An Approach for Treatment of Complex Pediatric Spinal Deformity
The Growing Spine Committee of the Scoliosis Research Society validated a novel Classification of Early-Onset Scoliosis that divides pediatric spinal pathology into congenital/structural, neuromuscular, syndromic, and idiopathic etiologies. Although treatment recommendations may vary between the specific etiologies, the main tenet of management involves delaying curve progression (without long-segment arthrodesis) so that thoracic growth and pulmonary function may be optimized. As such, novel growth-modulation techniques (vertebral body stapling/tethering) and nonfusion distraction-based techniques (growing rods, vertical expansion prosthetic titanium rib) may be effective treatments in skeletally immature patients. When surgery is indicated, studies support use of the Lenke classification for selecting fusion levels spanning structural (and not compensatory) idiopathic curves--emerging evidence suggests that compensatory curves adjust after correction, and that adjacent segment degeneration may occur with less frequency than previously expected. Operative management is associated with high complication rates in nonidiopathic deformities, which is of particular concern in neuromuscular scoliosis patients who often have significant comorbidities and long sweeping curves requiring long-segment correction with fusion from the high thoracic spine to pelvis. Despite the high complications rates, high-quality outcome studies demonstrate significant improvement in health-related quality of life. Operative trends in pediatric spinal deformity surgery over the last decade include: decreased use of anterior-only surgery in favor of posterior pedicle screw constructs, increased use of antifibrinolytics to decrease operative blood loss, intraoperative image guidance for screw placement, intraoperative neuromonitoring to avoid neurological sequelae, and an overall reduction in reported complication rates.
