Surgical Treatment Of Early Onset Scoliosis Research Articles

Minimally Invasive Controlled Growing Rods for the Surgical Treatment of Early-Onset Scoliosis—A Surgical Technique Video

Background: Spinal deformities in children and adolescents can be easily divided into those occurring and diagnosed before the age of 10—early-onset scoliosis—and those occurring and diagnosed after the age of 10—late-onset scoliosis. When the curvature continues to progress and exceeds a Cobb angle of more than 60–65 degrees, surgical treatment should be considered. The most common treatment procedure for EOS is the surgical correction of the deformity using standard growing rods (SGRs), and in the case of congenital defects with additional hemivertebrae, it is the resection of the hemivertebra and short fusion. Minimally invasive controlled growing rods (MICGRs) need to be distracted every 6–9 months through a minimally invasive approach that involves sedation and neuromonitoring to obtain the best possible correction while minimizing complications. The aim of our study is to present a less-invasive surgical technique for MICGR implantation based on a two-case presentation—early-onset idiopathic scoliosis and congenital kyphosis. The surgical technique is the less-invasive percutaneous and subfascial implantation of MICGRs without long incisions in the back. Conclusions: The use of MICGRs is an alternative and safe surgical technique for patients undergoing surgical treatment for EOS. Without the risk of metallosis, like in other implant systems, and the need for replacement after 2 years of use, like in using magnetically controlled growing rods (MCGRs), the MICGR system can be used as a less-invasive procedure, allowing for the avoidance of many periodic invasive procedures in children with a wider opening of the spine (like in using standard growing rods), minimizing the number of planned hospitalizations, reducing the length of hospital stays, and reducing the physical and mental burdens on young patients, parents, and families.

Predicting early return to the operating room in early-onset scoliosis patients using machine learning techniques.

Surgical treatment of early-onset scoliosis (EOS) is associated with high rates of complications, often requiring unplanned return to the operating room (UPROR). The aim of this study was to create and validate a machine learning model to predict which EOS patients will go on to require an UPROR during their treatment course. A retrospective review was performed of all surgical EOS patients with at least 2 years follow-up. Patients were stratified based on whether they had experienced an UPROR. Ten machine learning algorithms were trained using tenfold cross-validation on an independent training set of patients. Model performance was evaluated on a separate testing set via their area under the receiver operating characteristic curve (AUC). Relative feature importance was calculated for the top-performing model. 257 patients were included in the study. 146 patients experienced at least one UPROR (57%). Five factors were identified as significant and included in model training: age at initial surgery, EOS etiology, initial construct type, and weight and height at initial surgery. The Gaussian naïve Bayes model demonstrated the best performance on the testing set (AUC: 0.79). Significant protective factors against experiencing an UPROR were weight at initial surgery, idiopathic etiology, initial definitive fusion construct, and height at initial surgery. The Gaussian naïve Bayes machine learning algorithm demonstrated the best performance for predicting UPROR in EOS patients. Heavier, taller, idiopathic patients with initial definitive fusion constructs experienced UPROR less frequently. This model can be used to better quantify risk, optimize patient factors, and choose surgical constructs. Prognostic: III.

Dual Growing Rods Combined With the Apical Convex Control Pedicle Screw Technique Versus Traditional Dual Growing Rods for the Surgical Treatment of Early-Onset Scoliosis: A Case-Matched 2-Year Study.

Combination of apical control convex pedicle screws (ACPS) with traditional dual growing rods (TDGRs) had better apex control ability for early-onset scoliosis (EOS); however, there is a paucity of studies on the ACPS technique. To compare 3-dimensional deformity correction parameters and complications between the apical control technique (DGR + ACPS) and TDGR in the treatment of EOS. A retrospective case-match analysis consisting of 12 cases of EOS treated with the DGR + ACPS technique (group A) from 2010 to 2020, and matched with TDGR case (group B) at a ratio of 1:1 by age, sex, curve type, major curve degree, and apical vertebral translation (AVT). Clinical assessment and radiological parameters were measured and compared. Demographic characteristics, preoperative main curve, and AVT were comparable between groups. The correction ability of the main curve, AVT, and apex vertebral rotation were better in group A at index surgery ( P < .05). The increase in T1-S1 and T1-T12 height was large in group A at index surgery ( P = .011, P = .074). The annual increase in spinal height was slower in group A, but without significant difference. The surgical time and estimated blood loss were comparable. Six complications occurred in group A, and 10 occurred in group B. In this preliminary study, ACPS seems to provide better correction of apex deformity, while attaining the comparable spinal height at 2-year follow-up. Larger cases and longer follow-up are needed to achieve reproducible and optimal results.

Multistage surgical treatment of early-onset scoliosis in patients with Ehlers-Danlos syndrome: A series of observations

BACKGROUND: EhlersDanlos syndrome (EDS) is a group of hereditary pathological conditions caused by various disorders of collagen biosynthesis. The study analyzed the results of multistage surgical treatment of early scoliosis in patients with severe spinal deformities due to EDS. No similar observations have been found in the literature.&#x0D; CLINICAL CASES: Four patients with a verified diagnosis of EDS and progressive spinal deformities were subjected to multistage surgical treatment using the VEPTRII instrumentation, which included periodic distractions and final spinal fusion with segmental instrumentation. Stage-by-stage surgical treatment was initiated from the age of 3 to 6 years. In 3 of 4 cases, the kyphotic component prevailed over the scoliotic one (86140 vs. 21110). The number of staged distractions ranged from 6 to 10. The age of the final stage (correction and dorsal fusion) was 914 years (surgery was performed in three of four cases). The primary correction was 3056, the loss of correction before the final stage was 1435, and the correction during the final stage was 2240. A significant correction of the frontal and sagittal imbalances of the spine was noted. Blood loss during the final fusion was 540750 mL, and the operation time was 310350 min. Ten complications occurred, of which 9 were associated with implants and disappeared during staged distractions. No neurological and vascular complications occurred.&#x0D; DISCUSSION: Scoliosis occurring in the first decade of life in patients with EDS is characterized by early-onset, rapid progression, and tendency to form a significant kyphotic component of spinal deformity.&#x0D; CONCLUSIONS: Multistage treatment of early scoliosis in patients with EDS using VEPTRII tools allows for obtaining quite satisfactory results and has not severe complications. The final fusion gives a significant corrective effect; however, new research and accumulation of data are needed to optimize the treatment process.

Lengthening Behavior of Magnetically Controlled Growing Rods in Early-Onset Scoliosis: A Multicenter Study.

The "law of diminishing returns" is described for traditional growing rods. Magnetically controlled growing rods (MCGRs) have become a preferred implant for the surgical treatment of early-onset scoliosis (EOS). We examined a large cohort of patients with EOS to determine whether the law of diminishing returns applies to MCGRs. A prospectively collected, multicenter registry was queried for patients with EOS treated with MCGRs. Patients with only spine-based implants and a minimum of 2 years of follow-up were included; patients with congenital scoliosis, single rods, <3 lengthenings, or >25% missing data were excluded. Patients were analyzed in 3 cohorts: primary MCGR (pMCGR) had first-time MCGR implants, secondary MCGR (sMCGR) were converted from an MCGR to a new MCGR, and conversion MCGR (cMCGR) were converted from a non-MCGR implant to MCGR. A total of 189 patients in the pMCGR group, 44 in the cMCGR group, and 41 in the sMCGR group were analyzed. From post-MCGR placement to the most recent follow-up or pre-definitive procedure, there were no differences in the changes in major Cobb angle, T1-S1 height, or T1-T12 height over time between the pMCGR and cMCGR groups. There was a decrease in length achieved at subsequent lengthenings in all cohorts (p < 0.01), and the sMCGR group had a significantly poorer ability to lengthen at each subsequent lengthening versus the pMCGR and cMCGR groups (p < 0.02). The 1-year survival rate was 90.5% for pMCGR, 84.1% for sMCGR, and 76.4% for cMCGR; 2-year survival was 61.5%, 54.4%, and 41.4%, respectively; and 3-year survival was 37.6%, 36.7%, and 26.9%, respectively. Excluding MCGRs still expanding, 27.6% of pMCGRs, 8.8% of sMCGRs, and 17.1% of cMCGRs reached the maximum excursion. Overall, 21.7% reached the maximum excursion. Within the pMCGR cohort, idiopathic and neuromuscular etiologies had a decline in lengthening achieved over time (p < 0.001), while syndromic EOS demonstrated a preserved ability to lengthen over time (p = 0.51). When the etiological groups were compared with each other, the neuromuscular group had the least ability to lengthen over time (p = 0.001 versus syndromic, p = 0.02 versus idiopathic). The MCGR experiences the law of diminishing returns in patients with EOS. We found that only 21.7% of rods expanded to within 80% of the maximum excursion. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Modified Clavien-Dindo-Sink system is reliable for classifying complications following surgical treatment of early-onset scoliosis.

Appropriately measuring and classifying surgical complications is a critical component of research in vulnerable populations, including children with early-onset scoliosis (EOS). The purpose of this study was to assess the inter- and intra-rater reliability of a modified Clavien-Dindo-Sink system (CDS) classification system for EOS patients among a group of pediatric spinal deformity surgeons. Thirty case scenarios were developed and presented to experienced surgeons in an international spine study group. For each case, surgeons were asked to select a level of severity based on the modified CDS system to assess inter-rater reliability. The survey was administered on two occasions to allow for assessment of intra-rater reliability. Weighted Kappa values were calculated, with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.00 considered nearly perfect agreement. 11/12 (91.7%) surgeons completed the first-round survey and 8/12 (66.7%) completed the second. Inter-observer weighted kappa values for the first and second survey were 0.75 [95% CI 0.56-0.94], indicating substantial agreement, and 0.84 [95% CI 0.70-0.98], indicating nearly perfect agreement, respectively. Intra-observer reliability was 0.86 (range 0.74-0.95) between the first and second surveys, indicating nearly perfect agreement . The modified CDS classification system demonstrated substantial to nearly perfect agreement between and within observers for the evaluation of complications following the surgical treatment of EOS patients. Adoption of this reliable classification system as a standard for reporting complications in EOS patients can be a valuable tool for future research endeavors, as we seek to ultimately improve surgical practices and patient outcomes. Level V.

A Modified Self-Growing Rod Technique for Treatment of Early-Onset Scoliosis.

The patient is positioned prone on a radiolucent table, and the spine is prepared and draped in a standard fashion. A posterior midline skin incision is made from the upper to the lower instrumented level. Subperiosteal exposure of the spine is carried out, ensuring that capsules of the facet joints are spared. Pedicle screws are inserted bilaterally at the cranial and caudal ends of the instrumentation. Fixation with pedicle screws of at least 3 levels at the top and bottom end is usually advised; in nonambulatory patients with pelvic obliquity, caudal fixation can be extended to the pelvis with bilateral iliac screws. Sublaminar wires are positioned bilaterally at every level between the cranial and caudal ends of the instrumentation and are passed as medially as possible to avoid damage to the facet joints. Four 5-mm cobalt-chromium rods are cut, contoured, and inserted at each end of the construct. Ipsilateral rods are secured with use of sublaminar wires, making sure that they overlap over a sufficient length to allow for the remaining spinal growth. Correction of the deformity is achieved with use of a combination of cantilever maneuvers and apical translation by progressive and sequential tightening of the sublaminar wires. The wound is closed in layers over a subfascial drain. The patient is allowed free mobilization after surgery. No postoperative brace is required. Nonoperative alternative treatment for EOS includes serial cast immobilization and bracing4. Alternative surgical treatments include traditional growing rods5, magnetically controlled growing rods6, the vertical expandable prosthetic titanium rib-expansion technique7, and the Shilla technique8. The use of compression-based systems (i.e., staples or tether)9 or early limited fusion has also been reported by other authors. The main advantage of our technique is that it relies on physiological spinal growth and does not require surgery or external devices for rod lengthening, which is particularly beneficial in frail patients with a neuromuscular disease in whom repeated surgery is not advised. Segmental fixation by sublaminar wires allows good control of the deformity apex during growth. Concerns regarding early fusion of the spine have not been confirmed in our mid-term follow-up study10. This technique allows correction of the deformity and continuous spinal growth in the years following surgery. At 6.0 years postoperatively, the average main curve correction was reported to be 61% and the average pelvic obliquity correction was 69%. The spine was reported to lengthen an average of 40.9 mm (range, 14.0 to 84.0 mm) immediately postoperatively, and the T1-S1 segment was reported to continue growing at 10.5 mm/year (range, 3.6 to 16.5 mm/year) thereafter10. The most common complication is rod breakage at the thoracolumbar junction, which seems to be more common in patients with idiopathic or cerebral palsy EOS and during the pubertal growth spurt10. Subperiosteal exposure of the spine should be carried out, making sure to preserve facet joints in the unfused area of the spine.Achieve segmental fixation with use of sublaminar wires at every level and pedicle screws at the top and bottom ends of the instrumentation.If pelvic imbalance is present and the patient is nonambulatory, pelvic fixation with iliac screws is advised.First round correction of the deformity is achieved with a cantilever technique; correction fine-tuning can be performed by tightening sublaminar wires.Consider utilizing thicker rods in cases of idiopathic or cerebral palsy EOS. EOS = early-onset scoliosisAP = anteroposteriorEV = end vertebraSSEP = somatosensory evoked potentialsMEP = motor evoked potentialsPJK = proximal junctional kyphosisSMA = spinal muscular atrophyCP = cerebral palsyPACU = post-anesthesia care unit.

Rib-based Distraction Device Implantation Before Age 3 Associated With Higher Unplanned Rate of Return to the Operating Room.

Surgical treatment of early-onset scoliosis (EOS) with rib-based implants such as the vertical expandable prosthetic titanium rib (VEPTR) is associated with a high rate of complications including surgical site infection, skin breakdown, and implant migration. Many of these complications warrant the need for unplanned reoperations, increasing the burden on an already vulnerable patient population, and introducing the further risk of infection. To provide insight into the risks of early intervention, we investigate the relationship between initial device implantation before the age of 3 and the rate of unplanned reoperation. A retrospective review was performed of all patients at a single institution who had undergone VEPTR insertion for EOS with at least a 2-year follow-up from 2007 to 2016. Patients were stratified into the case-cohort (0 to 2 y of age) or the comparison cohort (3 to 10 y of age) based on age at the time of device implantation. Multivariate regression accounting for age and scoliosis etiology was performed to identify factors predictive of unplanned reoperation. A total of 137 of 185 patients treated with VEPTR were identified with 76 (56%) undergoing at least 1 unplanned reoperation during the study time period. There were 68 and 69 patients in the age 0- to 2-year and 3- to 10-year cohorts, respectively. Patients aged 0 to 2 years underwent a higher number of total procedures compared with those aged 3 to 10 (13.1±6.5 vs. 10.6±4.8, P=0.032). A significant difference was found in the rate of unplanned reoperation between the 2 cohorts with 44 (65%) patients aged 0 to 2 and 32 (46%) patients aged 3 to 10 undergoing at least 1 unplanned reoperation (P=0.031). Binary logistic multivariate regression accounting for age and scoliosis etiology demonstrated that patients aged 0 to 2 had a significantly greater odds of undergoing an unplanned reoperation (odds ratio=3.050; 95% confidence interval: 1.285-7.241; P=0.011) compared with patients aged 3 to 10 years. Overall, EOS patients aged 0 to 2 at initial VEPTR implantation are up to 3 times higher risk of undergoing an unplanned reoperation compared with those aged 3 to 10. Level III.

Growth-Friendly Implants With Rib Clawing Hooks as Proximal Anchors in Early-Onset Scoliosis.

Study Design:Retrospective study.Objectives:This study retrospectively evaluates the outcome of the surgical treatment of early-onset scoliosis with proximal clawing rib fixation in hybrid growing-rod constructs. The study examines spinal deformity correction with spinal growth maintenance, and the complications associated with this technique.Method:A hybrid rib construct surgery with serial lengthening was utilized for the treatment of 71 patients. Mean age at surgery was 66.6 months and mean time for follow-up was 43.9 months.Results:The coronal Cobb angle in patients fell from 63.1° preoperatively to 51.6° at the last follow-up, with a correction of 16.8%. The sagittal Cobb angle fell from 66.7° preoperatively to 38° at the last follow-up, with a correction of 42.6%. Coronal balance fell from 22.8° preoperatively to 22.3°, and sagittal balance fell from 35.4 mm preoperatively to 24.39 mm. T1-S1 spine height increased from 248.7 mm preoperatively to 282.4 mm, with a mean change of 1.13 cm per year. No neurological complications were detected.Conclusion:Surgical management for early-onset scoliosis using proximal clawing rib fixation technique is a good choice in terms of safety, ease of placing the proximal anchors, ability to use more than one form of instrumentation, and a lower complication rate.

Surgical growth guidance with non-fused anchoring segments in early-onset scoliosis.

Surgical treatment of early-onset scoliosis (EOS) requires a balance between maintained curve correction and the capacity for spinal and thoracic growth. Spinal fusion creates irreversible conditions that prevent the implementation of further treatment methods. Our hypothesis was that non-fused anchors in growth guidance show a comparable outcome as the technique described in the literature, which involves spondylodesis of the anchoring segments. This retrospective study analysed 148 surgeries in 22 EOS patients (11 female, 11 male) over a 15-year period. Patients underwent surgery with non-fused anchors and growth guidance techniques. Scoliosis, kyphosis, growth and anchoring segments were measured. For the latter, a new measuring technique was developed. Complications were recorded and classified. The mean Cobb angle reduced from 73.5 ± 24.4° to 28.4 ± 16.2° (60.2 ± 22.9%, p < 0.001) at the last follow-up. Spinal growth T1-S1 and T1-T12 were 41.1 ± 23.3mm and 24.9 ± 16.6mm (p < 0.001), respectively. Growth at the cranial and caudal anchoring segment was 1.5mm/segment/year and 1.9mm/segment/year, respectively. A total of 63 complications were documented in 20 patients, with 40 requiring unplanned revision surgery. Definitive spondylodesis was performed in three patients. Patients demonstrated a significant spinal growth including the anchoring segments. A comparable correction in Cobb angle and the type of complications was noted, although the rate of device-related complications was higher. No permanent impairment was reported. The rate of device-related complications is acceptable and outweighed by the significant degree of growth preservation and more flexible and individualised treatment strategy for patients with EOS. These slides can be retrieved under Electronic Supplementary Material.

Reliability and validity of the Arabic version of the Early Onset Scoliosis 24 Items Questionnaire (EOSQ-24).

Introduction: Early Onset Scoliosis (EOS) is a complex pathology that covers a variety of etiologies, with onset before the age of 10 years. Surgical treatment of EOS should have the objectives of fulfilling maximum pulmonary function, spine length, with minimal hospitalizations, complications, and family burden. Radiographic parameters are an important standard in assessing treatment outcomes. However, the Early Onset Scoliosis Questionnaire-24 (EOSQ-24) was developed to measure the wider dimensions of outcomes involving the quality of life of patients and caregivers post-treatment. The aim of this study was to evaluate the validity and reliability of culturally adapted Arabic version of the EOSQ-24. Methods: Translation and cross-cultural adaptation, based on published guidelines, were performed on the original English EOSQ-24 by a committee. The Arabic version of EOSQ-24 was applied to the caregivers of all 58 EOS patients who were treated surgically after signing a consent form. Reliability was assessed using Cronbach’s α and item-total statistics for the whole questionnaire initially and for the each domain separately. Data quality was assessed by mean, median, percentage of missing data, ceiling and floor effects. Discriminative validity was examined using non parametric tests. Results: The response for all items was excellent with only 1.7% (0–1) of responses missing. The floor effect ranged from 0% to 36.2% of patients and the ceiling effect ranged from 0 to 46.6%. Cronbach’s α test reliability was found excellent (0.919), as was the internal consistency of all domains, with Cronbach α ranging from 0.903 to 0.918. Corrected item-total correlations were good for all domains (>0.3). Only one item (Question 21) showed low corrected item-total correlations (r = 0.222). However, Cronbach’s α did not increase significantly when this item was deleted (0.920). Conclusion: The first adapted Arabic version of EOSQ-24 is found to have good validity and reliability, and it can be used to assess children in Arab societies with EOS.

A six-year observational study of 31 children with early-onset scoliosis treated using magnetically controlled growing rods with a minimum follow-up of two years.

Magnetically controlled growing rod (MCGR) systems use non-invasive spinal lengthening for the surgical treatment of early-onset scoliosis (EOS). The primary aim of this study was to evaluate the performance of these devices in the prevention of progression of the deformity. A secondary aim was to record the rate of complications. An observational study of 31 consecutive children with EOS, of whom 15 were male, who were treated between December 2011 and October 2017 was undertaken. Their mean age was 7.7 years (2 to 14). The mean follow-up was 47 months (24 to 69). Distractions were completed using the tailgating technique. The primary outcome measure was correction of the radiographic deformity. Secondary outcomes were growth, functional outcomes and complication rates. The mean Cobb angle was 54° (14° to 91°) preoperatively and 37° (11° to 69°) at the latest follow-up (p < 0.001). The mean thoracic kyphosis (TK) was 45° (10° to 89°) preoperatively and 42° (9° to 84°) at the latest follow-up. The mean T1-S1 height increased from 287 mm (209 to 378) to 338 mm (240 to 427) (p < 0.001) and the mean sagittal balance reduced from 68 mm (-76 to 1470) preoperatively to 18 mm (-32 to 166) at the latest follow-up. The mean coronal balance was 3 mm (-336 to 64) preoperatively and 8 mm (-144 to 64) at the latest follow-up. The mean increase in weight and sitting and standing height at the latest follow-up was 45%, 10% and 15%, respectively. The mean Activity Scale for Kids (ASKp) scores increased in all domains, with only personal care and standing skills being significant at the latest follow-up (p = 0.02, p = 0.03). The improvements in Cobb angle, TK and T1-S1 heights were not related to gender, the aetiology of the EOS, or whether the procedure was primary or conversion from a conventional growing rod system. A total of 21 children developed 23 complications at a rate of 0.23 per patient per year. Seven developed MCGR-specific complications. Complications developed at a mean of 38 months (3 to 67) after the initial surgery and required 22 further procedures. Children who developed a complication were more likely to be younger, have syndromic EOS, and have a single-rod construct (6.9 versus 9.3 years, p = 0.034). The progression of EOS can be controlled using MCGRs allowing growth and improved function. Younger and syndromic children are more likely to develop complications following surgery. Cite this article: Bone Joint J 2018;100-B:1187-1200.

Long-term Surgical Outcomes After Early Definitive Spinal Fusion for Early-onset Scoliosis With Neurofibromatosis Type 1 at Mean Follow-up of 14 Years.

Several authors mentioned surgical outcome for scoliosis associated with neurofibromatosis type 1 (NF-1). However, no studies have summarized long-term surgical outcomes after surgical treatment of early-onset scoliosis (EOS) with NF-1. The purpose of this study is to evaluate the long-term surgical outcome after early definitive spinal fusion for EOS in NF-1 patients. We performed a retrospective review on a cohort of 11 patients diagnosed with EOS associated with NF-1 between 1990 and 2009 in our hospital. The study included 7 male and 4 female NF-1 patients with a mean age at fusion surgery of 8 years 4 months who underwent early definitive spinal fusion for EOS. We reviewed radiographs, computed tomography and magnetic resonance images for each patient. The data collected included type of NF-1, Cobb angles, kyphotic angle, spinal length (T1-S1), and pulmonary function. We also evaluated progression of the dystrophic change through radiographs and computed tomography during the follow-up period. The mean follow-up duration was 14 years (5 y 10 mo to 25 y). All patients underwent anterior and posterior fusion surgeries in either 1 or 2 stages. Seven cases had subtotal tumor resection from the concave side followed by rib strut grafting. The mean preoperative Cobb angle of the primary curve was corrected from 71.2 to 24.1 degrees and was maintained at the final follow-up at 23.5 degrees. Mean values for preoperative and final follow-up T1-S1 heights were 30.7 and 36.2 cm, respectively. Mean values for preoperative and final follow-up % forced vital capacity (the present/the predicted) were 75.0% and 74.4%, respectively. The dystrophic change progressed in all cases during the long-term follow-up. Our goals for NF-1 scoliosis are to obtain deformity correction, to achieve stable instrumentation by using longer fusion levels and to attain a solid fusion mass that can tolerate continual erosion during the long-term follow-up. We achieve this by using a circumferential approach for EOS associated with NF-1. Level IV-case series.

VEffect of Growing Systems on Hyperkyphotic Deformities

Study Design: Retrospective mini case series, single centre. Objective: To report the efficacy of growing spine distraction-based implants in the treatment of hyperkyphotic and kyphoscoliotic early-onset deformities during initial surgery and lengthening. Background: Growth-sparing implants, such as growing rod and VEPTR-like systems, are distraction-based systems involving repetitive lengthening procedures, which mean that hyperkyphosis may be a relative contraindication in the treatment of early onset deformities. The role of growing implants in the treatment of coronal deformities is now acknowledged, but there are very few studies on the effect of both primary surgery and several lengthening procedures on sagittal balance. Methods: Twenty paediatric patients affected with kyphoscoliosis and surgically treated with growing systems were retrospectively reviewed. Etiology was heterogeneous; there were 10 males and 10 females, aged 7 yrs on average. The dual growing rod technique was used in 9 cases, VEPTR in 11. Preoperative main thoracic scoliosis averaged 64° (range, 10° to 100°) and thoracic kyphosis 71° (60° to 90°),67° in patients with Growing Rods and 77° in those with VEPTR with a history of EOS (Early Onset Scoliosis). At Follow-up ranging from 6 months to 7 years, 31 lengthening procedures had been performed (1.9 per patient). For the purpose of this study, patients were divided into two groups: Growing-Rod Group (GR-group) and VEPTR-like-Group (VL-group); preoperative and postoperative degrees of scoliosis and kyphosis were measured, as well as final results at follow-up. Results: A significant decrease in scoliosis and kyphosis was observed during initial surgery, then a significant loss of correction occurred during the FU period, first on coronal and then on sagittal plane, both in GR-group and in VL-group; however, in the VL-group the loss of correction in terms of kyphosis was significantly higher than in the other group. In particular, after initial surgery, in GR-group thoracic kyphosis was corrected from 67° to 44°, whereas in VLgroup from 77° to 60°. After the lengthening procedures, a loss of correction occurred: in GR-group, thoracic kyphosis increased from 44° to 50° (p<0.05), whereas in VL-group from 58° to 68°. 15 minor complications occurred in 8 patients and revision surgery was performed in 7. Conclusion: Growing implants can be safely used in the treatment of EOS, even in the presence of hyperkyphosis. Distraction procedures inevitably led to the loss of some correction on sagittal plane which was observed at follow-up and was higher in the VL-group. In any case, the final result was mostly related to the correction of kyphosis achieved during initial surgery and in any case the loss of correction was always lower than the first correction obtained. When the cantilever maneuver is performed during initial surgery, growing rods seem to grant a better sagittal plane restoration compared to VEPTR. The complication rate turned out to be a little higher (30%) than the rate observed after general surgical treatment of EOS, thus confirming an increase in complication rate when hyperkyposis is present; the most frequently encountered complication was proximal failure.

Comparative Analysis of Shoulder Balance through Growth Guidance Techniques in the Surgical Treatment of Early-onset Scoliosis

Objective: The purpose of this study was to compare the efficacy of growth guidance techniques (single and dual growing rods, Vertical Expandable Prosthetic Titanium Rod-VEPTR) on shoulder balance, in the surgical treatment of early-onset scoliosis. Methods: Thirty six patients with early-onset scoliosis (EOS) due to various etiologies who were operated on in two different institutions were included in the study and they were divided in 3 groups. Group 1 consisted of 11 patients (mean age 7.5 years) who were treated with a single growing rod, Group 2 had 13 patients (mean age 8.1 years) who were treated with dual growing rods, and Group 3 consisted of 12 patients (mean age 4.1 years) who were treated with VEPTR technique. The coracoid height difference (CHD), clavicular tilt angle difference (CTAD) and clavicula-rib cage intersection difference (CRID) were measured on standing anteroposterior X-ray images in the preoperative, early postoperative and the last follow-up periods. Data obtained from these measurements were subject to statistical analysis. Results: The average postoperative follow up period was 3.04 (range: 2.3 to 4.8) years for Group 1, 2.23 (range: 1 to 3.1) years for Group 2 and 2.18 (range: 1 to 3.2) years for Group 3. Clinical improvement in shoulder balance was obtained for Group 1 and Group 2 post-operatively, but there was no significance in the comparison among the three groups. Conclusion: The effect of growth guidance techniques on shoulder balance remains unpredictable in the surgical treatment of early-onset scoliosis.

Traditional Growing Rods Versus Magnetically Controlled Growing Rods for the Surgical Treatment of Early-Onset Scoliosis: A Case-Matched 2-Year Study

IntroductionTraditional growing rod (TGR) surgery is a treatment technique commonly used for progressive early-onset scoliosis. Studies have shown that repeated TGR lengthenings can significantly increase the risk of complications. Magnetically controlled growing rods (MCGR) are currently available outside of the United States and early results have been promising. The purpose of this study was to compare the effectiveness of MCGR versus TGR for the treatment of early-onset scoliosis. MethodsMagnetically controlled growing rod patients were selected based on the following criteria: aged less than 10 years, major curve greater than 30°, thoracic height less than 22 cm, no previous spine surgery, and minimum 2-year follow-up. A total of 17 MCGR patients met the inclusion criteria, 12 of whom had complete data available for analysis. Each MCGR patient was matched with a TGR patient by etiology, gender, single versus dual rods, preoperative age, and preoperative major curve. ResultsMagnetically controlled growing rod patients had a mean age of 6.8 years and mean follow-up of 2.5 years. Mean follow-up was greater for TGR patients by 1.6 years. Major curve correction was similar between MCGR and TGR patients throughout treatment. The MCGR patients experienced an average of 8.1 mm/year increase in T1–S1 during the lengthening period, compared with 9.7 mm/year for TGR patients (p = .73). There was a mean increase in T1–T12 of 1.5 mm/year for MCGR patients and 2.3 mm/year for TGR patients (p = .83). The TGR patients had 73 open surgeries, 56 of which were lengthenings. The MCGR patients had 16 open surgeries and 137 noninvasive lengthenings. Three TGR patients underwent 5 unplanned revision surgeries whereas 3 MCGR patients underwent 4 unplanned revisions. ConclusionsMajor curve correction was similar between MCGR and TGR patients throughout treatment. Annual T1–S1 and T1–12 growth was also similar between groups. The MCGR patients had 57 fewer surgical procedures than TGR patients. Incidence of unplanned surgical revisions as a result of complications was similar between groups.

2014 Update on the ‘growing spine surgery’ for young children with scoliosis

Spinal fusion procedures that are the mainstay of the treatment of progressive or severe curves in adolescents and adults are not suitable for most young children as there is a large magnitude of remaining growth. Early spinal fusion stunts the growth of the thorax and may interfere with the development of the lungs. Therefore, in children with early-onset scoliosis, 'growth friendly' instrumentation systems have been utilized to control the deformity while allowing the growth of the spine and the thoracic cage. The experience with growing rods has been increasing, along with expanding indications. Several self-lengthening instrumentation systems have been introduced aiming for guided spinal growth. There has been considerable progress in the clinical and laboratory studies using magnetically controlled growing rod constructs. Growing rods and vertical expandable prosthetic titanium rib (VEPTR) systems provide deformity control while allowing for spinal growth along with a risk of spontaneous vertebral fusions. VEPTR may cause rib fusions as the implants overlie the thoracic cage and, therefore, the use in pure spinal deformities is controversial. There have been exciting recent advances concerning the treatment of spinal deformities in young children. Despite these advances, the surgical treatment of early-onset scoliosis remains far from optimal and more development is on the way.

Evaluation of Shoulder Balance Through Growing Rod Intervention for Early-onset Scoliosis

Retrospective clinical study. To compare the single and dual growing rod techniques with an emphasis on shoulder balance in the surgical treatment of early-onset scoliosis. In the literature, there exist not much data about shoulder balance through growing rod intervention using either single or dual rods for progressive scoliosis in patients of young age. A total of 20 patients with early-onset scoliosis who were treated surgically using growing rod techniques (11 patients: single rod group, 9 patients: dual rod group) were analyzed radiographically. Radiographical measures of shoulder balance (difference of coracoid process height, clavicula-tilt angle, and clavicula-rib cage intersection point) and scoliosis of both groups that were obtained in the preoperative, postoperative, and final follow-up period underwent statistical analysis in comparison with each other. Both single and dual growing rod techniques improved the deformity correction, maintained the correction and allowed spinal growth in the surgical treatment of early-onset scoliosis. Single rod technique had a higher incidence of rod breakage. Both techniques effected the shoulder levels similarly. When evaluated separately, single rod technique does improve shoulder balance significantly. For a more definitive evaluation, a comparison study having more patients in both groups is essential.

Structure-Respiration Function Relationships Before and After Surgical Treatment of Early-onset Scoliosis

Spine and chest wall deformities in children with early onset scoliosis (EOS) frequently impair respiratory function and postnatal growth of the lung. While a relationship between deformity and such impairment has been reported in children with adolescent idiopathic scoliosis it is not well understood in children with early-onset scoliosis (EOS). We therefore describe (1) the preoperative relation between Cobb angle and forced vital capacity (FVC) in infants with EOS; (2) how changes in Cobb angle before and after surgery relate to changes in lung ventilation and perfusion in the right and left lungs. We measured FVC in 10 children with EOS<3years old using the raised volume rapid thoracic compression (RVRTC) technique and correlated them with Cobb angles. We then measured right lung contributions to total lung ventilation and perfusion using lung scans before and 4 to 57months after placement of vertical expandable prosthetic titanium ribs (VEPTRs) in 15 children with EOS and correlated changes in right lung function with postoperative changes in Cobb angles. In children 4 to 57months of age, preoperative FVC (mean value, 83%; range, 63%-109% of predicted values) did not correlate with Cobb angles (mean value, 56º; range, 14°-120º). In children 1.8 to 11.5years old, right lung ventilation and perfusion were abnormal in eight and seven children, respectively, but neither ventilation nor perfusion predictably normalized despite reductions in Cobb angle postoperatively. The data extend the age range of children with EOS whose Cobb angles correlate poorly with FVC preoperatively. The data are also consistent with reports that reduced Cobb angles after VEPTR insertion do not correlate with postoperative changes in respiratory function.