Strategies and manoeuvres for severe rigid scoliosis

Severe rigid scoliosis presents formidable surgical challenges, even for the most seasoned spine surgeons. Patients with idiopathic scoliosis frequently exhibit severe manifestations after years of progressive deformity, characterised by pronounced curves, significant rib humps, shoulder and trunk asymmetry, and cardiorespiratory complications associated with untreated scoliosis. In our practice, around one-third of patients with scoliosis present with advanced, severe, rigid scoliosis (>90° and 25 % correction on bending radiographs). Discourse persists concerning the optimal surgical technique for rectifying these inflexible curves. Rigid scoliosis typically manifests as either acute angular or rounded deformities. Rounded deformities can be effectively addressed through an anterior release to alleviate the apex and posterior instrumentation, including osteotomies if necessary. Halo traction, temporary internal distraction, releases, osteotomies, and apical vertebral resection are frequently employed concurrently to attain optimal outcomes. Intraoperative strategies include apical translation, rod derotation, cantilever, direct vertebral rotation, in-situ bending, and stiffer rods. Conversely, severe rigid scoliosis, characterised by a pronounced angular deformity, is inappropriate for anterior release and is optimally addressed via posterior-only vertebral column resection and posterior instrumentation.