an X-ray of the spine and see that there was a curve to the spine, that was more than ten degrees, that would be considered scoliosis.

We've actually learned over time it's more of a three dimensional deformity.

So it's actually in multiple planes.

Oh really?

Hum.

And so the spine curves and curves around.

But we usually only see that X-ray head on where we see the curve.

>> That's how does that differ then from kyphosis.

>> So kyphosis is typically talking about the upper part of the spine.

And if you were to look from the side of the spine, you would have more curve this way.

So what people typically would see that as is like a humpback or somebody who has more of a hunched back to them.

When you look from the side.

>> So are these conditions that one acquires or are people born with them?

>> Most frequently?

They're not born with them.

There are some types of scoliosis where you can be born with abnormal bones in your spine that cause a curve.

As children grow.

But the most common form of scoliosis is acquired.

So it's what we call idiopathic.

It typically shows up around adolescence or when we're around 10 to 12.

>> If you find it.

Do you have to do anything about it?

And what happens if you don't treat it?

>> So there's varying degrees of if we have to do anything about it.

So the more mild forms of curves in the spine, typically we just watch as the children grow, the more significant curves in the spine.

We do recommend treatment.

There's a varying degrees of treatment that we might recommend, such as physical therapy, a brace to prevent progression of the curve.

But our most severe or significant curves are when we recommend surgery.

But the goal is we try to prevent that with early detection.

>> So when are these things picked up?

I seem to remember.

I gotta remember I was around before dirt, so so you know, I remember they used to line us up in school and somebody would look at our backs.

Do people still do this sort of thing?

When are these conditions.

>> Picked up?

So most often, and what we recommend is at our well-child checks with pediatrician that they're monitoring, similar to what happened when you were way back in the day, getting checked out.

So typically those start in early childhood.

If there's concern before that time or if the pediatrician has a concern, an X-ray can be taken, which is how we diagnose this.

But the simplest way to detect is both looking at the patient, having them bend forward, seeing if there's uneven parts of their back.

>> Again, tell me though, if I decide not to do anything, you know, this is their going down the road.

What complications can you say, okay, if we don't address this now.

Yeah, this may or may not happen to you.

And how likely is it that this may happen?

>> Yeah.

So the really significant curves, the one that are the ones that we recommend surgeries for, the reason why we recommend surgery is to prevent those long term complications.

So if they're not treated or we don't address them when we can, those curves typically progress.

They can cause problems with breathing, with bowel function, you know, every day, things that we need to live.

And so that's why early detection and treatment is key.

>> So you mentioned putting on a brace.

When would you consider a brace.

And what does the brace actually do.

>> So the brace is reserved for patients that typically have curves that are about 25 degrees or bigger and have growth remaining.

So the idea behind the brace is not to make the curve go away, but it's to prevent the curve from getting bigger.

Everything we know about scoliosis from research that's been done over many years is that if a curve is around 30 degrees, when we're done growing, so we reach our final adult height, those typically don't progress or cause us problems in adulthood.

So that's the goal.

If our curve is progressing to that size or near that size, the brace is hopefully to help prevent that from progressing.

>> More.

Is the same thing true for kyphosis, where you get the bending coming up, humpback type thing?

>> I guess it's similar.

We do sometimes do a brace for that.

If the kyphosis is significant and they have growth remaining, the numbers are a little bit different of how much we allow of that.

Kyphosis curvature.

But yes, the idea behind a brace with kyphosis is to prevent it from getting larger.

As a patient grows.

>> Now you brought some horrible looking things with you today, and I want you to take me through some of the surgery.

But first, tell me, how has surgery changed now?

You've been doing this for about ten years now.

So when you sit back and you look back and everybody talks about stuff, 20 some odd years ago, what's different about now versus then?

>> Yeah, I mean, we're seeing great advances in how we treat spine conditions like or like scoliosis, even from the time that I've started, which is relatively recent compared to some others, but so some of the really nice things that we have for our children now are growth friendly types of surgeries, which really are helpful for if patients are young, when they get what do you.

>> Growth friendly.

>> So I have a couple props here.

So so when we think about how we fix the spine, the traditional way that we would do this would be a fusion.

So with the fusion screws and rods that go into the bone and all of this bone to form as one, this unique implant that we have here is relatively new, you know, within the last decade is when this got FDA approval to be used.

But this is what's called a glide procedure.

So at the tops and the bottom of the construct that you see here, these screws actually allow the rod to slide.

So the patient can grow along the rod.

We think of it like a train on rails.

>> So it's not a rigid structure.

>> This is not rigid.

Yes.

We can.

It can slide.

So this is for our patients that still have a lot of growth left but have very significant curves so that we can fuze the curve part of the spine.

So these are those fusion or those rigid screws.

And then allow them to grow above and below.

So that's very.

>> You're making an incision along the entirety of the Bakhtin to put this in.

>> Yes.

>> So this is not one of these little.

Minimally invasive things, you.

>> No, no.

It is a big surgery.

But the beauty of this is that it allows the child to continue to grow, which traditional fusions did not allow.

And we honestly didn't really have great answers for how to allow children to grow with their very big curves.

>> With this type of an apparatus in place, can a child play sports or are they limited by any kind of activity?

>> Most often, patients are allowed to play sports after they heal from their initial procedure.

Really, there's varying degrees of what surgeons will allow their patients to do as far as things like football or ride a BMX bike or something that's a little bit more aggressive.

But once this heals or once the patient heals from the surgery, essentially they can live a normal type of life.

>> What about the next one here?

>> So the other growth friendly one that I we also offer where we work and is also very new and unique to our practice is what's called a tether.

So this is a very unique type of procedure where we actually don't put metal in.

So there's screws and they're connected by a rope.

What that does you can see allows for motion in the spine.

So the fusion doesn't allow for motion.

The tether allows for motion.

>> So how does that keep the spine from curving.

>> Yes.

So when you put the tether in, what you're doing is you're correcting some of that spine curve.

But then the other thing you'll notice it's only on one side of the spine.

So then this is a growth modulator or it affects as they grow.

So in patients grow.

This holds that part of the spine.

While the spine that we didn't put any hardware or tether in is allowed to grow.

So the idea behind that is that the curve corrects over time with a flexible implant.

>> So you put the hardware on the side where the abnormal curve is located.

Yep.

Is there a tendency for things to curve more to the left or to the right?

>> The most common curve that we see is what's called a right thoracic curve.

So in the upper part of the spine, the thoracic part.

And then the curve goes to the right side of our body.

Sorry right side.

So that is the most common curve that we see.

>> Wow.

That how long is this kind of surgery.

>> Depends.

Depends how many levels that you're treating and how what you're doing.

But I would say the typical time that we tell our patients anywhere from 4 to 6 hours.

>> Do you ever have to go back in to take the apparatus out?

Or once it's put in, it's intended to be permanent.

>> So when we do things like fusions or the tether, like I just showed, when those are put in, they're intended to be forever.

The growth friendly option where we see that rail, where the screws slide, we typically know we are going to have to go back in for another procedure eventually to do that final fusion.

Once you get to the fusion where it's just screws and rods, the hope is that we're done.

That's the only procedure that we anticipate.

>> Now is the fusion.

Is that this other thing that.

>> I see, and it looks.

>> Very similar to the rails and screws, but similar thing where you just see screws and rods, but they're very rigid.

So nothing where they can slide.

>> Nothing where they can slide.

I don't want to sound like an idiot, but we all know about the MRIs now, and you can't have metal when you go to MRI.

Are these safe for going through MRIs?

>> Yes.

Most of our implants that we use are MRI safe.

So after our fusion has taken and healed, you can have an MRI with these implants.

It causes what we call scatter.

So it might make the images not as clear.

But you're able to get them.

>> And of course when traveling for the TSA, yes, you got to let them know that you've got this metal in the back.

>> Yeah.

>> People often ask if you get a card or anything.

We don't do that.

But typically nowadays they'll see on that X-ray image and see that you have hardware.

So it might set off the metal detector.

It might not.

Every metal detector is a little bit more sensitive than others, but they typically will see they might do a wand and see that.

>> So what about movement?

I want to lateral movement.

Or if I want to bend over and things like that, how does that, does that impair in any way?

Having this rod in there?

>> So the.

>> Fusion.

Yes.

What we know is that the more levels that you fuze in your spine.

So as you get into the lower part of your spine, your lumbar spine, you lose a little bit more flexibility, kind of bending forward and backwards.

Each level is about 5 or 10 degrees of what you would lose with that.

But that's why we love this tether implant, because what we're seeing is actually fuzing above and tethering below preserves motion and is really fantastic for patients.

So as long as you identify a curve, the sooner the better.

Most curves you're able to only fuze a small segment of the spine.

Some you can't if they're lower in the spine.

But the idea behind that early detection and treatment is that their function long term would be improved.

>> All right.

Now everybody and their brother has one of these little devices, and we're all hunched over doing this.

Is that leading to kyphosis or some other spinal problems?

>> It typically doesn't cause worsened curves in the back, but it can affect your posture.

And so posture, weakened core can cause things like back pain, which is a big problem for adolescents these days.

And even older people because yes, our.

>> I wish you'd stop looking at me like that.

When you say older people, but go ahead.

>> My self included.

No, our lifestyles just don't make it.

Yeah, that our backs are strong.

But like you said, we spend a lot of time on computers, on our phones.

So we're spending a lot of time in this position.

And that puts a lot of strain on our back.

It does not worsen curves.

We know that.

But it can worsen posture curves and back pain.

>> So that is not the same thing as technically as kyphosis in this case.

And we can do something about that.

Exercises to minimize or even correct it, perhaps.

>> Correct.

>> Interesting.

Tell me a little bit about some of these more uncommon things we hear about spina bifida every now and then.

What is that?

>> So spina bifida is kind of a global term, but just saying that the spine at the typically the lower part of the spine didn't form fully.

So we know that the spine and the spinal cord that goes through the bone of the spine is an enclosed area of bone spina bifida is when there's an absence, either of the bone or the overlying tissue.

>> How common is.

That?

>> It's not extremely common, but we do see it.

>> Are there things that you as the orthopedic surgeon, have to do or is that something else?

>> Typically, neurosurgery is who sees these patients.

Sometimes patients with spina bifida do end up with spinal curves.

And those are things in times when orthopedic surgery gets involved.

>> Probably a far more common thing, especially as kids are playing more, more contact sports are fractures and breaks.

How common and how serious can some of these things be?

>> They can be very serious.

There's a whole spectrum of what that is.

There's the overuse.

So stress fractures in the back, and then there's things like injuries or car accidents that cause more significant breaks in the back.

You know, when you think about that, that's when you worry about spinal cord injury or other things that go along with that.

But the stress fractures can sometimes be hard to diagnose because patients often just present with back pain.

>> So what's a common thing?

Is it just because of some I got run over by a guy, a kid's playing football and he gets run over or kids playing soccer, and he goes up the head.

Something and the cord gets compressed.

How does he think?

>> Typically those stress fractures occur with overuse.

Sometimes they can be a single event that causes an injury to the spine and cause it to break.

But a lot of times we see it with patients who do repetitive hyperextension type exercises.

So linemen with football divers, gymnasts, volleyball players, we see it in a lot of different athletes.

Sometimes all it takes is one single time and one injury, but sometimes it can just be that repetitive exercise.

>> How common do we see infections in the back?

>> It's not very common, but we do see it.

The most common place that we see it is typically in the discs, which are those spaces between the bones in the back.

But you can see it in the spine, in the bone as well.

>> That is usually require treatment to get rid of the infected area.

Or do they respond to antibiotics?

>> Most often it requires antibiotics.

That's typically the recommended treatment.

Very rarely.

But we do do surgeries for infections of the spine.

>> And I would imagine tumors are relatively uncommon back here.

>> Yeah, they can happen.

They can actually be a time when we see a curve.

But yes, I would say it's on the more rare version of when we see curves or due to tumors.

>> Now I know these things never happen to you guys over at Norton Leatherman spine, but I'm sure there's some complications that can happen with surgery going to happen to us all.

What are some of the more common things that you tell your patients?

What they should be looking out for?

>> Sure.

Anytime we operate, there's always risk of complications.

So we talk about things like infection.

You know, if when we're putting hardware in the bone, can the hardware fail or break or have other complications with that?

The things we always talk to our patients about, because it's a big concern for a lot of families, are neurologic problems from the surgery itself.

So things like paralysis, big things that are life changing and life altering.

The risk of that nowadays is fairly low.

It's less than 1%.

I think the most recent study showed even less than 0.5%.

So really one out of every thousand is kind of the numbers that we're seeing where that happens.

But we're very careful to protect the spine as we operate.

We actually do real time monitoring of all the nerves of the spine, so that we know that everything that we're doing is safe for the patient.

>> Really, how are you doing?

Monitoring of nerves.

>> So while the patient is asleep, we are monitoring them.

So they have many needles in all the different muscles in their body.

We're getting real time feedback, just seeing exactly what we're doing to the spine and how that's affecting the nerves that our spine supplies.

>> What is, I guess you can't say globally, the youngest age, but what typically is an age that you say, well, we don't really want to operate now.

And so what is that age?

Yeah.

Before, when you start thinking we might want to do something.

>> We try to get or allow patients to grow as much as possible before we do something like a surgery on the spine.

The nice thing about how we treat patients, especially when we're talking about scoliosis, is younger patients.

We can do casting.

So it usually requires anesthesia for this.

But we put them in a cast and it helps.

Body cast spine.

There's no age limit on when we can or can't operate on a child, but the older they are, the better it is for them and for everybody.

>> Tell me about the esthetics.

Obviously, I that's probably got to come into play about timing of surgery.

Does that when a kid, you know, because these are people who are pretty much aware of their bodies and there's a lot of body shaming that's going on nowadays.

How does that come into play when you're looking at taking care of patients with kyphosis and or scoliosis?

>> Yeah.

The body image is a big deal with things like scoliosis.

As you said, most often this is diagnosed when kids are in middle school.

That's a very rough time if you can remember all the way back to that time, it's hard to be different from your peers.

But when we talk about things like treating this, you know, we're aware of that and we want to be respectful of that.

Things that can be really difficult for a patient to hear, or that they need a brace for their back.

And that can be tough to have at school during the day.

So we're very aware of that.

There's lots of resources now that we can direct patients to that help them feel better about wearing something like a brace.

But also, if we do have to do something like a surgery, one of the secondary goals of that surgery is actually correcting the curve.

The primary goal is to prevent the curve from getting bigger.

Secondary goals are improving the curve, and so that's always a real victory for us.

When we can improve that cosmetic difference to our patients.

>> Give me your one minute answer.

One thing you want to make sure people take away from our discussion.

What is the most important thing?

>> The most important thing is if you have a concern about your child, talk to your pediatrician and we're happy to see you.

You know, I think most of our families know their child best, right?

And more than our doctors do, more than I do, more than you do.

And so if there's a concern, you know, bring it up.

And we're always happy to see our patients.

To me, it's an easy test to get something like an X-ray, to identify something that we might be concerned about.

It might be nothing.

Right?

There's a lot of people that have different shoulder heights, differences in how their body looks.

But an X-ray is an easy, inexpensive tool to identify.

So that's my takeaway is if you have concern, bring it up.

And that is an easy thing to find.

>> Do people have to get through you through their primary pediatrician, or can they call you directly?

Not you per se, but Norton.

>> Might go to me.

So it's honestly related to your insurance.

So sometimes, and I would say most of the time you have to get a referral through your pediatrician, but we're happy to see anybody.

So you can always call.

>> Fantastic.

Well, Kelly, thank you very, very much.

I appreciate you for being with us today.

And thank you for being with us today.

I hope that you have a better understanding of how the common and uncommon pediatric spinal conditions may present in the options are available for treating them.

If you wish to watch the show again or watch an archived version of past shows, please go to w w w dot ket.org/health.

If you have a question or comment about this or other shows, we can be reached at KY.

[MUSIC] Health at ket.org.

I look forward to seeing you in the next Kentucky Health.

But in the meantime, look at your children.

Look how their spines look.

Are they walking okay?

Are they having any weird complaints or things?

Please talk to your pediatrician or other health care provider, because if we can get these things looked at and treated early, we can prevent problems down the road.

See you next week on Kentucky Health.

Thank you.

>> Kentucky Health is funded in part by a grant from the Foundation for a healthy Kentucky.

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