8 Surgical Treatment: The Nottingham Experience



10.1055/b-0035-124593

8 Surgical Treatment: The Nottingham Experience

John K. Webb and Nasir A. Quraishi

Early onset scoliosis is a heterogeneous condition. The prognosis and natural history vary widely, depending on whether the cause is congenital, idiopathic, syndromic, or neuromuscular. The majority of cases of early onset idiopathic scoliosis resolve spontaneously. Fewer than 10% of cases progress, but unless they are treated early, progression may be rapid and lead to severe deformity. Therefore, the early recognition and stabilization of potentially progressive curves are key to the successful treatment of this complex problem. An ideal method of stabilizing early onset idiopathic scoliosis in a growing child should (1) correct and stabilize the curve, (2) allow normal growth of the spine, and (3) prevent the crankshaft phenomenon, which is due to disproportionate anterior vertebral growth. Unfortunately, there is no known surgical or nonsurgical treatment method that addresses all of these factors adequately.


The growth rate of the spinal column varies bimodally with age, with the most rapid growth taking place from birth to the age of 2 years and further rapid growth occurring at adolescence. Although the spine has a major effect on the development of the lungs and thoracic cavity, cross-sectional volume also depends on the growth of the ribs, both in length and degree of rib obliquity. The thoracic volume increases to 30% of its adult size by 5 years of age and to 50% of its adult size by 10 years of age. Curve progression or early fusion can limit the thoracic volume, which in turn can lead to respiratory failure and early mortality.


Because of the dismal natural history of early onset scoliosis and the unfavorable effects of early fusion, a variety of surgical techniques have been used in an attempt to avoid, delay, or limit spinal fusion. These “growth-friendly” techniques and implants provide curve control and limit early spinal fusion. 1 Casting techniques were commonly used for the treatment of scoliosis before the introduction of spinal instrumentation. 2 Skin complications have been reported, and attention to meticulous technique is essential. Growth-friendly implants to control thoracic spinal deformity and minimize its adverse impact on the growth and development of the spine and thorax can be based on distraction techniques; these include growth rods and the vertical expandable prosthetic titanium rib (VEPTR; Synthes, West Chester, Pennsylvania). Implants can also be based on guided growth (e.g., Luque trolley, Shilla procedure) or compression techniques (e.g., tethers, staples). In larger curves, preoperative halo traction is sometimes used before instrumentation in an effort to decrease neurologic risk, obtain better correction, and improve pulmonary function before surgery. The use of traction in early onset scoliosis with curves larger than 80 degrees and curves associated with kyphosis before the placement of growth-friendly instrumentation has been described. 3


In 1990, the senior author [JKW] first reported the use of segmental spinal instrumentation in which Luque rods were used without fusion for early onset idiopathic scoliosis. The principle was to leave a part of the Luque rods straight at either end, beyond the overlapped section, to allow the spine to grow along the rods. The Luque rods acted like a trolley to guide spinal growth while maintaining correction until the adolescent growth spurt, when the construct might fail because of growth of the spine beyond the limit that the construct could hold. The Luque trolley (LT) could then be replaced with definitive instrumentation for final curve correction and fusion.


Over the years, the configuration of the LT has evolved to some extent, but the basic principle has remained the same. In 1999, a short-term result (up to 5 years) was published. 4 This showed that LT instrumentation alone did not prevent curve progression (Cobb angle corrected from 56 degrees [range, 46–67 degrees] to 43 degrees [range, 24–55 degrees]). Additional convex epiphysiodesis resulted in curve resolution in some patients; the mean preoperative Cobb angle was 65 degrees (range, 40–95 degrees), the mean Cobb angle was 26 degrees (range, 8–66 degrees) after the combined surgery, and it was 32 degrees (range, 0–86 degrees) at the 5-year follow-up. The 5-year growth was 2.9 cm (49% of that expected for age- and gender-matched normal subjects; range, 31–71%) for LT only and 2 cm (32% of expected for age-and gender-matched normal subjects; range, 11–53%) for convex hemi-epiphysiodesis (CE) and LT. These results emphasized that the LT construct alone was ineffective to prevent curve progression, but when used in conjunction with CE, it supported spinal growth while either the curve resolved or correction was maintained. During further follow-up, deterioration of the curve at around the time of the adolescent growth spurt was noted in some of the patients, as expected, and they were treated with definitive instrumentation and fusion. Surprisingly, the curves of many patients did not deteriorate, and they not require any further surgery despite having significant spinal growth. In this chapter, we describe our technique of CE and LT for patients with early onset idiopathic scoliosis and their long-term follow-up at a minimum age of 16 years.



8.1 Surgical Technique



8.1.1 Convex Epiphysiodesis


A convex thoracotomy was performed through the rib two levels above the apex. The apex was exposed, and the apical disks and adjacent growth plates that did not correct on side-bending films were excised on the convex side back to the posterior longitudinal ligament (three to five levels around the apical vertebra). The excised rib furnished graft for that side. The combination of LT and epiphysiodesis was staged; the epiphysiodesis was done first, with a mean interval of 5 weeks between the procedures.



8.1.2 Segmental Spinal Instrumentation without Fusion


We employed a posterior extraperiosteal approach with diathermy to prevent new bone formation. The facet joint capsules were preserved. Sublaminar wires were passed at each level and the end vertebrae double-wired. Before 1988 (14 patients), Luque rods were used in an overlapped l configuration (Fig. 8.1). The straight ends of the rods were kept 3 to 5 cm longer beyond the curved end of the other rod at either end, which allowed the spine to grow along its length. After 1989, because the proximal straight end tended to project prominently under the skin, the configuration was changed to an overlapped u shape (Fig. 8.2 , Fig. 8.3 , Fig. 8.4). Postoperative bracing was not used in any case. Spinal cord monitoring with sensory evoked potentials and motor evoked potentials was done in all cases.

Fig. 8.1 Fig. 8.1 (a) A 4-year-old boy with a 44-degree right thoracic curve. (b) Radiograph obtained immediately after initial surgery with a convex hemi-epiphysiodesis and Luque trolley growing rod and an l construct with projected straight ends to accommodate growth. (c) At 3.6-year postoperative follow-up, the curve is well maintained (12 degrees) with the instrumentation while growing along the rods. (d) At 5-year follow-up (patient 9 years of age), the spine continues to grow beyond the limits of the projected straight ends of the rod at the superior end, and the curve tends to deteriorate (21 degrees).
Fig. 8.2 Fig. 8.2 (a, b) A 7-month-old boy presented with a 45-degree right thoracic curve. (b) When the patient was 18 months of age, the curve rapidly deteriorated to 85 degrees. He was treated at this time with convex hemi-epiphysiodesis and the Luque trolley growing rod technique (overlapped u construct). (c–e) The curve was maintained at 32 degrees, permitting significant spinal growth along the rods until the boy was 11½ years old. (f, g) During his adolescent growth spurt (at 12½ years of age), the curve started to deteriorate, with decompensation of the coronal and sagittal balance. (h, i) The Luque trolley was removed, and a definitive fusion was performed at 12½ years of age. The final curve magnitude was 45 degrees.
Fig. 8.3 Fig. 8.3 (a, b) A 12-month-old boy presented with a 20-degree left thoracic curve and dextrocardia. (c) When he was 16 months of age, the curve rapidly deteriorated to 44 degrees. (d–f) At 2 years of age, he was treated with convex hemi-epiphysiodesis and the Luque trolley growing rod technique (overlapped u construct). (g) The curve was maintained at 32 degrees, permitting significant spinal growth along the rods until the boy was 11½ years old. (g–i) During his adolescent growth spurt, the curve remained stable at 25 degrees until he reached skeletal maturity at 16 years of age, without the need for any definitive surgery.
Fig. 8.4 Fig. 8.4 (a) A 60-degree progressive left thoracic scoliosis in a 1½-year-old child was treated with a Luque trolley growing rod (overlapped u construct), and the Cobb angle was corrected to 28 degrees. (b) At 7 years of age, the patient had outgrown the Luque trolley growing rod construct, and the Luque trolley rods were exchanged, with a longer overlap of the u construct. At 14 years of age, when he entered the adolescent growth spurt, he had further growth of the spine (5 cm total growth). The scoliosis was maintained at 28 degrees, but progressive kyphosis developed at the apex of the curve, at the junction of the overlapped proximal and distal rods. He underwent a definitive surgery with posterior instrumented fusion (Universal Spinal System; Synthes, Oberdorf, Switzerland).

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6 Congenital Deformities of the Spine 5 Neuroaxial Anomalies 7 Surgical Treatment of Congenital Spine Deformity 2 Development of the Spine 22 Nonoperative Treatment of Syndromic Scoliosis 12 Dual Growing Rod Treatment

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Jun 8, 2020 | Posted by in ORTHOPEDIC | Comments Off on 8 Surgical Treatment: The Nottingham Experience

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