Surgical stapling delays spinal fusion in scoliosis: orthotics helpful.
The idea is that the staples restrict growth on the convex side of the curve, allowing the concave side to grow, eventually bringing the spine into a more equal alignment, said Dr. Lubicky of Shriner's Hospital for Children, Chicago.
Although long-term data on the procedure are not available, "right now it's controlling the curves in these kids and it doesn't require repeat operations," he said. It's not clear whether these children will eventually require spinal fusions, or if the vertebral stapling procedure will simply be an alternative to orthotic braces until spinal fusion can be performed, said Dr. Lubicky, who is tracking the progress of about 40 patients who have undergone the procedure so far.
Nor is it clear if the staples should be removed once the curve straightens. There should be no harm in leaving the staples in, as long as they don't migrate, he said.
Even if the vertebral stapling procedure is a short-term solution, it may turn out to be a welcome alternative to wearing orthotic devices. Such devices don't halt the progression of scoliosis in children, but are designed to improve function enough to delay surgical correction until the child's bones are mature enough to undergo the surgery. Braces improve trunk alignment, sitting, and standing as long as the spine is flexible, until the child is a candidate for spinal fusion.
Spinal fusion should be delayed as long as possible on the growing child, because any fused vertebrae will cease to grow. "These kids with early fusions end up with very short trunks," he observed.
Fusions performed too early can also result in the "crankshaft phenomenon," which causes a postoperative recurving of the spine. Crankshafting occurs because, although fused vertebrae stop growing longitudinally, they can still grow in the anterior plane, causing another curve. Children are most at risk for this complication if the triradial cartilage in the hip is still open. If surgery is necessary in these children, an anterior fusion is indicated.
If vertebral stapling does turn out to be a long-term solution, it would help patients avoid complications such as trunk foreshortening and the crankshaft phenomenon, Dr. Lubicky noted in an interview.
If surgical treatment is recommended, parents and patients should be advised before the surgery that it will improve function in the long term, but the initial adjustment might be difficult. "The child may actually lose function for a while," since his posture is altered, affecting the adaptations he has made to compensate for the spinal curve, he said.
It's also important to impress upon patients and their families that the treatment's goal is to maintain or improve function, not to improve appearance, he added. "We want to get a stable spine in a balanced position. It doesn't mean the scoliosis has to be 100% corrected. The cosmetic part is the icing on the cake."
Although spinal surgery entails a long recovery, patients and caregivers are generally pleased with the outcome. Surgery halts the progression of the curve, which without correction can continue even after growth ceases, though at a much slower rate. Bringing the spine into a more physiologic alignment relieves pain, improves respiration, makes eating easier, improves urinary and bowel function, frees the arms to do tabletop activities, and makes caregiving much easier, he said.
In a survey of the parents of 100 patients who underwent spinal reconstructive surgery for cerebral palsy, more than 90% of the parent caregivers were satisfied with the results and said that they would agree to the surgery again, even knowing the postoperative challenges.
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|Title Annotation:||Clinical Rounds|
|Author:||Sullivan, Michele G.|
|Date:||Jan 1, 2004|
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