Scoliosis - Braces

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The Texas Scottish-Rite Hospital (TSRH) Instrumentation. The Texas Scottish-Rite Hospital (TSRH) instrumentation is similar to the Cotrel-Dubousset procedure in that it uses parallel rods and other devices that reverse rotation as well as improve curvature. TSRH, however, uses smooth rods and hooks that are designed to make removal or adjustment easier later on if complications arise. Complications are similar to the Cotrel-Dubousset procedure.

Additional Forms of Instrumentation. Other instrumentation procedures have refined the hardware used in the Harrington and Cotrel-Dubousset operations. Some, but not all, are listed below:

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• Luque instrumentation is used primarily in people whose scoliosis is due to problems of nerves and muscles, such as in children with cerebral palsy. After surgeons developed Luque instrumentation to help maintain normal lordosis, experts hoped that bracing would not be needed. Several studies showed, however, that without braces, correction was lost after this operation, and the procedure may have a higher risk for spinal cord injury than other standard procedures.
• Wisconsin segmental spine instrumentation (WSSI) is as safe as the Harrington rod and nearly as strong as the Luque instrumentation.

Instrumentation for Anterior Approach. The anterior approach, in which the surgeon performs the operation by opening the chest wall, requires specific hardware. Halm-Zielke instrumentation, for example, uses TSRH instrumentation with bone grafts constructed from ribs to prop open the spaces between the disks. It allows true three-dimensional curve correction. However, it does not solve specific problems -- higher risks for kyphosis (an outward curve) and pseudoarthrosis (a false joint at the fusion site). Variants using two rod systems, fusion cages, or other instruments appear to improve this procedure.

Approaching the Spine

Posterior Approach (Through the Back). Many surgeons use a posterior approach for scoliosis, which reaches the surgical area by opening the back of the patient. It has been the gold standard for decades and is generally used with Harrington instrumentation. The posterior approach has advantages and disadvantages:

• Advantages. Surgeons are familiar with it, so fusion rates are excellent, curve correction is good, and it has few complications.
• Disadvantages. Preadolescent children are at risk for the crankshaft phenomenon (a worsening of the curve) later on. (Newer posterior instrumentation, such as the Isola instrumentation, may prevent this occurrence.) The posterior approach also does not always correct hypokyphosis (the loss of normal outward curvature) in the thoracic (upper) spine. The procedure is not always effective for curves in the thoracolumbar region (where the upper and lower spine meet) and may cause spinal abnormalities there.

Anterior Approach (Through the Front). Increasingly, surgeons are using the anterior approach, in which the surgeon performs the operation through the chest wall (called a thoracotomy). With the anterior approach, the surgeon makes an incision in the chest, deflates the lung, and removes a rib in order to reach the spine. This rib can be used during the operation as a strut to support the spine. It also may be repositioned within the patient until it is used for bone grafting during fusion.

The anterior approach also has its advantages and disadvantages:

• Advantages. Because the frontal approach allows the procedure to be performed higher up in the spine than with standard procedures, the patient may have a lower risk for lower-back injury later on. In addition, transfusion rates are much lower with the anterior approach. With increasing experience, the anterior approach is as effective as the posterior approach.
• Disadvantages. It is a newer procedure than the posterior approach, and, among inexperienced surgeons, carries a higher risk for complications than in the more standard posterior approach. Poorer lung function after surgery has been noted, possibly because the wide chest incision impairs the chest muscles, which can affect lung function afterward. Hardware failure rates may also be higher in the anterior approach than in the posterior approach. Increasing experience and newer hardware designs are reducing many of these problems.

The Combined Anterior-Posterior Approach. The combination approach uses an anterior approach first, which allows better correction of the problems. The fusion part of the operation is done with the posterior approach. This is a very long and complex procedure. It appears to be safe, however, and is proving to be useful, even in very young patients, for preventing the crankshaft phenomenon. It also may correct large rigid curves and specific severe curves in the thoracic spine.

Researchers are evaluating new approaches to treating thoracic scoliosis in adolescents and children. A new device, the vertical expandable prosthetic titanium rib (VEPTR), is showing promise in the treatment of severe congenital scoliosis with chest deformities. The device, which is implanted through surgery, can be adjusted as the child grows. VEPTR expands the thoracic cavity, thereby correcting the curvature and allowing spinal, thoracic, and lung growth. Several studies to date have shown this device is safe and effective in improving breathing problems and appearance in young children.

Video-Assisted Thoracoscopic Surgery (VATS). The anterior thoracoscopic surgery uses a video-assisted anterior approach and recently-developed spinal instrumentation. Some studies have found no significant differences between the anterior thoracoscopic and the traditional posterior approach in terms of kyphosis, coronal balance, or tilt angle.

This procedure is complicated, and few surgeons are trained to perform it. The surgery is generally used only for single curves in the upper back, or for patients with a curve in the upper back and a compensating curve in the lower back. Some surgeons are now able to operate on areas below the diaphragm, including the lumbar spine. The patients must still wear a brace for 3 months after surgery. Long-term studies to compare results of VATS to those of standard procedures are needed.

Advantages of the anterior thoracoscopic approach include fusion of fewer vertebrae, less blood loss, quicker recovery time (often out of bed in 2 days), better cosmetic results, and lower transfusion rate. However, the operative time is nearly twice as long as that of the posterior approach.

These new treatments have shown some early positive results, but more research will be needed to determine their true value.

Complications of All Procedures

Complication rates are high with any of the procedures, including the standard Harrington method and the newer Cotrel-Dubousset procedure. A survey of fusion procedures done between 1993 and 2002 for idiopathic scoliosis found the complication rates were nearly 15% in children, and 25% in adults.

Complications for all procedures include allergic reactions to anesthesia and the following:

Bleeding. Standard procedures increase the risk for major blood loss during the procedure. Patients are encouraged to donate blood before the operation for use in possible transfusions. Children sometimes require more than one transfusion following surgery. Researchers are investigating various methods for reducing the need for transfusions, such as the use of preoperative erythropoietin (rhEPO), which increases production of red blood cells in the bone marrow.

Newer endoscopic techniques are reducing the need for transfusions.

Infection. Infection is always a risk with any operation. One study reported changes in the immune system for about 3 weeks after surgery, which indicated a greater risk for infection. Researchers recommended being very vigilant for signs of infection, including those in the pancreas and urinary tract. Doctors also recommend antibiotics, given before and after surgery.

Nerve Damage. Patients often worry about neurological injuries, but the risk is actually very low. In general, nerve injury occurs in 1% of patients, with the risk highest in adults. If neurological damage occurs, it most often causes muscle weakness. Paralysis is very rare and can be prevented using monitoring techniques during the operation. Nearly all monitoring procedures use a so-called wake-up test, in which the patient is brought out of anesthesia during or at the end of the procedure and assessed for sensations to be sure no injury has occurred. One simple method is to wake patients up in the middle of their operations and ask them to wiggle their toes. More sophisticated methods measure the electrical activity of the spinal cord; if the monitor indicates a fall in electrical response and possible injury, the surgeon makes adjustments to avoid further damage to the spinal cord.

Pseudoarthrosis. If the fusion fails to heal, pseudoarthrosis, a painful condition in which a false joint develops at the site, may develop. In one study, teenagers who smoked and heavier adolescents (over 154 pounds) who had hyperkyphosis (hunchback) were at higher risk for this complication. The anterior approach may pose a higher risk for pseudoarthrosis. One study reported that pseudoarthrosis may be underdiagnosed, and rates may average 20% after surgery, therefore acting as a major contributor to post-surgery pain.

Disk Degeneration and Low Back Pain. Fusion in the lumbar area produces great stress on the lower back and eventually can cause disk degeneration. Loss of trunk mobility, balance, and muscle strength from surgical treatments can also cause lower back pain and chronic problems in future years. Patients who are surgically treated with fusion techniques lose flexibility; their back muscles may be weakened if they were injured during surgery. In most cases, however, the consequences are mild to moderate.

Lung Function. Some patients may develop serious lung problems after surgery. These complications are highest in children whose scoliosis is due to neuromuscular problems, such as spina bifida, cerebral palsy, or muscular dystrophy. Lung problems can develop up to 1 week after surgery. Lung function may not become completely normal until 1 - 2 months after surgery.

Other Complications. Other problems can include, but are not limited to, the following:

• Hooks dislodging or a fused vertebra fracturing
• Gallstones
• Pancreatitis (inflammation of the pancreas). Among adolescents, this complication tends to occur more often among those who are older or who have a lower body mass index.
• Intestinal obstruction

Click the icon to see an image of gallstones.

Postoperative Therapy

Patients must perform breathing and coughing exercises shortly after the procedure and continue them through the recovery process to rid the lungs of congestion. The patient is usually able to sit up the day after the operation, and most patients can move on their own within a week. A brace may be necessary, depending on the procedure. With the anterior approach in the upper back, patients may have some trouble with activities involving the arms and hands, such as tying shoes and cutting food. However, occupational therapy using stretching and strengthening exercises, may allow for full resumption of daily activities, including dressing, bathing, and grooming, within 3 months.

Some pain always follows these procedures, requiring intravenous administration of strong painkillers right after the operation (endoscopic procedures may require only mild pain relievers). NSAIDs (nonsteroidal anti-inflammatory drugs, such as aspirin, Motrin, and Advil) for pain relief right after fusion may increase the risk for fusion failure. Consult with your doctor before taking any pain medication after surgery.

Patients are often concerned that surgery will stiffen their backs, but most cases of scoliosis affect the upper back, which has only limited movement, so that patients do not notice much difference. It may take a year or more for muscle strength to return. In some cases, the operation cannot completely correct the curve, and one leg may be shorter than the other. Heel lifts may help in this case.

Revision (Salvage) Surgery

Patients may need a corrective procedure called revision or salvage surgery, usually for one of these reasons:

• Failure of the previous procedure
• Curvature progression around the fusion site
• Disk degeneration
• Poor posture alignment

Minimally Invasive Surgery

Growing Rod Technique. This technique is used for very young children in whom bracing has not helped. Instead of doing spinal fusion, doctors surgically insert a rod into the patient's back. Additional surgeries are performed every 6 months to extend the rod so that the spine can continue to grow. Some growing rod techniques use a single rod, while others use two rods. Studies suggest that dual rods are stronger than single rods, which may help provide better spinal stability and correction.

Vertebral Body Stapling and Anterior Spinal Tethering. These fusionless procedures are performed with an anterior approach surgery and without fusion. Vertebral body stapling is an experimental technique that may prevent curve progression in some young patients with curves less than 50 degrees. It involves stapling the outer curve of the side of the spine facing the chest, which helps stabilize and reduce progression of the inner curve. The procedure uses a special metal device that is clamp-shaped at body temperature, but can be straightened when subjected to cold temperatures and inserted into the spine. When warmed up, the staple returns to its clamp shape and supports the spine. While short-term results have been favorable, long-term results are not yet available.

Review Date: 04/06/2010
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org).