Thursday, October 27, 2016

Surgical treatment of scoliosis in adolescents, in 2016, is most commonly a posterior spinal fusion with instrumentation (PSF/PSSI).  Though this blog is, in general, dedicated to the “growing spine” this entry will focus on adolescent idiopathic scoliosis (AIS) and the many questions that are asked by parents/caregivers about PSF/PSSI.

Top Frequently Asked Questions about PSF/PSSI in AIS:

How strong will the spine be after surgery? Do I need to be careful?
Your spine will not be fragile. Multiple screws and rods are used, in a linked fashion, which corrected your spine deformity and will be holding it firmly in place. Activities of Daily Living (ADLs) will not harm the outcome of surgery or your spine.

What plans need to be made at home?
1. When you go home you will sleep in your regular bed, in your regular bedroom, wear regular clothes, eat regular food, go on walks, car rides, and see your friends.
2. You can walk up and down stairs, we are not doing surgery in your legs. You will be fully mobile though you may not walk as fast as you did prior to surgery, at least temporarily.  When you do walk up and down stairs, it is recommended someone stand below you to make sure you do not fall down the stairs.
3. You can eat in the kitchen and walk to the family room. You will not be a "patient" at home.
4. No physical therapy or braces are needed after discharge from the hospital.
5. Regular clothes may be worn. Tight fitting clothes may be uncomfortable.
6. For those patients who were driving cars before surgery it is recommended to avoid driving until after the 6-week postoperative clinic visit.
7. Driving home from the hospital does not require any special vehicle. If there is a long drive home you may need to stop more frequently and take breaks.
8. You will eat regular food at home. Fatty salty, and spicy foods may not taste good after surgery for several weeks.  Don’t worry the taste of food and your appetite will return to the way it was before surgery.

How will I sleep at home? You can sleep in any position you choose. If you prefer to lie on your stomach then use a flatter pillow than normal. It is fine to sleep on your back.

When can I take a shower or bath after surgery? The first shower or bath can be taken at 2 weeks after surgery. Before then sponge baths are recommended.

How will the pain after surgery be handled? Postoperative pain will be managed by the Pain Service, an anesthesiologist driven service. They have a detailed, thoughtful plan to manage postoperative pain. You will go home with pain medications that work for you in the hospital. After discharge from the hospital you will be able to contact the Pain Service if any problems or issues occur. Most patients are off the prescription narcotic pain medication at 2 weeks after surgery.

What is the follow up after surgery? The first follow up is at 6 weeks after surgery. Routine follow up is at 6 months, 1 year, 2 years, 3 years and 5 years.

How do is the fusion assessed after surgery? Radiographic imaging of the fusion mass is difficult, even with a 3-d imaging like a CT (computerized tomography) scan. During follow-up visits plain radiographs will be obtained to evaluate the implants integrity. If the implants are intact at 5 years postoperative then the fusion is intact.

What are the activity limits after surgery? Competitive athletics is not recommended for 6 months after surgery. There is no PE or gym class for 6 months. Athletic training and fitness activities are usually acceptable but must be approved by the surgeon.

Is there any limitation of lifting?  There is a 10 pound lifting limit for the first 6 months after surgery.

What is the chance of needing a second surgery? The historical reoperation rate at our children's hospital is 3.9%. The spine implants used will stay in place permanently.  This is a one-shot surgery, one-and-done.

Will the implants need to be lengthened? No. When a fusion is done the spine growth is stopped over the length of the spine implants.

Will the fusion stop all future growth? The fusion will stop growth only over the part of the spine that has spine implants. The spine above and below will continue to grow, and your legs will continue to grow.

What type of metal is in the implants to be used in surgery? The spine implants used will be a combination of titanium and cobalt chrome.

What sports are not recommended after surgery? In general collision sports, such as American football, rugby and wrestling are not recommended. In addition tumbling and gymnastics are not recommended due the stiffening of the spine fusion and since the repetitive, excessive motion may loosen the spine implants, prevent fusion and require repeat surgery. All other contact and noncontact sports are acceptable.

How much school will be missed?
It is expected you will return to school part-time in 2 weeks and full-time 4 weeks after surgery. Contact the school to inform them of the surgery date and the time out of school. Let us know what paperwork is needed.

What are risks of surgery? In general there are two types:
1. There are some risks which are common with all surgeries. General anesthesia is necessary and though the risk of an adverse event occurring is low, it is not zero. Also an incision is made and incisions can have problems healing and get infected. Antibiotics are given before, during and after surgery to minimize the risk of a deep wound infection. There are also many other things which are done to decrease the risk of infection as close to 0% as possible.
2. There are other risks which are unique to the spine. The spine surgery will be on the spinal column, or the bone of the spine. Inside of the bone is the spinal cord, and nerves, which runs from the brain to the lower extremities. For the purpose of the surgery the spinal cord and nerves acts like a wire from the brain to the legs, enabling muscle function and sensation in the legs and controls bowel and bladder function. During surgery the spinal cord function is continuously monitored by a Neuromonitoring specialist. If the spinal cord function becomes abnormal this is usually detected quickly using motor and sensory tract monitoring. This usually, but not always, occurs during correction if the spinal deformity, typically as the deformity is maximally corrected. If this happens the surgeon is alerted quickly and several actions are taken simultaneously to get return of normal spinal cord function.  If this happens there is over a 90% chance that the neurologic condition will return to baseline. We are always prepared for neurologic problems during surgery.

What are the most likely complications after a spine fusion? As mentioned above anesthetic problems, wound infection, neurologic deficit (paralysis, bowel or bladder incontinence, nerve problem, etc...), failure of fusion, implant breakage or pullout, cerebrospinal fluid leak, need for additional surgery, and postoperative pain.

How do you choose what spine implants to use for each surgery? Most spine fusions currently are performed from the back through one midline incision. The implants used are mainly based on patient size. There are different sized system to maximize correction and fusion yet to be as low profile as possible.

Where is the incision for a fusion and how long is it? There is one incision in the middle of the back and it is as long as the planned fusion.

How is the skin closed at the end of surgery? Staples vs. sutures vs. glue? A plastic surgery-type closure is performed leaving no sutures/stitches above the skin level. All sutures are absorbable and will dissolve and disappear with time.  On the skin there will only be glue, much like the Super Glue you can buy at the store, which gradually falls off in 3-4 weeks.

Can I put vitamin E on the incision? After the skin had completely healed, and the glue falls off, can lotions be applied. It is inconclusive that vitamin E lotion improves the appearance of surgical scars.

Will I need a brace after surgery? No

Will I need physical therapy (PT) after discharge from the hospital? No.

Thursday, October 6, 2016

Spine Casting of Early-Onset Scoliosis


Spinal casting is a time-tested intervention which was first described, in modern literature, by Cotrel and Morel in 1964.  At that time there were no other effective means to correct spinal deformities and maintain the improvement, since spine instrumentation as we now know it was not yet created. In 1963 Dr. Harrington developed the first effective, posteriorly-based spine instrumentation, using mainly two points of fixation on the spine and distraction as it main treatment force.  It was common to supplement fusions postoperatively with casts and braces for an extended period of time (years).  The technique of spine casting was advanced by Risser in 1976 with the utilization of a three-point molding technique.  It was around this time the first segmental spine instrumentation was created by Cotrel and Dubousset and made spine casting less needed for scoliosis treatment.  Since that time spine instrumentation has evolved significantly, enabling physicians to better correct the spine three-dimensionally without a need to use spine casting.  Hence casting was performed less and less for the treatment of scoliosis until in 2005 when Min Mehta reported the use of Cotrel spine casting technique in children younger than 2 years.  Her results re-invigorated interest in spine casting as a method to improve and, at times, definitively correct scoliosis.

The two main factors that occur between 0-5 years of age, which makes spine casting effective is the rapid growth of the spine and the child’s spine flexibility.  So castings will be more effective if the child is less than 18 years of age, with a highly flexible deformity which is mild to moderate in magnitude.  It is in this age group spine casts have the greatest chance of permanently “curing” the scoliosis.  In the older children, say 2-5 years, casting can be helpful but will only be a “cure” if the scoliosis is very mild.  Even if the casting doesn’t “cure” the scoliosis it may delay the need for surgical correction.

If spine casting is deemed appropriate for a child’s scoliosis, the number of casts and the length of application is individual specific.  No two children are treated exactly the same, since no two scoliosis deformities are the same.  Each doctor who using spine casting is attempting to correct the child's spine deformity optimally with the minimum number of anesthetics and surgical procedures.  Hopefully the child will never need a surgical intervention.   

One last point: it is important not to get pre-occupied with the “name” of the spine casting the surgeon is recommending.  Parents have, on occasion, come to think that only Mehta casting works and that a cast by any other name does not.  Sometimes the casts are referred to as Risser casts, but any surgeon who cares for early-onset scoliosis in 2016 will do the technique which is attributed to Mehta.  As mentioned earlier the actual technique was described by Cotrel and Morel in 1964 and can be called by many names: derotation casting, Cotrel casting, Cotrel derotation casting, Extension-derotation casting, etc…….  What is most important is the surgeon focuses the corrective maneuvers of casting to unspin the spine’s abnormal twist with scoliosis.


Cotrel Y, Morel G.  The elongation-derotation-flexion technic in the correction of scoliosis.  Rev Chir Orthop Reparatrice Appar Mot 194;50:59-75.

D’Astous JL, Sanders JO.  Casting and traction treatment methods for scoliosis.  Orthop Clin N Am 2007;38:477-84.

Mehta MH.  Growth as a corrective force in the early treatment of progressive infantile scoliosis.  J Bone Joint Surg [Br] 2005;87:1237-47.

Risser JC.  Scoliosis treated by cast correction and spine fusion.  Clin Orthop Relat Res 1976;116:86-94.


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