The Tried-and-True Plus the Exciting-and-New: Treating Pediatric Scoliosis

Feb. 1, 2019

Young boy with his dog.

Kids are not simply small adults. If an adult used dental floss and dog leashes to connect all the cabinets in the kitchen, then sat on the floor and earnestly described his dog becoming both a grandma and a rock star, you would recognize the behavior as unusual. But when a kid does it? Par for the course. That’s because kid brains are different from adult brains. Similarly, kid bodies are different from adult bodies. These physical differences are important when it comes to treating scoliosis.

Scoliosis, or a side-to-side curvature of the spine, is a fairly common disorder. In a group of 100 adolescents, usually between one and five will have scoliosis. Some schools even screen for the condition.

Scoliosis that begins in adolescence is usually idiopathic, or due to causes that are not yet understood. Scoliosis in kids under 10, while much rarer, is more likely to have an identifiable cause. (Scoliosis that begins in adulthood is also rare, and it is also more likely to be the result of an identifiable cause.) Whatever the age of the patient, and whatever the cause of the scoliosis, doctors such as pediatric neurosurgeon Dr. Richard Anderson have several options for treatment—including surgery.

Scoliosis surgery is generally reserved for severe curves, which may cause pain, deformity or difficulty with lung function. But scoliosis surgery for kids and young adults is a little bit different than scoliosis surgery for adults. Their bones are less mature, their bodies are proportioned differently and some of them have a lot of growing left to do. Dr. Anderson and other pediatric specialists are always looking out for the best ways to address these important factors.

Recently, Dr. Anderson and two colleagues in the CU Orthopedics department published a paper on scoliosis treatment in kids and adolescents. The paper, called Modern Surgical Management of Early Onset and Adolescent Idiopathic Scoliosis, was published in the journal Neurosurgery (author list below). In their paper, the authors review the best techniques for treating scoliosis in pediatric patients, including the principles that have been around for nearly 100 years and the improvements in recent decades.

Many scoliosis treatment decisions rely on the classic imaging scan, the X-ray. X-ray images allow doctors to calculate the angle of a scoliosis curve, known as the Cobb angle. Not only is the size of the Cobb angle important, but doctors also need to track its change over time. Doctors also use X-rays of the hand to estimate how much skeletal growth a patient has ahead of her. So-called “skeletal maturity” is an important factor in making pediatric scoliosis treatment decisions, because curves tend to increase during a child’s growth. Using X-rays to establish the child’s skeletal maturity helps a doctor determine whether a kid is near the end of her growth–and a curve is near the end of its progression–or not.

Since X-rays are such an important diagnostic tool, young patients with scoliosis may have many X-rays taken during the course of their care—potentially receiving a lot of radiation. A relatively recent innovation called EOS imaging provides about the same amount of detail as an X-ray while delivering less radiation. This makes it ideal for reducing radiation exposure in children and young adults with scoliosis. (New York Presbyterian Hospital has one EOS system at Morgan Stanley Children’s Hospital, where Dr. Anderson sees patients, and another at their Allen Pavilion location.) EOS or X-ray imaging helps doctors determine when surgery might be necessary.

When it comes to scoliosis surgery itself, the general idea has been the same for a long time: Straighten the spine as much as possible and prevent it from curving again. But in recent decades, the methods available to help a surgeon achieve these aims have gotten better and better.

In adolescents, surgical treatment to straighten the spine usually depends on a procedure called an instrumented spinal fusion. In this procedure, a surgeon fastens rigid metal rods to the bones of the spine and also creates bone “bridges” that, over time, fuse previously separate bones into one strong bone.

Ultimately, the bone fusion locks the spine in its new, straightened alignment. The rods simply hold the spine in place as the bones fuse. Once fusion occurs, the rods are no longer necessary. As long as the rods are stable, though, additional surgery is not required to remove them. They can just be left in place.

Today, improvements in technology have made the rods more stable over the long term, meaning fewer repeat surgeries are required. Modern rods may also mimic the natural contour of the spine, an improvement in many cases over the straight rods, which were the only option for many years.

In younger kids, though, rigid rods that stay in place over the long term are actually not ideal. As these kids grow (and grow and grow), rigid rods that are fixed in place can themselves cause deformity, pain or compromised lung function. Modern techniques developed to handle this concern include rods that can be lengthened via surgery as a child grows, or magnetically controlled rods that can be lengthened from outside the body, without additional surgery.

In addition to these improvements on the tried-and-true methods, newer surgical techniques called compression techniques target individual bones of the spine. A single vertebra (bone of the spine) in a scoliosis curve has a wedge-like shape: The side on the outside of the curve is taller, and the side on the inside of the curve is “squashed.” Compression techniques squeeze the taller side of a single vertebra, restricting its growth and allowing the “squashed” side of the vertebra to catch up.

Nobody likes to hear that their kid may need scoliosis surgery. But doctors have been working to research and provide treatments tailored specifically to the physical needs of children and young adults. Today’s options for imaging scans, adjustable rods and compression techniques mean that doctors and patients have more good choices than ever before. And that means today’s kitchen-cabinet dental-floss connectors can more smoothly become tomorrow’s grandmas and rock stars.

Learn more about Dr. Richard Anderson on his bio page here.

Modern Surgical Management of Early Onset and Adolescent Idiopathic Scoliosis: Beauchamp EC, Anderson RCE, Vitale MG.

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