Scoliosis in Adolescents: The Best Chance to Avoid Surgery & the Best Treatment, the First Time

Published on

Orthopaedics Update

Idiopathic scoliosis side-by-side xray For more than a generation, the gold standard in treatment for adolescent idiopathic scoliosis – the most common spinal deformity in the world – has been spine deformity correction with posterior spinal fusion.

At Children’s Hospital of Philadelphia (CHOP), where the Division of Orthopaedics has been twice recognized as No. 1 in the nation by U.S. News & World Report’s Honor Roll of Best Children’s Hospitals, a dedicated team is investigating treatment options for adolescent patients with idiopathic scoliosis.

“Our goal is always to provide a patient with the best chance not to need surgery, and in the event they do, our goal is to do the safest and best possible surgery, done right the first time,” says Keith D. Baldwin, MD, MPH, MSPT, attending surgeon in the Division of Orthopaedics and one of a team of outstanding surgeons in the Spine Program. “But just because one treatment is successful for many, doesn’t mean it’s ideal for all. We continue our research efforts with the goal of being able to provide each child the optimal treatment for their specific condition.”

Read on for recent research highlights contributing to this body of work.

Spinal tethering as an alternative to spinal fusion

Led by Patrick J. Cahill, MD, CHOP was the first institution to study anterior vertebral body tethering (AVBT), under an FDA-approved protocol, as a treatment for idiopathic scoliosis. In certain curve patterns in children with significant growth remaining, AVBT can treat surgical magnitude curves without spinal fusion (fusing bones together). During AVBT, screws are placed on the convex side of the spinal curve, then a rope-like device (the tether) is secured along the side of the vertebrae and pulled taut. When implanted, the device partially corrects the spinal deformity, then as the child grows, the tether can guide growth leading to some further correction in the months after surgery.

While AVBT presents a promising advance, research and data is still evolving. When CHOP researchers compared outcomes vs. with those of traditional posterior spinal fusion (PSF) surgery, AVBT is associated with a higher revision rate and complication rate than PSF at three years follow up. For that reason, based on current data available, researchers recommend “that while a potential fusionless treatment for adolescent idiopathic scoliosis merits excitement, clinicians should consider AVBT with caution.”

While AVBT and other fusionless solutions to scoliosis represent an exciting area of research, the current patient population for which this fusionless solution represents a favorable risk benefit ratio is unclear. At the 2021 International Congress of Early Onset Scoliosis, John “Jack” M. Flynn, MD, congress program director and chief of CHOP’s Division of Orthopaedics, dedicated a day of the conference to explore and identify who, when, why and how AVBT fits into the treatment algorithm for pediatric scoliosis patients. At the current time, we believe posterior spinal fusion remains the most predictable and reliable option for most children with scoliosis, but indications for AVBT are being refined and techniques are being improved.

Read more from JBJS Open Access: “Complications, Reoperations, and Mid-Term Outcomes Following Anterior Vertebral Body Tethering Versus Posterior Spinal Fusion: A Meta-Analysis.

Use of CT navigation to place screws during spine surgery

Dr. Flynn pioneered the use of CT navigation for pediatric spinal deformity surgery more than 15 years ago. Since that time, CHOP has been a leader in navigated pediatric spinal fusion surgery. CHOP clinicians – led by Dr. Baldwin and Jason B. Anari, MD, pediatric orthopaedic surgeons who specialize in the treatment of spine disorders – recently performed a meta-analysis on whether intraoperative CT navigation could improve the accuracy of pedicle screw placement, improve long-term outcomes, and reduce complications for patients.

14 year old female with 65 degree thoracic idiopathic scoliosis, before and after spinal fusion using CT navigation for screw placement 14 year old female with 65 degree thoracic idiopathic scoliosis, before and after spinal fusion using CT navigation for screw placement. Screw placement during scoliosis surgery is critical due to the proximity of vital structures. Study authors found that screws placed under CT navigation were twice as likely to be perfectly placed using this technology. The team has also found there is no significant difference in radiation imparted when using this method, which historically has been thought of as a limitation of this approach.

Read more from Spine Deformity: “Does Intraoperative CT Navigation Increase the Accuracy of Pedicle Screw Placement in Pediatric Spinal Deformity Surgery? A Systematic Review and Meta-Analysis.

Using skeletal maturity to create a model for assessing risk of scoliosis progression

A diagnosis of scoliosis can cause anxiety, even though most scoliosis can (and should) be treated without surgery. To this end, CHOP clinicians also sought to create a model that would predict a patient’s risk of curve progression – and ultimate need for surgery – based on modern non-operative treatment. The study retrospectively reviewed the curve size, hand radiographs, and follow-up through skeletal maturity for more than 600 patients with adolescent idiopathic scoliosis (AIS), over a three-year period.

Results showed that when following CHOP’s standard of care for AIS, progression to surgery is more than 80% predictable using curve size and skeletal maturity at presentation. These results can serve as a valuable reassurance for families and guidelines for referring providers regarding a patient’s risk of progression and ultimate risk of needing further treatment. CHOP’s Spine Program and Dr. Baldwin received a grant from the Scoliosis Research Society to perform a prospective multicenter study to assess these factors, along with brace adherence, to determine the baseline risk of curve progression and if risk can be modified so more children can be successfully treated non-operatively. Prospective enrollment is currently underway.

Read more from the Journal of Pediatric Orthopaedics: “Risk of Scoliosis Progression in Nonoperatively Treated Adolescent Scoliosis Based on Skeletal Maturity.

An informed approach to counseling patients

Information gathered from studies like these can be used to help orthopaedic physicians assess the risk of severe spinal curve progression and the likelihood a patient will require surgery. Clinical and research leaders at CHOP continue to explore new, cutting-edge treatments, as well as refine existing treatments, to improve outcomes for all patients with idiopathic scoliosis.

“We’re constantly looking for ways to improve the quality of our patients’ lives,” says Dr. Anari. “We are always available for a consultation about a patient, and to partner with other providers to achieve the best possible outcomes for children and teens with scoliosis.”

To discuss a patient, review testing or explore treatment options, please contact Orthopaedic Nurse Navigator Maribeth Magarity, MSN, RN, at 215-590-1527 or use our online second opinion form.

Next Steps
Teenaged girl stretching before a run

Why Choose the Spine Program

The Spine Program is a cornerstone of CHOP’s Division of Orthopaedics, which is top ranked in the nation.

mother hugging son

Would you like a second surgical opinion from a CHOP expert?

Our referral nurse navigator can give your family timely access to world-renowned pediatric orthopaedic surgeons in every specialty.

You Might Also Like
Kristi and Dr. Baldwin

A Turning Point

Scoliosis surgery at CHOP allowed Kristi to keep up her active lifestyle in ways she never thought possible.

patient with doll wearing brace

Bracing for Scoliosis

Emma’s diligence in adhering to her bracing treatment plan for scoliosis produced an amazing outcome.

Children doing stretching exercises

Scoliosis: Early Detection Matters

When scoliosis treatment is delayed, spine curvature can advance and make treatment more challenging.