Treating idiopathic scoliosis in a very young child is a challenge. Whatever treatment is used must allow for growth and development because most of the children affected are less than three years old. They still have a lot of growing to do — not just the spine, but also the muscles, ribs, and internal organs. Fusing the spine (an effective treatment for other forms of scoliosis) is not an option until much later. The earliest fusion can be considered is around 10 years old.
Treatment can consist of bracing, body cast, or more recently, the Vertical Expandable Prosthetic Titanium Rib or VEPTR. Bracing is done using a rigid plastic orthosis that supports the thoracic, lumbar, and sacral spine. This type of bracing is called a thoracolumbosacral orthosis (TLSO). It is worn as close to 23 hours per day as possible with short breaks for bathing and skin care.
Casting requires surgery under general anesthesia. The child must be healthy with good lung function to have surgery. While the child is relaxed under the effects of the anesthetic, the spine is straightened as much as possible. A cast is applied over two layers of a protective material called stockinette. Every two months, the cast is removed and replaced until maximum correction of the curve is obtained. When the curve is decreased to less than 10-degrees, then a brace can be used instead.
The VEPTR also known as the titanium rib is a vertical titanium rod that can be expanded as the child grows (about every four to six months or so). The rod is curved to match the curve of the rib cage. The upper end of the rod is clamped around a rib above the spinal curve. The lower end is attached to a rib (or the pelvis) below the curve. As the child grows taller, the telescoping rod can be lengthened. The goal is to separate and support the chest, giving the lungs room to expand and grow. Each expansion procedure requires surgery and a four-to-seven day hospital stay.
Young children with flexible curves seem to respond the best to casting. The growing rod is a great idea but doesn’t seem to yield as good of results as casting. Rod failure is a potential problem. Sometimes the rod eats through the rib, requiring reattachment to another rib. On the positive side, any correction obtained with the rod system seems to hold and doesn’t slip back after the rod is removed.
Given the results of a recent study comparing results of these three treatment techniques for idiopathic scoliosis, surgeons at Shriners in Philadelphia suggest using casting for children whose curves are between 30 and 60 degrees (larger and stiffer). If the curves are larger than that, they may go from casting to the VEPTR system or directly to the VEPTR. The VEPTR has some advantages over other types of growing rods. Since it’s not attached directly to the spine, there is less risk that the spine will fuse itself. Care must be taken when placing the rod not to jam it up against a nerve in the brachial plexus, a collection of nerves that supply the neck and arms. If symptoms of nerve irritation or compression develop, tension on the rod can be reduced.