Prakash Chandran: I'm your host Prakash Chandran. Today, I invite you to listen while we discuss children's spinal care. Joining us is Dr. Michal Szczodry,, a pediatric spine surgeon at Shriner's Hospital for Children in Chicago. Dr Szczodry I really appreciate your time today. Thank you so much for joining us. I just maybe wanted to get started with the basics around a child's spine. When we say an abnormal spine curve. What exactly does that mean?

Michal Szczodry, MD: Hi, thanks for having me. So I think we should start this discussion with the definition what the normal is. And we first should probably discuss that there are some curvature to spine that are normal. And we obviously know what those values and ranges are. And some of those curvatures involve the spine being looked from the side, so called sagittal plane when you're looking at the patient or a child from the side. And usually on the child that is already walking in is fully developed, they will have four notable curves.

The first one i s cervical or dos, which is your cervical spine also called neck going forward kind of in the shape of letter C, then there's your thoracic kyphosis going more distal, which is in the shape of reverse C, then there's your lumbar spine, which is again, going into the letter C. And then there's your tailbone going again into kind of a reverse C. So if you really look globally at that spine, it will have double S type of shape.

And that's actually normally that allows your spine to absorb any sort of shocks when you jump, when you run and really protects actually your brain from getting damage or smashed over your spine by having this type of formation. Unfortunately, sometimes we have abnormalities in those normal curves

.

And then there is your Coronal plane when you're looking at the spine from the front. And generally speaking the spine when looking from the front should be straight or that's what's considered normal. If the spine goes to the side it curves in the coronal plane, usually we deal with something that we call coliosiss and that's the other type of Deformity that we very often treat.

Prakash Chandran: Yeah, that makes a lot of sense. And I know there's a lot of nuance there. So in terms of diagnoses, is it just looking at those planes and seeing if there's something that's slightly off, how is an abnormal spine curve traditionally diagnosed?

Michal Szczodry, MD: So this is actually very true, what you just described. We as a spine doctors and also as pediatricians who we kind of trying to make sense on those abnormal curvatures, trying to catch those abnormalities first in the physical exam. And when there is any sort of suspicion that the abnormal curvature is present or developing, then we would start using imaging, usually x-ray and image spine, at least in two planes to define those abnormalities.

Prakash Chandran: Okay, understood. Now, you know, one of the things that we're talking about today is information on casting and halo traction. So let's start with casting. I've heard of different types of casting, like serial casting. Can you talk about the different types of casting, how they work and when they are used?

Michal Szczodry, MD: Generally speaking over the decades, we develop pretty standardized type of cast that we would use for spinal deformity. This is pretty much reserved for very little kids starting from maybe one year of age, up to four or five years of age. And this is basically a shirt that is made of the cast that we apply usually under anesthesia when the kid is asleep. We use traction to allow us for some spine strengthening during the process. Then the cast is being applied and once the kid is being awake, the spine is being in a way pushed or held in that position in which the cast was applied.

And that's what allows really the spine growth to be modulated as the kid is growing, it really has nowhere else to go, but kind of straight instead of going sideways and making scoliosis worse. But as far as types of casts, we pretty much now use just one type of cast. It has a fancy name after people who contributed to the design. But it generally speaking, it's one type of cast and we also call it body cast because it really goes from the hips all the way to the neck.

Prakash Chandran: Okay. And so what is that type of casting called? I think people sometimes have heard of serial casting, which is sometimes even used on your foot. Like when you break your foot or something like that for this, spine casting, does it have a specific name?

Michal Szczodry, MD: Yeah. So most of the institutions will call the meta catrel. And again, this is after two people who like contributed to the final design, there were two physicians kind of living in different eras. But one take on another and kind of. Their cause better. So most doctors who do the casting these days will use this combined name meta contrel. But as far as how they look or again, the body cast is also used name. They look generally speaking pretty universal among institutions.

Prakash Chandran: Okay, understood. I Think when it comes to casting, I imagine that you have parents or families that have thoughts on the entire process. Can you talk to us about maybe some of the most common questions that they ask and how you answer them?

Michal Szczodry, MD: I think the most common question is really this is really necessary type of measure to, to control the curvature. And if there are any other options. And the main reason people ask the question is because we are dealing with multiple anesthesia on the young child. We believe have little to know effect on their development, but there are some data suggesting that effect may exist, even if it's still little. And we need to be honest [inaudible] and tell them that the data is out there kind of make them aware that when they sign up for the serial casting that multiple anesthesia will happen. So that's where the question comes like, why we actually need to do it. And is there any other alternative? That's probably the most common discussion and maybe the most difficult discussions I have with those families.

Prakash Chandran: Now, another thing that we're talking about today is halo traction. Can you talk about what this is?

Michal Szczodry, MD: So halo traction is basically a weight that is attached to the patient hat and is done through special halo ring that is attached to the skull through at least six pins that go around the ring. And we use that ring to attach the weight to it. And that actually allows us to stretch the spine. This is to most often help us with controlling the deformity and also prepare patient for surgical intervention where some of the stress that we are hoping to get throughout the surgery is being done by gravity, basically.

By hanging the way through special system of police that allow that way to actually stretch the spine. So in a way, some of the work is already being done before we even start the surgery. And another benefit of it is each time we do those surgeries on spinal deformities, we are to certain degree stressing spinal cord by straightening the spine. So the weight in a way helps us to like, Precondition spinal cord to do that almost tells us like how the spinal cord will react to the stretch during surgery.

And that the beauty of the traction is that it happens kind of gradually because after we put the rin g, we increase the weight a gradual fashion over usually like one week period versus the stretch during the surgery happens fairly quickly within few hours. So in a way we allowing spinal cord to kind of get used to the forces it will see during the surgery.

Prakash Chandran: Okay. So if I'm understanding it correctly, it's kind of like a halo or a circular device that sits on the head. And there's a series of pullies. And in terms of its use, is it usually used before the surgery or after, or both? Can you talk a little bit more about that?

Michal Szczodry, MD: That's actually a great question. So let's start with the fact that it is reserved for more severe deformities, where we feel like we do need some help outside of our spinal implants that we'll use during surgery. And it is used in all kind of fashions, but most common one would be to actually give a patient a period of traction before surgery for usually a couple to few weeks. There is also a situation when we actually have to perform two surgeries on a patient. When we are releasing some of the spine stiffness through the chest surgery, like anterior approach.

When we approach the spine through the chest release some of the [inaudible] that caused the spine stiffness. Then we go back to the traction period where the patient will do additional few weeks of traction after that surgery. And then there is a final procedure in which we are locking everything from the back of the patient, from posterior approach. And this is a timeline. We would also remove the halo because we consider the process to be completed.

So it kinda varies, but there's pretty much always presurgical period in halo when the ha is being used. And generally speaking after posterior surgery is done or surgery where we like use implants to lag the spine in certain position, the halo can be removed.

Prakash Chandran: So I wanna move on and learn a little bit more about the approach to spine care at Shriner's Children's Chicago. I know that this is something that's unique to Shriner, so maybe you can talk a little bit about it?

Michal Szczodry, MD: So, first of all, I wanted to start with our tremendous team that has been taking care of spines for really decades. And even if there's always somebody new coming to the team, including me. I only joined like six years ago. But I feel like we standing on the should. People who did this work before us. And there's always some overlap with senior members of the team. So we all like learning from each other. So, I think this kind of unique care continues through the generation of those care providers. And that's one of the biggest thing. And obviously the other thing comes with it is just experience.

I started my career under the wing of two senior doctors who kind of taught me their ways and I'm trying to follow their way of doing surgeries and taking care of those patients. So in a way, like by them, Teaching me and teaching others that legacy continues. Those are probably the two most unique things that give us a bit of a unique approach. And the other one is just basically Sean is being extremely kids, friendly institution and everything. When they come here is very kid oriented including. The colorful walls and all the toys we have and the video games that they can play and really everybody is being center and focused on the child.

Prakash Chandran: Yeah, I think that's absolutely wonderful. And to have a child centric environment like that especially when addressing spine care I think is so critical. So Dr. Szczodry, just as we wrap up, is there anything else that you would like to add or discuss for our listeners?

Michal Szczodry, MD: No, I think we touch on all the very interesting subjects and I encourage people if they do have more questions to just contact us directly. If they feel like they do have a problem, then obviously we have. Pretty straightforward system of scheduling consults. So I honestly encourage anybody with even the smallest questions, but the one that, that bugs them to just come and get checked. And I think that's really the best way probably to addressing some of those issues.

Prakash Chandran: Well, Dr. Sh that I really appreciate your time today. Thank you so much.

Michal Szczodry, MD: Thank you. Thanks for having me.

Prakash Chandran: If you'd like to make an appointment or for more information on the amazing care at Shriner's Children, Chicago, you can visit Shrinerschicago.org or call 773-622-5400. Thanks so much for listening. This has been Pediatric Specialty Care Spotlight with Shriner's Hospital, for Children in Chicago. I'm your host Prakash Chandran. Thank you so much and be well.