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Early-onset Scoliosis: Contemporary Decision-making and Treatment Options
1Department of Orthopedics, Children's Hospital, Basel, Switzerland.
Insights
Early-onset scoliosis (EOS) care has evolved, but growth-friendly surgeries still pose challenges. Current strategies offer improved deformity control and growth promotion for pediatric patients.
Area of Science:
- Pediatric Orthopaedics
- Spinal Deformity
- Surgical Innovation
Background:
- Early-onset scoliosis (EOS) presents complex challenges in pediatric orthopaedics, impacting growth and respiratory function.
- Historical approaches like early spinal fusion have shown negative effects on survival and pulmonary health.
- Despite advancements, current growth-friendly surgical techniques for EOS continue to present burdens and require further optimization.
Purpose of the Study:
- To review the evolution of Early-onset scoliosis (EOS) management, focusing on growth-friendly surgical strategies.
- To discuss the benefits and limitations of various surgical options for EOS, including implants and techniques.
- To highlight current challenges and future directions in the surgical treatment of pediatric spinal deformities.
Main Methods:
- Review of historical and current surgical strategies for Early-onset scoliosis (EOS).
- Analysis of different implant systems and techniques, including vertical expandable prosthetic titanium ribs, Mehta casting, growing rods, magnetically controlled growing rods, Shilla growth-guiding technique, and anterior flexible tethering.
- Discussion of patient selection criteria and outcomes for various treatment modalities.
Main Results:
- Vertical expandable prosthetic titanium ribs are indicated for thoracic insufficiency syndrome.
- Serial Mehta casting is effective for flexible deformities (<60 degrees) without thoracic involvement.
- Growing rods, magnetically controlled growing rods, and the Shilla technique offer deformity control and growth promotion, with anterior flexible tethering representing a promising non-fusion approach.
Conclusions:
- Growth-friendly spine surgery for EOS has evolved significantly, offering diverse options for deformity correction and growth.
- While current techniques improve outcomes, challenges such as implant failures and the need for eventual fusion persist.
- Ongoing innovation, including non-fusion techniques like anterior flexible tethering, aims to further minimize patient burden and optimize long-term results in EOS management.
Abstract:
Early-onset scoliosis (EOS) describes a wide array of diagnoses and deformities exposed to growth. This potentially life-threatening condition is still 1 of the biggest challenges in pediatric orthopaedics. The enlightenment of Bob Campbell's thoracic insufficiency syndrome concept and the negative impact of the earlier short and straight spine fusion approach on respiratory function and survival have fueled the evolution of EOS care. Despite all the progress made, growth-friendly spine surgery remains to be a burden to patients and caregivers. Even down-sized implants and remote-controlled noninvasive rod expansions do not omit unexpected returns to the operating room: failures of foundations, rod breakage, difficulties to keep the sagittal balance, progressive transverse plane deformities, stiffening, and the need for final instrumented fusion are still common. However, past experience and the current multitude of surgical strategies and implants have sharpened the decision-making process, patients with thoracic insufficiency syndrome require earliest possible vertical expandable prosthetic titanium ribs application. Flexible deformities below 60 degrees, with normal spinal anatomy and without thoracic involvement, benefit from serial Mehta casting which revived as a long available but not-used strategy. In case of progression, standard double growing rods or-if available, affordable, and applicable-magnetically controlled motorized rods provide deformity control and growth promotion. Shilla growth-guiding technique is a less costly alternative. Its lack of stiff lengthening boxes or actuators may be beneficial in difficult deformities. Anterior convex flexible tethering promises benefits of sparing the trunk muscles and keeping mobility. However, this step towards a true nonfusion concept has yet to stand the test of broad clinical application.
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