Spinal Fusion for the Treatment of Idiopathic Scoliosis in Children: Orthopedic Surgery to Treat Curvature of the Back in Children and Teenagers

Considering surgery

Types of surgery recommended

There are several different types of surgical options for idiopathic scoliosis.

The most common is to perform a spinal fusion where a surgical incision is made and the spine is exposed either from the back which is called a posterior approach or from the side which is called an anterior approach. Rods are fixated to the spine from the direction of the approach. Over the last 10 to 15 years, the use of anterior spinal procedures has increased. These procedures involve approaching the patient from the side and inserting the metal rods to support the spine. The rods are attached directly to the vertebral bodies.

Who should consider idiopathic scoliosis?

What happens without surgery?

In the best case, the scoliosis remains stable throughout the patient’s adult life and creates no particular problems. This is especially true for curves that are “borderline”. If a child is finished growing and the curve in the chest is 50 to 60 degrees or if the curved lower portion of the back is 40 to 45 degrees and the child is not experiencing symptoms or is not bothered by his or her back, it is reasonable not to perform surgery on these patients. 

The worse case scenario for scoliosis is that the deformity will progress over time.  If that occurs, then delaying surgery is not recommended as the deformity can become quite severe and increasingly difficult to manage.  Also, the risks of surgery will increase with an extremely large deformity. 

Surgical options

As outlined above, conventional options include spinal fusion through either a posterior or anterior approach. In some cases, a combination of an anterior and posterior approach will be necessary to effectively stabilize the back.

For very young children with scoliosis that is progressive and for whom bracing has not been successful, stabilization of the back may be done by inserting metal rods to support the spine without performing a spinal fusion.  This type of procedure is called insertion of a “growing rod.”  The rods need to be elongated about every six months with surgery.

A newer method involving stapling of the spine to try to modulate the growth is currently under review, but it is not yet approved for general use. 

Effectiveness

The success rate of stable fusion and correction of spinal deformity is very high in experienced hands. The average curve correction is approximately 70 percent and the likelihood of complications has been about 2 to 3 percent overall. The fusion of the bones (enabling the bones to grow together) is permanent.

There are concerns about long-term degenerative arthritis that may appear 30 to 50 years later in segments of the spine that were not fused. Currently, there is not adequate follow-up information on the procedure to know the frequency of this problem.

Urgency

The urgency of spinal fusion is based on how rapidly the curve is changing. For a child who is in the early stages of their pubertal growth spurt, the spine can increase deformity at a rate of up to 2 to 3 degrees per month, so while scoliosis surgery is plainly not an emergency, neglecting rapidly progressive curves for long periods of time is not a good idea

As an adult, or someone in the later stages of growth, the rate of change will only be 1 to 2 degrees per year, therefore, the urgency is less.    

In general, waiting six months to a year is an acceptable time to wait to have fusion surgery. 

Risks

The most common risks of spinal fusion surgery for scoliosis are:

1) Infection: risk of infection is approximately 1 to 3 percent for idiopathic scoliosis. There is an increasingly recognized possibility that infection can occur for up to two to three years after the initial procedure.

2) Failure of the bone to fuse: the failure of the bones to grow together and heal with scar tissue, rather than bone, occurs in 1 to 2 percent of cases in children. In these cases, repeat surgery will sometimes have to be performed to get the bone to effectively grow together. This concern may not be apparent for several years after the initial procedure. 

3) Injury to the spinal cord resulting in partial or permanent paralysis of the lower extremities: the risk of this injury has been reported from 0.2 to 5 percent of cases depending upon where the procedure was performed on the spine and the seriousness of the deformity that has been treated. 

Managing risk

1) Infections following spinal fusion surgery are not generally life threatening to the patient. They may require additional surgery to clean out the infection, long-term use of antibiotics until the bones are solidly healed, and in some cases, may require removal of the metal rods and implants to allow for final treatment of the infection.

2) Problems with bone healing are best managed by having the patient go back to the OR for a follow up procedure to re-stimulate the healing process by surgically grafting bone to the area involved and replacing some of the instrumentation used to stabilize the spine

3) Injuries to the spinal cord that lead to paralysis with loss of lower limb function may require removal of implants to relax the correction of the scoliosis. It is thought that a blood flow problem to the spinal cord may be created.  By relaxing the spine, tension will be alleviated and this should help patients regain function. Eventually the spine implants will have to be replaced but in a less “corrected” position.

Surgery for Idiopathic Scoliosis at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington

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