Spinal Fusion for the Treatment of Idiopathic Scoliosis in Children: Orthopedic Surgery to Treat Curvature of the Back in Children and Teenagers
Edited By: Kit M. Song, M.D.
Last updated Thursday, October 20, 2005
SummaryOverview Idiopathic scoliosis is a curvature of the spine that occurs
in children and young teenagers.
This condition affects about 2 to 3 percent of children
under the age of 16. Most of the time,
the curve in the back will remain small and will not progress, however, with
growth and over time, it may worsen. This condition causes a visible deformity
or a bump that appears on the child’s ribs or in the muscle adjacent to the
spine.
In most cases, the curve will stop progressing or changing
once the child stops growing. However, curves that are very large may continue
to worsen in adulthood, even though the individual is no longer growing.
Spine surgery is sometimes performed to correct the curve
and fuse of the affected part of the spine.
This surgery causes the bones of the spine to grow together to become a
solid bone that can no longer twist.
Metal rods are placed into the spine to pull it into a corrected
position and to hold it there in a stable manner. This allows the bones to heal
together, much as a broken bone in the arm or leg would heal.
Patients are able to get out of bed within a few days of
surgery while the average patient length of hospital stay is about five
days. Full recovery takes approximately
three to six months. Characteristics of idiopathic scoliosis Scoliosis usually appears as a bump on the chest or muscle adjacent to
the spine. This bump is caused by the rotation of the spine as the
curve increases. Internal organs are, in general, not damaged by
worsening scoliosis. However, sometimes curves located in the chest can
affect the lungs and cause difficulty in breathing. This happens when
a curve in the chest or upper spine area becomes extremely large. The
effects of this curvature are generally seen in the mid to late adult
years. There has been some concern that large spinal deformities in the
lower portion of the spine (“lumbar”) may lead to degenerative changes
of the lower back over a period of 40 to 50 years.Types Idiopathic scoliosis means that the scoliosis does not have a definite
cause. Children with idiopathic scoliosis are otherwise normal. The
only subtypes of this condition are related to age.
This condition is classified as either “early onset” or “late onset”
scoliosis. Early onset is recognized in children under 8 years
old while late onset starts after the age of 8. Children who develop
large curves at a young age may experience adverse lung development and
growth that can lead to an early death due to breathing difficulties. Similar conditions Other types of scoliosis are congenital and neuromuscular
scoliosis.
In congenital scoliosis, patients have malformed bones that
grow crookedly over time. Children are born with this condition and the cause
is unknown. The management of these patients is very different from those with
idiopathic scoliosis. Surgery is
generally needed to correct or control these deformities.
Children with neuromuscular scoliosis will have associated,
underlying abnormalities, such as cerebral palsy, muscular dystrophy, or many
other neurologic or genetic syndromes that may affect the scoliosis. It is important when evaluating children to exclude
other associated conditions by a careful medical and developmental history and
physical examination. Incidence and risk factors Idiopathic scoliosis affects approximately 2 to 3 percent of
all children under the age of 16. It is
estimated that about 1 in 1,000 people will experience significant progression
of their scoliosis. The frequency of small curves in girls and boys is
equal. For curves that are progressive,
however, statistically girls out number boys 7 to 1.Diagnosis Idiopathic scoliosis can be diagnosed through a careful
physical examination by a physician. This examination involves the patient
bending forward while he or she is standing in front of the physician and
leaning either toward or away from the physician. A key sign of this condition
is asymmetry of the ribs or surrounding muscles due to rotation of the
spine. This presents as a bump along the
spine and can be easily recognized when the child bends forward. X-rays of the spine can confirm whether or
not scoliosis is present.
Medications No. Medication has not been shown to affect the
progression of scoliosis.Exercises To date no exercise regimen or program has been shown to
affect the likelihood of curve progression for scoliosis. Muscle strengthening
or generalized conditioning may help mechanical back pain problems.
However, some patients, particularly younger patients, with
curves that are not severe can be treated with a brace. There is some
controversy about this, but there are some studies that have shown this to be
effective when used in the appropriate patients. Non-operative intervention,
such as massage, physical therapy, chiropractic manipulations, exercise
programs, and electric stimulation do not adversely affect the spine, but have
not been shown to stop or prevent the progression of scoliosis. Possible benefits of idiopathic scoliosis Spinal fusion has been shown to be very effective in
correcting the deformity and preventing further progression of scoliosis.
Spinal fusion is generally recommended if other non-operative methods of
controlling scoliosis have failed.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.
Most recently, instrumentation can be inserted using a
minimally invasive procedure called
thoracoscopy. Telescopic instruments are
inserted into the chest with the lung deflated and metal rods can be attached
to the vertebra without needing to make large incisions. The technique is useful for moderately large
curves in the chest, but is technically demanding and is best done by medical
centers with extensive experience in thoracoscopic work.Who should consider idiopathic scoliosis? Q: Patients who have a curve in the chest area where the
spine is tilted more than 50 degrees or are curved in the lower portion of the
back where the spine is tilted more than 40 to 45 degrees should consult a
spinal deformity specialist for information regarding surgical procedures, such
as spinal fusion.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 Managing risks that occur involves the following:
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. Preparation Children are advised to be in good general health and well
nourished. Problems of infection and
bone healing increase in situations where the patient doesn’t have adequate
calorie or protein intake. In most healthy young people, this will not be an
issue.Timing As long as the curve is not changing dramatically, surgery
can be postponed indefinitely. If a curve is stable and changing at a very slow
rate, the observation period can be quite long.
In general, surgery to treat a curve that is increased by 10 to 15
degrees is not more complicated or difficult.
However, if a curve increases by 30 to 40 degrees, the magnitude of
difficulty of surgery is greater and safety is less certain.
Costs Most commercial and government-sponsored insurance plans
will cover this procedure. Many children
in the state of Washington
and nationally are covered by Medicaid which will also cover the cost of the
surgery.Surgical team Spinal fusion is a complicated and technically demanding
procedure. This procedure should be performed by a medical team whose members
perform a high volume of these surgeries and at institutions where they are
experienced in spinal cord monitoring and offer good anesthesia support. For younger children undergoing this
procedure, the team should include a pediatric anesthesiologist.
If an anterior spinal fusion is performed, the surgeon
should have experience with chest and abdominal procedures. If thoracoscopic
procedures are to be performed, there should be a team in place that has
received formal training in these techniques and is experienced with
thoracoscopy procedures. Finding an experienced surgeon A good resource for spinal surgeons is the Scoliosis
Research Society (www.srs.org).
This organization includes surgeons who perform high volumes of spine surgery
and are skilled in spinal reconstruction for pediatric spine conditions.
Another source is the Pediatric Orthopaedics Society of
North America web site. The site
includes a listing of skilled orthopaedic surgeons who have experience in
pediatric conditions. Facilities The majority of spinal fusions for childhood scoliosis are
performed in major pediatric children’s hospitals in North
America. Adult facilities may also have expertise provided they
have a pediatric unit and a designated and skilled spine team.Technical details For posterior procedures, the spine is exposed after the
patient is positioned face down on a special frame. Then the patient’s X-ray is
used to guide the surgeon in placing hooks or screws into the vertebrae where
rods are later attached. The joints between the bones are removed and then the
spine is straightened by attaching rods to the hooks or screws. The spine is
then repositioned and the screws and hooks are tightened securely to the rod.
Usually bone grafts serve as scaffolding for new bone cells
to grow into. The bone graft can be taken from the patient or can be taken from
the bone bank. In children, either bone supply works equally well for healing.
It is advisable to discuss the options thoroughly with the surgeon and to
evaluate the pros and cons of either bone graft source.
The spinal cord is monitored throughout surgery to track
impulses up and down the spinal cord.
This is a precaution taken to add an extra margin of safety and to
decrease the possibility of cord injury.
Following surgery, a brace may be used for added support, depending on
the patient’s condition. In the majority
of cases (in 2005), braces were not used.
For anterior procedures, the patient is placed on his or her
side. An incision is made to the spine
either through the flank for the abdominal area or through the chest for the
thoracic area. Screws are placed into the bone and the discs between the
vertebrae are removed. Bone is then placed into these areas to help stimulate
bone healing in between vertebrae. A rod
is attached to the screws and the spine is straightened and locked securely
into position. Braces are often not used
after surgery.
After either anterior or posterior surgery, a tube is
typically left in to drain off any bleeding that occurs after the surgery. Anesthetic Monitoring of spinal cord function is done during scoliosis
surgery. The standard monitoring should include monitoring of the pathways that
transmit sensation and of the pathways that transmit motor movement. Most
patients are administered general intravenous (IV) anesthetic. A medication
called Propofol is often used along with pain medication and Nitric Oxide,
which is a gas to help sedate the patient and help him or her drift off to
sleep. The use of paralytic agents is often avoided due to the potential of
interfering with the spinal cord monitoring.Length of idiopathic scoliosis The length of surgery depends on how much of the spine needs
to be fused and the approach that is used. Most anterior or posterior surgical
procedures take three to five hours. The actual time in the operating room is
longer than just the surgery because there is a need to apply monitors and
position the patient appropriately for surgery.
If a thoracoscopic procedure is performed, the length of time is a bit
longer then it is for a more conventional open approach. If a combined anterior and posterior spinal
fusion is performed, the surgery may take up to 8 to 10 hours.
Pain and pain management Scoliosis and spine surgery can be quite painful. In major
medical centers where spinal fusions are performed on a regular basis, there is
often a pain service with specially trained staff to help manage the patient’s
pain after surgery. Intravenous use of medications, such as morphine, are used.
This is often given with a patient controlled analgesic (PCA) which is a pump
with a push button allowing for more rapid delivery of medication when
necessary. Typically, intravenous pain medication is used for three to four
days after the procedure. The patient usually transitions to oral medication by
day four or five. Patients are then
discharged from the hospital on oral pain medication. More recently, epidural catheters have been
left in the space adjacent to the spinal cord and pain medications are
delivered directly to the spine for a few days before transitioning to oral
pain medications.
Pain medication will generally be
needed for two to three weeks after discharge from the hospital. The pain is
usually managed well with oral medications by the time the patient leaves the
hospital. At this time, they are also able to move about without much
limitation. Effectiveness of medications Nausea and vomiting are common
when taking pain medication.
Additionally, constipation can be a significant problem and may require
stool softeners or other medication to help with bowel movements. Sedation and
sleepiness after pain medication is also common.
Hospital stay The typical course of recovery
after spinal fusion is for the patient to sit on the edge of the bed the first
day after surgery. By the second day after surgery, the patient is up and
walking in the room and later in the hallway. Pain medications are given by IV
for three to four days after surgery. A liquid diet is started shortly after
surgery and is advanced rapidly to a regular food program.
X-rays are taken with the patient
in an upright position three to four days after surgery to make sure the spinal
instrumentation is in the same place it was left at the end of surgery. On
average, the length of stay is about four to five days in the hospital. Recovery and rehabilitation in the hospital A physical therapist will
initially assist the patient in getting out of bed. Following that, the goal is to have the
patient move independently and to be able to get out of bed with only minimal
assistance by the time they are discharged.
Most patients are extremely tired
and fatigued for about three to four weeks after the operation. This is because
the body requires a large amount of energy to heal from surgery like this and
because blood counts are low due to blood loss during surgery. By four or five
weeks after the surgery, most patients are feeling pretty well and by six
weeks, frequently parents must slow their children down to avoid a too rapid
return to full activity. Hospital discharge Generally, patients will be
restricted from sport activities and heavy lifting for at least six weeks.
After six weeks, patients are allowed to do a little bit of light swimming. The
weight limitation for lifting is about 10 to 15 pounds. School-age patients
will typically miss about four weeks of school.
Parents are advised to secure an extra set of books at school so
patients do not have to carry a heavy backpack to and from classes and to
arrange for children to be released from class a few minutes early to avoid the
rush in the hallways.
After three months, patients may
return to light sports. This includes running on level ground, swimming and
riding a bicycle.
After six months, they can return
to full activity. Convalescent assistance Patients can go home following
spinal fusion for idiopathic scoliosis and they do not require a convalescent
facility. They will need some help from their family members to move up and
down stairs and to walk until they can do so without assistance.
All rehabilitation can be
completed at home and does not require special expertise. The goal in the first
four to six weeks after surgery is simply to increase the distance of walking
each day. Summary of idiopathic scoliosis for idiopathic scoliosis 1. The overall complication rate
for spinal fusion is low. The most worrisome complications are infection,
problems with bone healing, and paralytic injury to the spinal cord. These
complications are rare, but if they occur, they may require additional surgery.
2. The recovery period from scoliosis surgery
is fairly predictable. The average length of stay is about four to five days in
the hospital and length of time to recover to more functional daily activities
is about four weeks. Return to full
activities should occur about 3 to 6 months out from surgery.
3. Spinal fusion surgery for
idiopathic scoliosis addresses problems of deformity and progression of
deformity well. However, it does not make the back normal and so the patient
may experience degenerative problems in 30 to 50 years which may require
additional treatment.
4. Spinal fusion surgery is
technically demanding and should be performed by highly skilled medical teams
whose members perform high volumes of scoliosis-related surgical cases.
5.The medical facilities performing this type
of work should have in place a very good spinal cord monitoring team, in
addition to excellent anesthesia support. The team effort is key to ensuring
successful outcomes for patients. Surgery for Idiopathic Scoliosis at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-4288 (outside the Seattle area: 800-440-3280) to make an appointment.
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