Early Onset Scoliosis Surgery
What is it?
Long spinal fusion may endanger the thoracic growth and are associated with an increased risk of crankshaft phenomenon (anterior column progressively deforming while posterior column is fixed) or decompensation. Therefore, growth friendly technique have been more frequently used: distraction based implants (traditional growing rods, magnetically controlled growing rods and vertical expandable prosthesis titanium ribs), guided growth implants (Shilla system and Luque trolley), compression based implants (vertebral body stapling and tethering).
Traditional growing rods (TGR) achieve correction by progressive distraction of the rods, instrumentation is apical and distal, leaving the unfused segments of the spine free to grow. Multiple surgeries are necessary to distract the rods. This problem can be avoided with the magnetically controlled growing rods that are extendable through an external magnetic device. Vertical expandable prosthesis titanium ribs is indicated in case of high risk of thoracic insufficiency syndrome. Complications of distraction based implants are implant breakage and dislodgments, infections, wound healing problems and neurological problems (due to surgery and frequent anesthesia procedures).
Shilla system guides spinal growth achieving correction and fusion at the apex of the curve and letting rods free to slide in the caps of the distal and apical screws while the spine grows. In the same way, Luque trolley consists in gliding spinal anchors travelling along fixed overlapping rods. Complications of guided growth implants include: implant breakage and dislodgments, infections and wound healing problems. Less re-interventions are required compared to TGR.
Vertebral body stapling slow down the growth of the curvature convexity using the same principle as the epiphysiodesis. Vertebral body tethering in realized with screws in the vertebral bodies and a tether stretch over the convexity. These procedures promote the growth of vertebral bodies on the concave side progressively correcting the curve. Complication of compression based implants are overcorrection and potential pulmonary impact of transthoracic surgery.
Osteotomies and short fusion con be performed as early surgical intervention in congenital spine deformities to prevent the progressive development and worsening of congenital EOS.
Patient affected by neuromuscular and syndromic EOS have higher risk of complications during and after surgery, related to the overall impairment. At the end of grow implants can be removed or converted to definitive fusion.
When is this procedure indicated?
Surgery to correct Early Onset Scoliosis is generally indicated in presence of a primary curve greater than a Cobb angle of 40° or in case of rapidly progressive curves which are not responsive to the conservative treatment . The procedure is also indicated in presence of a reduced respiratory capacity or alterations of lung function.
How is it performed?
The surgical procedures are performed under general anaesthesia, in prone position, with spinal cord monitoring of somatosensory and motor evoked potentials. A dedicated instrumentation is used to provide the correction of the deformity. The implants positioning may be performed, free hand, under fluoscopic giudance or in specific case under CT guidance. Finally bone grafts, augmented by biologic or synthetic bone per surgeon preference, are placed in a specific area of the spine in order to obtain there a solid fusion. For the anterior approaches the procedure requires general anaesthesia and it is performed in laterl position with a mini-invasive approach to the spine. Also in these cases spinal cord monitoring and PESS and PEM are highly recommended.
Recovery
After scoliosis surgery, patients are in most cases transferred to a surgical intensive care unit or surgical step-down unit. Pain management consists of long-acting intravenous pain medication. Surgical drains are placed and remain until 24 hours post-surgery. Patients are expected to ambulate on postoperative day 1 or 2 at surgeon preference, with or without a post-operative brace. Patients are able to come back home in 5-7 days and to school after 2-4 weeks. For about 4 months sport and strong phisical activity are discouraged. In specific cases a postoperative rehabilitation period (7-20 days) is reccomended. The TGR techniques need multiple re-operations to follow the growth of the spine (every 6-8 months): this negative aspect is partially reduced with other techniques such as Magnetically controlled Growing Rods or Guided Growth Implants. Usually at the end of puberty the final spinal fusion is recommended.
Short-term complications
The most fearful short-term complications after surgical treatment of scoliosis are neurological ones, ranging from the temporary loss of skin sensitivity, to weakness or loss of strength in the feet or legs, up to paralysis. Other possible complications are postoperative anemia that sometimes needs blood transfusion, persistent postoperative pain, superficial or deep infections, skin breakthrough. Pulmonary, intestinal or thromboembolism complications may rarely occur. The underlying etiology of the secondary scoliosis may increase the risk of complications
Long-term complications
In some cases, there is an increased incidence of back pain, loss of flexibility with limited range of motion, and loss of strength in the muscles surrounding the spine. Possible long-term complications may involve the instrumentation used for fixation, for its breakage or loosening, or for a late deep infection.
Where do we treat it?
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