Surgical management of idiopathic scoliosis is based on the natural history of this spinal disorder and on the likelihood of developing a worsening deformity. Anterior surgical treatments continue to evolve and provide advantages over posterior procedures in specific instances.
Open and thoracoscopic anterior approaches allow direct access to the anterior stabilizing structures of the spine, enable mobilization of a rigid deformity, and provide a large surface area for arthrodesis. Thoracoscopic procedures provide a more cosmetically appealing alternative to a large midline posterior or anterolateral thoracotomy scar.
Although the indications and contraindications for anterior versus posterior surgical intervention (for thoracic and thoracolumbar curve patterns) have been defined to some degree, there remains appropriate flexibility in the decision-making process, allowing the surgeon to make an optimal recommendation for each patient based on surgeon experience and patient needs.
Scoliosis is the most common disorder of the spine that is encountered by pediatricians and pediatric orthopaedic surgeons. Scoliosis can alter the physical appearance of the affected individual dramatically, and it has both physiological and psychological impact. Depending on its severity and on the skeletal age of the child, scoliosis is managed by close observation, bracing, and/or surgery.
- Idiopathic: unknown, familial, neurologic
- Key Point: need to rule out other causes
- Secondary causes: inflammatory, tumor-Osteoid osteoma, NF, leg length discrepancy (LLD)
- Neurologic causes: ethered cord, syrinx
- Connective tissue abnormalities: Marfans, Ehlers-Danlos, and homocystinuria
There are three options for management of idiopathic scoliosis: observation, bracing, and surgical correction. Most cases of scoliosis are detected when the curvature is mild or moderate, and are treated successfully with non-operative management alone.
Observation. For curves between 10° and 29° and in the absence of progression, observation alone is recommended. Bracing is indicated for skeletally immature patients who have curves greater than 30°. In some smaller curves, we occasionally initiate brace treatment if rapid progression has occurred.
Surgery is considered for curves greater than 40° in skeletally immature patients, and for curves greater than 50° in skeletally mature patients. In selected patients with curves of lesser magnitude than these stated criteria, physical deformity may be substantial enough to warrant surgery. These are patients who have large rib prominences, torsal decompensation, shoulder obliquity, or pelvic obliquity.
Families frequently inquire as to whether exercise, posture, mattresses, shoes, or backpacks cause or contribute to scoliosis. With a high level of certainty, it appears that there is no relationship between any of these factors and scoliosis incidence or progression. Nonetheless, modifications (e.g., a properly loaded backpack) may improve secondary pain or discomfort. Electrical stimulation therapy has been shown to be ineffective halting or reversing scoliosis, and consequently, it has been abandoned in scoliosis treatment.
Bracing. Bracing is recommended for skeletally immature individuals with curves between 30° and 40°. The goal of bracing is to diminish or halt progression of scoliosis, and it is the only accepted non-surgical treatment modality (Figure 4). An underarm thoracolumbosacral orthosis (TLSO) is currently the most commonly prescribed brace for idiopathic scoliosis (Figure 5).
This lower profile brace is more easily concealed that the higher profile Milwaukee brace used commonly in the past. The design of the TLSO lessens the negative psychosocial impact of brace wear in adolescents, and consequently it has a higher likelihood of achieving patient compliance.
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