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Physicians Update

 
Spring 2010

Advanced Techniques, Instrumentation a Boon to Young Patients

03/01/2010

PhyUpdate-Spring2010 Young Ortho PatientIt used to be that children who underwent surgery to correct scoliosis — abnormal curvature of the spine — had to endure months of immobility in a post-operative cast or metal braces until their vertebrae fused. But today’s new implantable devices, using pedicle screws rather than hooks or wires, enable many of these patients to be back on their feet walking within two days, engaging in noncontact sports within a month and contact sports within six to 12 months.

This among other advances in instrumentation and techniques, both surgical and nonsurgical, has dramatically changed the outlook for youngsters with spinal deformities, and resulted in both improved safety and correction, says Anthony Scaduto, M.D., pediatric orthopaedist at UCLA Medical Center, Santa Monica.

“In addition to newer surgical approaches, nonfusion techniques that allow for spinal growth, as well as improved casting techniques, are enabling us to intervene for children with scoliosis at a younger age and at an earlier stage than we could in the past,” Dr. Scaduto says.

About 3 percent of children have some type of spinal deformity; approximately 80 percent are girls. Scoliosis most commonly becomes apparent during adolescence, but can also be identified during infancy or early childhood. In most cases, scoliosis is idiopathic, though there are also congenital forms as well as neuromuscular scoliosis associated with such conditions as cerebral palsy, spina bifida and muscular dystrophy. One in 10 children with scoliosis will require corrective surgery.

The impact on quality of life and mortality depends on the severity of the curvature and the age of onset. Children with scoliosis that begins at an early age are the most severely affected; children with infantile scoliosis have a 50 percent mortality rate before the age of 60. But health and function also can be significantly affected in less severe cases. “For adolescent idiopathic scoliosis left untreated, when the curvature becomes large there is a high risk of back pain as well as some decreased pulmonary function,” Dr. Scaduto notes. “That’s why early intervention is so important.”

Routine screening for scoliosis at the age of puberty is essential, Dr. Scaduto says, so that any detected problems can be corrected during the crucial growth period. Many children are screened by school nurses or their primary care physicians. Any asymmetry of the ribs evident on the Adams Forward Bend Test indicates the need for a spine X-ray, and scoliosis is typically diagnosed based on the degree of spinal curvature (11 degrees or more) and the angle of the trunk rotation.

“Untreated scoliosis can lead to deformity in the ribs and internal organs and, in the most severe cases, to breathing problems,” Dr. Scaduto says. “But when treated in a timely and appropriate manner, it shouldn’t have a significant negative impact on a child’s life.”

PhyUpdate-Spring2010 Scoliosis ChildWhether the recommended course is observation, bracing or surgery depends largely on the extent of the curvature and the age of the child. In general, curvatures of less than 30 degrees are observed; children with more than two years of growth remaining who have 30- to 50-degree curves are braced to prevent further progression until surgery can be performed; and curves of more than 50 degrees usually require immediate surgery to fuse adjacent segments, prevent progression and restore balance. However, the vast improvements in bracing and surgical techniques have changed both the timing and number of patients recommended for interventions, Dr. Scaduto says.

Unlike the metal braces of the past, today’s appliances are made of soft plastics and often can’t be detected under clothing, Dr. Scaduto notes. For children with moderate scoliosis, bracing can serve as an effective holding technique, although it rarely corrects the curvature. Recent advances in electrophysiologic monitoring and anesthesia have also enabled surgeons to achieve safer and greater correction of severe cases of scoliosis with spinal osteotomies.





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