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In Patients with Early-Onset Scoliosis, Can Growing Rods Be Removed Without Further Instrumentation? An Evidenced-Based Review.

ABSTRACT: Early-onset scoliosis (EOS) is defined by the presence of spinal deformity in children 10 years of age or younger. Left untreated, patients with EOS are at high risk for thoracic insufficiency and early demise. This article provides a critical review of a recent prospective cohort study of children with EOS: "Graduation Protocol After Growing-Rod Treatment: Removal of Implants without New Instrumentation Is Not a Realistic Approach," by Kocyigit and colleagues (J Bone Joint Surg Am. 2017;99(18):1554-1564). Treatment for EOS requires deformity correction while accommodating the growing spine. Dual growing rod implantation is a well-described technique that consists of the placement of two telescoping rods anchored to vertebrae proximal and distal to the apex of the curve. Multiple lengthening procedures are then performed as the child grows. Management of the endpoint of growing rod treatment remains controversial, with high complication rates associated with final fusion. As an alternative to final fusion or implant retention, Kocyigit and colleagues examined the removal of growing rods without spinal fusion and found that this procedure resulted in substantial worsening of the deformity in nine out of ten patients. This treatment group was terminated on ethical grounds. We believe this important result demonstrates that the removal of implants without fusion is an unacceptable treatment strategy that leads to poor outcomes.

SUBMITTER: Shen TS

PROVIDER: S-EPMC6609653 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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In Patients with Early-Onset Scoliosis, Can Growing Rods Be Removed Without Further Instrumentation? An Evidenced-Based Review.

Shen Tony S TS Schairer William W Widmann Roger R

HSS journal : the musculoskeletal journal of Hospital for Special Surgery 20190227 2

Early-onset scoliosis (EOS) is defined by the presence of spinal deformity in children 10 years of age or younger. Left untreated, patients with EOS are at high risk for thoracic insufficiency and early demise. This article provides a critical review of a recent prospective cohort study of children with EOS: "Graduation Protocol After Growing-Rod Treatment: Removal of Implants without New Instrumentation Is Not a Realistic Approach," by Kocyigit and colleagues (<i>J Bone Joint Surg Am.</i> 2017; ...[more]

PMID: 31327953

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Project description:Magnetically controlled growing rods have been used to treat early-onset scoliosis for the last 9 years; however, few studies have been published, with only short-term follow-up. The aim of the present study is to systematically review the outcomes of magnetically controlled growing rods in the treatment of early-onset scoliosis with a minimum of 2-year follow-up. Studies were included if patients with early-onset scoliosis (scoliosis diagnosed before 10 years of age) underwent implantation of magnetically controlled growing rods with a minimum of 2-year follow-up. The literature review and data extraction followed the established preferred reporting items for systematic review and meta-analysis guidelines. Data of distraction frequency, number of distractions, distracted length, Cobb angle, kyphosis, T1-T12 length, and T1-S1 length preoperatively, postoperatively, and at final follow-up were collected. Data regarding complications and unplanned reoperations were also extracted. The mean values of these parameters were calculated, or pooled meta-analysis was performed if available. Ten articles were included in this systematic review, with a total of 116 patients and a follow-up period between 23 and 61 months. The mean preoperative Cobb angle and kyphosis angle were 60.1° and 38.0°, respectively, and improved to 35.4° and 26.1° postoperatively. At final follow-up, the Cobb and kyphosis angles were maintained at 36.9° and 36.0°, respectively. The average preoperative T1-T12 and T1-S1 lengths were 180.6 mm and 293.6 mm, respectively, and increased to 198.3 mm and 320.3 mm postoperatively. T1-T12 and T1-S1 lengths were 212.3 mm and 339.3 mm at final follow-up, respectively. The overall rate of patients with complications was 48% (95% confidence interval [CI], 0.38-0.58) and unplanned reoperation 44% (95% CI, 0.33-0.55) after sensitivity analysis. The current evidence from different countries with a minimum of a 2-year follow-up suggests that magnetically controlled growing rods are an effective technique to treat pediatric scoliosis and promote spine growth. However, nearly half of patients still developed complications or required unplanned reoperations.

Project description:BackgroundSpinal deformities constitute one of the most common types of manifestations of neurofibromatosis type-1 (NF-1), which can lead to either dystrophic or non-dystrophic early-onset scoliosis (EOS). Surgical treatment for EOS with NF-1 is challenging, and the outcomes have rarely been reported. The anterior-posterior procedure is widely used, but posterior-only fusion is theoretically easier and safer to perform. Is it possible that a new surgery that accommodates growth is a better choice? A direct comparison between posterior fusion and growth-friendly surgery in terms of surgical outcomes has not yet been conducted in dystrophic EOS with NF-1 patients.MethodsBaseline information was extracted from the NF-1 database at our institute with approval from the local ethics committee. All enrolled patients were diagnosed with NF-1. Clinical and radiographic data were recorded preoperatively, after the initial surgery, and at the final follow-up. Implant-related, alignment, neurological complication and unplanned revision surgery data were recorded. We compared the outcomes of these two groups in terms of curve correction, growth parameters, complications and unplanned revision surgeries.ResultsThere were eight patients in the PF group and eight patients in the GR group, with a mean follow-up of 51.0 ± 17.5 months. The main curve size was similar (PF 67.38° ± 17.43° versus GR 75.1° ± 26.43°, P = 0.501), and there were no significant differences in the initial surgery correction rate or the rate of correction. However, the patients in the GR group exhibited more T1-S1 growth during the follow-up overall and per year than did those in the PF group. The operative time was significantly longer for the PF group than for the GR group (PF, 4.39 ± 1.38 vs. GR, 3.00 ± 0.42 h; p = 0.008). Significantly fewer segments were involved in the PF group (8.25 ± 3.20) than in the GR group (13.00 ± 1.60).ConclusionFor the initial treatment of dystrophic EOS in patients with NF-1, the GR technique is possibly a more appropriate treatment than is the PF technique in terms of trunk growth. However, the repeated procedures required for GR may be a considerable disadvantage. More studies with direct measurement of pulmonary function must be conducted to determine the effect of GR on pulmonary development. More studies with larger sample sizes and longer follow-up periods are needed to fully assess the treatment strategies.

Project description:BackgroundObtaining and maintaining final shoulder balance after the entire treatment course is essential for early-onset scoliosis (EOS) patients. The relatively small number of growing-rod (GR) graduates who complete final fusion has resulted in an overall paucity of research on the GR treatment of EOS and a lack of research on the shoulder balance of EOS patients during GR treatment.MethodsTwenty-four consecutive patients who underwent GR treatment until final fusion were included. Radiographic shoulder balance parameters, including the radiographic shoulder height (RSH), clavicle angle (CA), and T1 tilt angle (T1T), before and after each step of the entire treatment were measured. Shoulder balance changes from GR implantation to the last follow-up after final fusion were depicted and analysed. Demographic data, surgical-related factors, and radiographic parameters were analysed to identify risk factors for final shoulder imbalance. The shoulder balance of patients at different time points was further analysed to explore the potential effect of the series of GR treatment steps on shoulder balance.ResultsThe RSH showed substantial improvement after GR implantation (P = 0.036), during the follow-up period after final fusion (P = 0.021) and throughout the entire treatment (P = 0.011). The trend of change in the CA was similar to that of the RSH, and the T1T improved immediately after GR implantation (P = 0.037). Further analysis indicated that patients with shoulder imbalance before final fusion showed significantly improved shoulder balance after fusion (P = 0.045), and their RSH values at early postfusion and the final follow-up did not show statistically significant differences from those in the prefusion shoulder balance group (P > 0.05). Early postfusion shoulder imbalance (odds ratio (OR): 19.500; 95% confidence interval (CI) = 1.777-213.949; P = 0.015) was identified as an independent risk factor for final shoulder imbalance.ConclusionsShoulder balance could be improved by GR implantation but often changes during the multistep lengthening process, and the final result is relatively unpredictable. Final fusion could further adjust the prefusion shoulder imbalance. Focusing on the prefusion shoulder balance of GR graduates and providing patients with early shoulder balance after fusion might be necessary.

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In Patients with Early-Onset Scoliosis, Can Growing Rods Be Removed Without Further Instrumentation? An Evidenced-Based Review.

Publications

In Patients with Early-Onset Scoliosis, Can Growing Rods Be Removed Without Further Instrumentation? An Evidenced-Based Review.

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