Blog Topic: New publication comparing MAGEC Growing Rods, Posterior Spinal Fusion and Vertebral Body Tether in 8-11 year old scoliosis patients.

 

 

Spine (Phila Pa 1976). 2021 Oct 1.

 doi: 10.1097/BRS.0000000000004245. Online ahead of print.

Magnetically Controlled Growing Rods (MCGR) Versus Single Posterior Spinal Fusion (PSF) Versus Vertebral Body Tether (VBT) in Older Early Onset Scoliosis (EOS) Patients: How Do Early Outcomes Compare?

Catherine Mackey ¹, Regina Hanstein, Yungtai Lo, Majella Vaughan, Tricia St Hilaire, Scott J Luhmann, Michael G Vitale, Michael P Glotzbecker, Amer Samdani, Stefan Parent, Jaime A Gomez, Pediatric Spine Study Group

Affiliations expand

·        PMID: 34610613

·        DOI: 10.1097/BRS.0000000000004245

Abstract

Study design: Retrospective review of prospective data from multicenter registry.

Objective: Compare outcomes of posterior spinal fusion (PSF) versus magnetically controlled growing rods (MCGR) versus vertebral body tethers (VBT) in 8- to 11-year-old idiopathic early onset scoliosis (EOS) patients.

Summary of background data: In EOS, it is unclear at what age the benefit of growth-sparing strategies outweighs increased risks of surgical complications, compared with PSF.

Methods: One hundred thirty idiopathic EOS patients, 81% female, aged 8-11 at index surgery (mean 10.5 yrs), underwent PSF, MCGR, or VBT. Scoliosis curve, kyphosis, thoracic and spinal height, complications, and Quality of Life (QoL) were assessed preoperatively and at most recent follow-up (prior to final fusion for VBT/MCGR).

Results: Of 130 patients, 28.5% received VBT, 39.2% MCGR, and 32.3% PSF. The VBT cohort included more females (P < 0.0005), was older (P < 0.0005), more skeletally mature (P < 0.0005), and had smaller major curves (P < 0.0005). At follow-up, scoliosis curve corrected 41.1 ± 22.4% in VBT, 52.2 ± 19.9% in PSF, and 27.4 ± 23.9% in MCGR (P < 0.0005), however, not all VBT/MCGR patients finished treatment. Fifteen complications occurred in 10 VBTs, 6 requiring unplanned surgeries; 45 complications occurred in 31 MCGRs, 11 requiring unplanned surgeries, and 9 complications occurred in 6 PSFs, 3 requiring unplanned revisions. Cox proportional hazards regression adjusted for age, gender, and preoperative scoliosis curve revealed that MCGR (hazard ratio [HR] = 21.0, 95% C.I. 4.8-92.5; P < 0.001) and VBT (HR = 7.1, 95% C.I. 1.4-36.4; P = 0.019) patients were at increased hazard of requiring revision, but only MCGR patients (HR = 5.6, 95% C.I. 1.1-28.4; P = 0.038) were at an increased hazard for unplanned revisions compared with PSF. Thoracic and spinal height increased in all groups. QoL improved in VBT and PSF patients, but not in MCGR patients.

Conclusion: In older idiopathic EOS patients, MCGR, PSF, and VBT controlled curves effectively and increased spinal height. However, VBT and PSF have a lower hazard for an unplanned revision and improved QoL.Level of Evidence: 3.

 

Blog Topic:

Talking Points between Surgeon and Patient/Family about Thoracic Vertebral Body Tethering vs. Thoracic Posterior Spinal Fusion

 

Vertebral Body Tethering (VBT) is a procedure which has garnered a lot of attention from surgeons, patients and families.  Below is a list of talking points which should be known about VBT so there can be informative, educated, transparent discussions about VBT, when compared to the other commonly-performed procedure Posterior Spinal Fusions.  Discussions on these points is necessary before VBT surgery between the surgeon and patients/families to be fully-informed.

		Tether	Posterior Spinal Fusion
Preoperative
	FDA approved	Yes	Yes
	FDA approved diagnoses	Idiopathic only	All diagnoses
	Length of Time Procedure has been Performed in U.S.	About 16 years	>100 years; >45 years with metal implants
	Skeletal Maturity Risser	0 to 2	Any
	Skeletal Maturity Sander Grade	2 to 4	Any
	Curve Size	45 to 60 degrees	>50 degrees
	Curve Flexibility	Sidebender <30 degrees	Not applicable
	Compensatory Curve Size	<45 degrees	Any size
Surgical
	Incisions, Total Number	3 to 5	1
	Incisions, Total Length	10 cm	25 cm
	General Surgeon Assisting?	Yes	No
	Need to deflate one lung?	Yes	No
	Major Curve Correction, Immediate	Mild to Moderate	Moderate to High
	3D correction	Mild to Moderate	Moderate to High
	Length of Hospital Stay	3 days	3 days
	Risk of Complications	Low	Low
After Discharge
	Return to Sports	6 weeks to 3 months	6 months
	Loss of Flexibility	Little	Moderate, depends on fusion length
	Risk of Reoperation	>20%	<3%
	Curve correction over time	Low to High	None
	Risk of Implants Breaking	100%	<1%
	Predictability of Outcome	Uncertain	High
	Long-term Outcome	Uncertain	Good

 

Thanks to Dr. Mike Vitale, Columbia University in New York, for discussing this topic and providing the concept idea at the ICEOS meeting in Salt Lake City.

 

Blog Topic: Pain Control and Muscle Spasm Management after Idiopathic Scoliosis Surgery

 

11-12-2021

 

1.      Preoperatively

At  At the last outpatient clinic visit before surgery, all patients will also have a visit with the Pediatric Anesthesia service on the same day.  This group of physicians and Advanced Practice Providers (AAPs) will provide the general anesthesia (means the patient will be asleep) for the entire surgical procedure AND manage the postoperative pain and muscle spasms (by the Pain Service). 

2.      After surgery, the Pain Service will start its care immediately after surgery and will continue care until hospital discharge.

       Postoperatively

3.      Pain management. after surgery will be a combination of opioids and non-opioid medications.  By using non-opioid medications the amount of opioid medications can be minimized. The negative aspects of opioids are well-known, specifically addiction. In the short-term, after surgery, these medications also decrease breathing rate, lower blood pressure, induce nausea and vomiting and create constipation.  These are all great reasons to minimize opioids, as much as possible.  The below medications in our protocol work together to minimize pain and the side effects of opioids.

a.      Opioids:

                                                    i.     Intravenous morphine or morphine-equivalent medication, by a device call a PCA which stands for “Patient-Controlled Analgesia”: day 0-1

                                                   ii.     Oral oxycodone: days 1 to discharge

b.      Use of non-opioids

                                                    i.     Intravenous ketorolac: days 0-2

                                                   ii.     Oral acetaminophen: days 0 to discharge

4.      Muscle spasm management. Spine surgery requires operating around or through muscle, which creates swelling and secondarily muscle spasm.  To minimize muscle spasm the below medication are used, and they work together with the above-mentioned pain medications to make the patients as comfortable as possible.

a.      Methocarbamol: days 0-2

b.      Diazepam: days 0-2

c.      Flexeril: days 2+

5.      Discharge (at-home treatment).  The below medications are the typical medications spine patients have for pain and muscle spasm management.

a.      Oral oxycodone (as needed)

b.      Flexeril (as needed)

c.      Acetaminophen (as needed)

6.      Pain Service is available to patient/family as needed to optimize patient comfort.

7.      Gradually pain and muscle spasm will resolve, with most patients using only oral acetaminophen about 2 weeks after surgery.