Why treat scoliosis?
Along with obvious externally deformities, left untreated, scoliosis can also deform the chest wall and cause problems with many internal organs. It can impede the normal development of the lungs and affect other internal organs such as the heart and spinal cord, causing a multitude of other issues. If not treated, Scoliosis, depending on its severity, can significantly decrease the height of a person.
What are the treatments for scoliosis?
There are numerous treatments depending on the child’s age, curve location, size, flexibility, the type of scoliosis (each has a different prognosis and response to certain treatments) and other possible conditions the child may have.
The traditional treatment for the most common type of scoliosis (Adolescent Idiopathic Scoliosis or AIS) is: watch, brace, fuse. The Pediatric Spine Foundation’s hope is to advance fusionless strategies – vertebral body stapling and vertebral body tethering.
Here is a brief description of treatment options:
Observation – Observation is common with very small (<20°) curves or in mature patients with stable curves. It involves periodic examinations and careful comparisons of serial x-ray measurements to verify that the scoliosis is not progressing.
Serial “Mehta” Casting – Casting takes advantage of the rapid growth in toddlers and young children to potentially correct infantile idiopathic scoliosis. It involves a series of plaster torso casts. These casts are applied, under anesthesia, at 2 to 3 month intervals for a 12-18 month period. Many curves in children under 2 years of age can be cured, while larger curves or those in pre-school children can be greatly reduced with casting and then stabilized with maintenance bracing.
Bracing – Bracing is commonly used to treat numerous (but not all) types of scoliosis in a growing child. These braces are custom fitted and worn externally (under clothes) for a prescribed number of hours everyday. There are many brace styles. Some common ones are Boston, Providence, Milwaukee, Charleston, Rigo Cheneau, or otherwise generic TLSO. Bracing will not correct a curve but, in some cases, it may slow or stop the curve from progressing during the high risk periods of normal childhood/adolescent growth. Curves that can be held to less than 30°, by maturity in late adolescence, have a very low risk of further progression in adulthood. A brace may also be worn to augment other treatments or to protect the spine after surgery.
Growing Rods – Growing rods are used in a child that has a large progressive curve and a significant amount of growing left. Rods allow some of the spine to continue to grow. Under general anesthesia, the curved spine is partially straightened and “growing” rods are surgically attached to the spine above and below the curve. This allows the spine in the middle to continue to grow. A less involved surgery is required about every 6 months, as the child grows, to expand or lengthen the rods in order to continue controlled growth of the spine. Every 2-3 years, when a rod becomes fully expanded, it will need to be replaced with a new, longer rod. Shilla and MAGEC rods are examples of newer “self expanding” growing rods that minimize the need for repeated “expansion” surgeries.
VEPTR – Vertical Expandable Prosthetic Titanium Rib is a very specific type of growing rod system used to treat severe cases of scoliosis associated with significant deformity of the rib cage where it is difficult for the underlying lungs to grow and to breathe normally. Also called a “titanium rib”, the vertically expanding rod is surgically attached (most commonly) to the ribs above and the spine below the curve to help straighten the spine as well as expand the ribcage. This “growing” system requires less involved surgeries every 4-6 months so the rods can be expanded to keep pace with the growth of the child.
Fusion – Fusion is a permanent treatment for large scoliosis curves that have reached above 45° while still growing, or above 50° when growth has stopped. The goal is to prevent curve progression and to obtain some correction of the deformity. The implants consist of metal rods and screws, hooks or cables that are attached to each of the vertebral bones of the spine that are creating the curve. The surgeon will straighten the spine as much as possible, then the screws and rod are tightened in place. Pieces of bone material are laid alongside the spine so the body can use this additional bone to help the existing bones fuse and become one solid bone structure – the fused spine. Once fully healed, this fused portion of the spine will not grow and does not bend although the untouched bones above and below the fused portion can still grow and bend.
VBS – Vertebral Body Stapling (“stapling”) was conceived decades ago as a type of “internal brace” that controls the uneven growth and progressive curvature of the young spine with scoliosis. This procedure wasn’t used often until 2002, when new staples made of a “shape memory alloy” solved the initial concern about a staple becoming dislodged. This instituted a movement away from just stabilizing the curve with external bracing to being able to modulate the growth process of the child’s spine internally in order to correct the curve. In 2020, stapling is unavailable because there are no companies currently manufacturing the staple. We expect the procedure to become available again in a few years for patients with smaller curves (thoracic less than 35°, lumbar less than 45°) who would rather have an internal brace instead of wearing an external brace for 6 or more years.
VBT – Vertebral Body Tethering (“tethering”) for scoliosis emerged around 2011 and has challenged the status quo of permanently fusing young spines. Similar to VBS, tethering is a minimally invasive surgical procedure that substantially corrects scoliosis at the time of surgery but is more powerful and versatile than stapling. Using a thoracoscopic approach (with several small portals) through the side of the chest, bone screws are anchored to the front of each vertebra in the curve, and a flexible cord (“tether”) is attached to each screw and tensioned to achieve the desired degree of spine straightening. Unlike traditional fusion, VBT allows for continued growth and mobility of the entire spine as well as additional straightening of the spine as the adolescent finishes growing. VBT is best suited for thoracic curves measuring 35° to 70° which bend to 30° or more and the patient is skeletally immature (Risser scores of less than 2 and Sanders less than 5). It is especially good for active preteens and teenagers who are told they are candidates for traditional posterior fusion surgery but who wish to maintain spine flexibility while correcting the curve.
ASC – Anterior Scoliosis Correction is the most advanced non-fusion surgical technique, incorporating the same minimally invasive, motion sparing principles of VBT (tethering) and using the same bone-screw and flexible cord construct. However, ASC differs from VBT in several important ways. First performed in 2015, it can be used in the vast majority of thoracic, thoracolumbar, and lumbar curves in immature as well as more mature adolescents as well as adults (incorporating growth modulation and tissue remodeling principles). ASC can be used for any size curves, including the same as VBT but even those > 70°. Patients with stiff curves that do not bend below 30° are still candidates for ASC. Unlike the VBT thoracoscopic approach, in ASC a mini-open muscle sparing approach through the side of the chest is used to reach the spine and allow tissue releasing procedures to “de-tether,” which allows untwisting (derotation) and straightens even large, stiff curves. Releasing the anterior longitudinal ligament (the long stiffened ligament in the front of the spine) and disc annuli (which connect the vertebrae) in the very stiff segments of the curve allow greater 3-dimensional spine correction in both immature and mature spines. Growth is not essential to obtain correction, so ASC allows many more patients to choose a non-fusion option which maintains flexibility.
ApiFix (posterior dynamic concave distraction device)
The newest non-fusion option is the Minimally Invasive Deformity Correction (MID-C) system by ApiFix, Ltd (Misgav, Israel). Unlike the anterior VBS, VBT, and ASC procedures described above, ApiFix is a posterior surgical procedure which can be used for single curves measuring 40° to 60° which bend below 30°. Through two minimally invasive incisions on the patient’s back, 2-3 screws are placed at the top and bottom vertebrae forming the curve, and the screws are connected to a mini-ratcheting device that corrects the spine at the time of surgery and also allows for additional gradual curve correction with growth, sometimes incorporating specific physical therapy exercises. Modest, secondary derotation of the spine occurs which allows some reduction of the rib prominence (“hump”) that often accompanies scoliosis. Although more flexible than fusion, this device does modestly limit forward and backward bending by about 40% as compared to a normal spine.