Scoliosis surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; {AE}} Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]
Overview
Surgical correction of idiopathic scoliosis is primarily considered for curves greater than 45° in immature patients and for curves greater than 50° in mature patients. In addition, surgery is usually indicated for curves that have a high likelihood of progression, curves that cause a significant amount of pain with some regularity, curves that would be cosmetically unacceptable as an adult, curves in patients with spina bifida and cerebral palsy that interfere with sitting and care, and curves that affect physiological functions such as breathing. For various reasons it is usually impossible to completely straighten a scoliotic spine, but in most cases very good corrections are achieved.
Surgery
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- Surgical treatment is recommended for patients with curves greater than 45 degrees who are Risser 2 or less or for curves greater than 50 who are Risser 3 and greater.[1]
- The goal of surgery is to arrest the curve progression while improving spinal balance and alignment.
- The goal is achieved by inducing fusion of the spine by way of instrumentation and bone grafting.
- Principle of all fixation techniques involves the placement of bony anchors such as hooks, wires, or pedicle screws to the vertebrae and connecting them to a dual rod construct.
- Fusion can be performed via anterior, posterior, or both approaches depending on the curve type, magnitude, skeletal maturity, and the available skill set of the surgeon.
- The factors to consider in preoperative planning include the curve type and magnitude, spinal balance, curve flexibility, and the level of skeletal maturity.
Spinal Arthrodesis with instrumentation
- Spinal arthrodesis is the most widely performed surgery for scoliosis.
- Procedure:
- Bone, autograft or allograft is grafted to the vertebrae so that when it heals, they will form one solid block and the vertebral column becomes rigid.
- This prevents worsening of the curve at the expense of spinal movement.
- The procedure can be performed from the using the anterior or posterior approach of the spine. A combination of both is used in more severe cases.
Posterior Instrumentation
- Initially, spinal fusions were done without metal implants and a cast was applied after the surgery, usually under traction to pull the curve as straight as possible and then hold it there while fusion took place.[2]
- However, there was a relatively high risk of pseudarthrosis at multiple levels and significant correction could not always be achieved.
- In 1962, Paul Harrington introduced a metal spinal system of instrumentation which assisted with straightening the spine, as well as holding it rigid while fusion took place.[3]
- A major shortcoming of the Harrington method was that it failed to produce a posture where the skull would be in proper alignment with the pelvis and it didn't address rotational deformity.
- As a result, unfused parts of the spine would try to compensate for this in the effort to stand upright.
- The second generation instrumentation system developed by Cotrel and Dobousett, tried to achieve correction using rod rotation manoeuvres.[4]
- Modern spinal instrumentation are able to address sagittal imbalance and rotational defects which was unresolved by the Harrington rod system.
- They involve a combination of rods, screws, hooks and wires fixing the spine and can apply stronger, safer forces to the spine than the Harrington rod.
- Modern spinal instrumentation generally have good outcomes with high degrees of correction and low rates of failure.
- When scoliosis with severe curves have led to significant deformity resulting in a rib hump, it is necessary to perform a surgery called a costoplasty also known as thorocoplasty in order to achieve a more pleasing cosmetic result.
- This procedure is usually performed at the same time with arthrodesis.
Anterior Instrumentation
- Anterior approach allows correction with shorter fusion levels in the scoliotic thoracolumbar and lumbar regions.[5][6][7][8]
- Postoperative pain and scar formation decrease in patients with the advent of the video assisted thoracoscopic surgery.
- However, this approach has a higher incidence of implant failure and pseudarthrosis, and has been associated with a risk of pulmonary complications secondary to the need for single lung anesthesia during the procedure.[9][10]
Non-Fusion Surgery
- Non-fusion surgery is another option in order to control growth in the treatment of idiopathic scoliosis.[11][12][13]
- Progression of the curve might be avoided by means of instrumented or non-instrumented epiphysiodesis on the convex side of the curve.
- Recently, new implants have been developed that allow more spinal growth in young children.
- These include rods that are extendable and allow growth while still applying corrective forces and vertebral stapling which is a method of retarding normal growth on the convex side of a curve, allowing the concave side to catch up.
- After the fusion surgery at younger ages, the body remains shorter than the limbs. Shorter body prevent the development of lungs.
- The upper and lower parts of the curve can be fixed by Isula double rod system developed by Akbarnia, attached to the rods and the rods are attached to one another with an additional rod.
- The rods are extended in 6-month follow-up. After reaching the full growth, fusion is completed with instrumentation.
- For the youngest patients, ribcage implants that push the ribs apart on the concave side of the curve may be beneficial.
- Vertical expandable prosthetic titanium ribs (VEPTR) weredeveloped to treat the thoracic insufficiency syndrome that is caused by combination of ribs and curves.[14]
- The deformity can be corrected acutely by means of VEPTR following the wedge thoracostomy.
- VEPTR device is expanded in 4-6 months time.
Complications of Surgery
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- Pain
- Pseudoarthrosis
- Cosmetic deformity
- Infection
- Lung hypoplasia
- Stunted growth
- Spinal cord or nerve damage
- Intracranial hemorrhage[15]
- Low back arthritis and disc degeneration as an adult
References
- ↑ El-Hawary R, Chukwunyerenwa C (2014). "Update on evaluation and treatment of scoliosis". Pediatr Clin North Am. 61 (6): 1223–41. doi:10.1016/j.pcl.2014.08.007. PMID 25439021.
- ↑ Yaman O, Dalbayrak S (2014). "Idiopathic scoliosis". Turk Neurosurg. 24 (5): 646–57. doi:10.5137/1019-5149.JTN.8838-13.0. PMID 25269032.
- ↑ Desai SK, Brayton A, Chua VB, Luerssen TG, Jea A (2013). "The lasting legacy of Paul Randall Harrington to pediatric spine surgery: historical vignette". J Neurosurg Spine. 18 (2): 170–7. doi:10.3171/2012.11.SPINE12979. PMID 23216320.
- ↑ Hopf CG, Eysel P, Dubousset J (1997). "Operative treatment of scoliosis with Cotrel-Dubousset-Hopf instrumentation. New anterior spinal device". Spine (Phila Pa 1976). 22 (6): 618–27, discussion 627-8. PMID 9089934.
- ↑ Turi M, Johnston CE, Richards BS (1993). "Anterior correction of idiopathic scoliosis using TSRH instrumentation". Spine (Phila Pa 1976). 18 (4): 417–22. PMID 8469999.
- ↑ Newton PO (2005). "The use of video-assisted thoracoscopic surgery in the treatment of adolescent idiopathic scoliosis". Instr Course Lect. 54: 551–8. PMID 15948480.
- ↑ Newton PO, White KK, Faro F, Gaynor T (2005). "The success of thoracoscopic anterior fusion in a consecutive series of 112 pediatric spinal deformity cases". Spine (Phila Pa 1976). 30 (4): 392–8. PMID 15706335.
- ↑ Reddi V, Clarke DV, Arlet V (2008). "Anterior thoracoscopic instrumentation in adolescent idiopathic scoliosis: a systematic review". Spine (Phila Pa 1976). 33 (18): 1986–94. doi:10.1097/BRS.0b013e31817d1d67. PMID 18665023.
- ↑ Lowe TG, Alongi PR, Smith DA, O'Brien MF, Mitchell SL, Pinteric RJ (2003). "Anterior single rod instrumentation for thoracolumbar adolescent idiopathic scoliosis with and without the use of structural interbody support". Spine (Phila Pa 1976). 28 (19): 2232–41, discussion 2241-2. doi:10.1097/01.BRS.0000085028.70985.39. PMID 14520036.
- ↑ Betz RR, Harms J, Clements DH, Lenke LG, Lowe TG, Shufflebarger HL; et al. (1999). "Comparison of anterior and posterior instrumentation for correction of adolescent thoracic idiopathic scoliosis". Spine (Phila Pa 1976). 24 (3): 225–39. PMID 10025017.
- ↑ Schmid EC, Aubin CE, Moreau A, Sarwark J, Parent S (2008). "A novel fusionless vertebral physeal device inducing spinal growth modulation for the correction of spinal deformities". Eur Spine J. 17 (10): 1329–35. doi:10.1007/s00586-008-0723-9. PMC 2556471. PMID 18712419.
- ↑ Schleicher P, Onal MB, Hemberger F, Scholz M, Kandziora F (2018). "The C2-Pars Interarticularis Screw as an Alternative in Atlanto-Axial Stabilization. A Biomechanical Comparison of Established Techniques". Turk Neurosurg. 28 (6): 995–1004. doi:10.5137/1019-5149.JTN.23791-18.2. PMID 30478824.
- ↑ Maruyama T, Takeshita K (2008). "Surgical treatment of scoliosis: a review of techniques currently applied". Scoliosis. 3: 6. doi:10.1186/1748-7161-3-6. PMC 2346456. PMID 18423027.
- ↑ Campbell RM, Smith MD, Mayes TC, Mangos JA, Willey-Courand DB, Kose N; et al. (2004). "The effect of opening wedge thoracostomy on thoracic insufficiency syndrome associated with fused ribs and congenital scoliosis". J Bone Joint Surg Am. 86-A (8): 1659–74. PMID 15292413.
- ↑ Bhimani R, Bhimani F, Singh P (2018). "Subdural Hemorrhage after Scoliosis and Detethering of Cord Surgery". Case Rep Med. 2018: 5061898. doi:10.1155/2018/5061898. PMC 5902091. PMID 29808094.