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.
Idiopathic scoliosis is a curvature of the spine with no known cause. By definition, the curve is at least 20 degrees. Boys are affected more often than girls and a left-sided curve is the rule rather than the exception. It might be said that most children with idiopathic scoliosis outgrow this condition, as it seems to resolve in up to 90 per cent of children.
Treatment can consist of bracing, body cast, or more recently, the Vertical Expandable Prosthetic Titanium Rib or VEPTR. Bracing was done using a rigid plastic orthosis that supported 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 breaks for bathing and skin care.
Casting required surgery under general anesthesia. While the child was relaxed under the effects of the anesthetic, the spine was straightened as much as possible. The cast was applied over two layers of a protective material called stockinette. Every two months, the cast was removed and replaced until maximum correction of the curve was obtained. When the curve was decreased to less than 10-degrees, then a brace could 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 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.
Which treatment option works best: casting, bracing, or the expandable rod? How does the surgeon know what to choose? Pediatric orthopedic surgeons from the Shriners Hospital in Philadelphia offer their thoughts on this subject. They used the results of 31 children treated with one of these three methods. Standard Cobb angle measurements from X-rays were used to determine the degree of curvature. Before and after measurements were taken for each child.
Only children with idiopathic scoliosis and no other deformities or known cause of the scoliosis were included in the study. Ages ranged from three months up to seven years of age. Slightly more than half the group was put in a brace. Ten children received a body cast, which was changed as the spine straightened up. They call this approach serial casting. Another 10 had the VEPTR device implanted. Each expansion procedure required surgery and a four-to-seven day hospital stay.
After comparing measurements before and after for each procedure and comparing the results of one procedure to another, here’s what they found:
results, others worse, but most of the children got around this much correction.
largest curves seemed to respond the best to the titanium rod.
Other results of importance included the fact that children in casts were the most likely to suffer complications, mostly skin irritation. The orthosis (brace) could be removed everyday to look for skin problems and treated daily. Since the cast was only removed every four to six months, finding areas of skin irritation was more difficult and more progressed by the time it was discovered.
The idea that casting works best for idiopathic scoliosis has been shown by other researchers as well. 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 this study, the authors 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.
Bracing just doesn’t seem to work well. Because the brace can be removed, patient cooperation isn’t all it should be. Bracing seems to work best when it is a follow-up treatment to maintain successful results from casting or VEPTR. The brace can be discontinued when the spine correction holds steady for six months’ time.
Since some of the patients in braces really did have good results, it’s possible they either wore it as was intended or there is a subgroup of patients who do respond well to bracing. Future studies might be able to sort this all out as well as look at all three treatment options from a long-term perspective. Ideally, surgeons would like to identify subgroups of patients who respond well to each treatment technique and use each approach accordingly.