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Shaw KA, Miyanji F, Bryan T, Parent S, Newton PO, Murphy JS. Vertebral body tethering for Lenke 1A curves: the lumbar modifier predicts less optimal outcomes. Spine Deform 2024; 12:663-670. [PMID: 38340229 DOI: 10.1007/s43390-023-00815-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/23/2023] [Indexed: 02/12/2024]
Abstract
INTRODUCTION The addition of the L4 "AR" and "AL" lumbar modifier for Lenke 1A idiopathic scoliosis (IS) has been shown to direct treatment in posterior spinal fusion; however, its utility in vertebral body tethering (VBT) has yet to be evaluated. METHODS A review of a prospective, multicenter database for VBT in IS was performed for patients with Lenke 1A deformities and a minimum of 2 years follow-up. Patients were categorized by their lumbar modifier (AR vs AL). Less optimal VBT outcome (LOVO) was defined as a final coronal curve > 35°, lumbar adding-on, or revision surgery for deformity progression or adding-on. RESULTS Ninety-nine patients met inclusion criteria (81% female, mean 12.6 years), with 55.6% being AL curves. Overall, there were 23 instances of tether breakage (23.3%) and 20 instances of LOVO (20.2%). There was a higher rate of LOVO in AR curves (31.8% vs 10.9%, P = 0.01). Patients with LOVO had greater preoperative deformity, greater apical translation, larger coronal deformity on first erect radiographs, and less coronal deformity correction. Failure to correct the deformity < 30° on first erect was associated with LOVO, as was LIV selection short of the last touch vertebra (TV). Independent risk factors for LOVO included AR curves (OR 3.4; P = 0.04) and first erect curve magnitudes > 30 degrees (OR 6.0; P = 0.002). DISCUSSION There is a 20.2% rate of less optimal VBT following VBT for Lenke 1A curves. AR curves are independently predictive of less optimal outcomes following VBT and require close attention to LIV selection. Surgeons should consider achieving an initial coronal correction < 30 degrees and extending the LIV to at least the TV to minimize the risk of LOVO.
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Affiliation(s)
- K Aaron Shaw
- Department of Pediatric Orthopaedic Surgery, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Firoz Miyanji
- Department of Orthopaedic Surgery, BC Children's Hospital, Vancouver, BC, Canada
| | - Tracey Bryan
- Department of Orthopaedic Surgery, Rady's Children's Hospital, San Diego, CA, USA
| | - Stefan Parent
- Department of Orthopaedic Surgery, University of Montreal, Montreal, QC, Canada
| | - Peter O Newton
- Department of Orthopaedic Surgery, Rady's Children's Hospital, San Diego, CA, USA
| | - Joshua S Murphy
- Department of Pediatric Orthopaedic Surgery, CPG-Orthopaedics, Children's Healthcare of Atlanta Scottish Rite, Atlanta, GA, USA.
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Hori Y, Kaymaz B, da Silva LCA, Rogers KJ, Yorgova PK, Gabos PG, Shah SA. Differences in spine growth potential for Sanders maturation stages 7A and 7B have implications for treatment of idiopathic scoliosis. Spine Deform 2024; 12:621-628. [PMID: 38372941 PMCID: PMC11068661 DOI: 10.1007/s43390-024-00829-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/13/2024] [Indexed: 02/20/2024]
Abstract
PURPOSE This study aimed to clarify the differences in spine and total body height growth and curve progression between Sanders maturation stage (SMS) 7A and 7B in patients with adolescent idiopathic scoliosis (AIS). METHODS This retrospective case-control study involving patients with AIS at SMS 7 evaluated the differential gains in the spine (T1-S1) and total body height and curve progression between SMS 7A and 7B. A validated formula was used to calculate the corrected height, accounting for height loss due to scoliosis. A multivariable non-linear and logistic regression model was applied to assess the distinct growth and curve progression patterns between the SMS 7 subtypes, adjusting for potential confounders. RESULTS A total of 231 AIS patients (83% girls, mean age 13.9 ± 1.2 years) were included, with follow-up averaging 3.0 years. Patients at SMS 7A exhibited larger gains in spine height (9.9 mm vs. 6.3 mm) and total body height (19.8 mm vs. 13.4 mm) compared with SMS 7B. These findings remained consistent even after adjustments for curve magnitude. Non-linear regression models showed continued spine and total body height increases plateauing after 2 years, significantly greater in SMS 7A. More SMS 7A patients had curve progression over 10°, with an adjusted odds ratio of 3.31. CONCLUSION This study revealed that patients staged SMS 7A exhibited more spine and total body growth and a greater incidence of substantial curve progression than those at 7B. These findings imply that delaying brace discontinuation until reaching 7B could be beneficial, particularly for those with larger curves. LEVEL OF EVIDENCE Level III (Case-control study).
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Affiliation(s)
- Yusuke Hori
- Department of Orthopaedic Surgery, Nemours Children's Health, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Burak Kaymaz
- Department of Orthopaedic Surgery, Nemours Children's Health, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | | | - Kenneth J Rogers
- Department of Orthopaedic Surgery, Nemours Children's Health, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Petya K Yorgova
- Department of Orthopaedic Surgery, Nemours Children's Health, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Peter G Gabos
- Department of Orthopaedic Surgery, Nemours Children's Health, 1600 Rockland Road, Wilmington, DE, 19803, USA
| | - Suken A Shah
- Department of Orthopaedic Surgery, Nemours Children's Health, 1600 Rockland Road, Wilmington, DE, 19803, USA.
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Sullivan MH, Jackson TJ, Milbrandt TA, Larson AN, Kepler CK, Sebastian AS. Evidence-based Indications for Vertebral Body Tethering in Spine Deformity. Clin Spine Surg 2024; 37:82-91. [PMID: 37684718 DOI: 10.1097/bsd.0000000000001521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 06/21/2023] [Indexed: 09/10/2023]
Abstract
Posterior spinal fusion has long been established as an effective treatment for the surgical management of spine deformity. However, interest in nonfusion options continues to grow. Vertebral body tethering is a nonfusion alternative that allows for the preservation of growth and flexibility of the spine. The purpose of this investigation is to provide a practical and relevant review of the literature on the current evidence-based indications for vertebral body tethering. Early results and short-term outcomes show promise for the first generation of this technology. At this time, patients should expect less predictable deformity correction and higher revision rates. Long-term studies are necessary to establish the durability of early results. In addition, further studies should aim to refine preoperative evaluation and patient selection as well as defining the benefits of motion preservation and its long-term effects on spine health to ensure optimal patient outcomes.
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Froehlich S, Mittelmeier W, Desai B, Pandey SJ, Raddatz H, Lembcke B, Klinder A, Osmanski-Zenk K. Surgical Treatment of Adolescent Idiopathic Scoliosis with the ApiFix Minimal Invasive Dynamic Correction System-A Preliminary Report of a 24-Month Follow-Up. Life (Basel) 2023; 13:2032. [PMID: 37895414 PMCID: PMC10608253 DOI: 10.3390/life13102032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/28/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Adolescent idiopathic scoliosis (AIS) is a three-dimensional growth disorder. Corrective surgical procedures are the recommended treatment option for a thoracic angle exceeding 50° and a lumbar major curve of 40°. Over the past few years, dynamic growth modulation implants have been developed as alternatives to permanent fusion. The ApiFix system was designed as a 2D "posterior dynamic device" for curve correction. After implantation in a minimally invasive procedure, it uses polyaxial joints and a self-adjusting rod to preserve the degree of motion and to accommodate the patient's growth. It provides an effective method of controlling deformity and fills the gap between the conservative treatment of major curves that are >35° and the fusion procedure. The objective of the two-center cohort study was the analysis of the correction results of patients, who underwent surgical intervention with the ApiFix system. The inclusion criteria were AIS, Lenke type 1 or type 5, a major curve on bending films of ≤30°, and an angle of the major curve of between 35° and 60°. Postoperative radiograph data were obtained longitudinally for up to 24 months of follow-up and compared to preoperative (preop) values. For comparisons of the different time points, non-parametric tests (Wilcoxon) or paired t-tests for normally distributed values were used to analyze repeated measures. Overall, 36 patients (25 female and 11 male) were treated with the ApiFix system from April 2018 to October 2020. Lenke type 1 was identified in 21 (58%) cases and Lenke type 5 was identified in 15 (42%) cases. The average angle of the thoracic major curve for Lenke 1 was 43°. The preoperative lumbar major curve (Lenke 5) was determined to be 43°. Over a follow-up of 24 months, a correction of the major curve to an average of 20° was observed for Lenke 1 and that to an average of 15° was observed for Lenke 5. Lenke type 1 and type 5 showed significant changes in the major curve over the individual test intervals in the paired comparisons compared to the starting angle (Lenke 1: preop-24 months, 0.002; Lenke 5: preop-24 months, 0.043). Overall, 11 events were recorded in the follow-up period, that required revision surgery. We distinguished between repeated interventions required after reaching the maximum distraction length of the implant due to the continued growth of the patient (n = 4) and complications, such as infections or problems associated with the anchorage of the implant (n = 7). The results from the present cohort revealed a statistically significant improvement in the postoperatively measured angles of the major and minor curves in the follow-up after 24 months. Consequently, the results were comparable to those of the already established vertebral body tethering method. Alignment in AIS via dynamic correction systems in combination with a possible growth modulation has been a treatment alternative to surgical fusing procedures for more than a decade. However, the long-term corrective effect has to be validated in further studies.
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Affiliation(s)
- Susanne Froehlich
- Orthopedic Clinic and Policlinic, University Rostock Medical Center, 18057 Rostock, Germany; (W.M.); (B.L.); (A.K.); (K.O.-Z.)
| | - Wolfram Mittelmeier
- Orthopedic Clinic and Policlinic, University Rostock Medical Center, 18057 Rostock, Germany; (W.M.); (B.L.); (A.K.); (K.O.-Z.)
| | - Biren Desai
- Sana Dreifaltigkeits-Hospital Cologne, 50933 Köln, Germany
| | | | - Herbert Raddatz
- Orthopedic Clinic and Policlinic, University Rostock Medical Center, 18057 Rostock, Germany; (W.M.); (B.L.); (A.K.); (K.O.-Z.)
| | - Bjoern Lembcke
- Orthopedic Clinic and Policlinic, University Rostock Medical Center, 18057 Rostock, Germany; (W.M.); (B.L.); (A.K.); (K.O.-Z.)
| | - Annett Klinder
- Orthopedic Clinic and Policlinic, University Rostock Medical Center, 18057 Rostock, Germany; (W.M.); (B.L.); (A.K.); (K.O.-Z.)
| | - Katrin Osmanski-Zenk
- Orthopedic Clinic and Policlinic, University Rostock Medical Center, 18057 Rostock, Germany; (W.M.); (B.L.); (A.K.); (K.O.-Z.)
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Jackson TJ, Sullivan MH, Larson AN, Milbrandt TA, Sebastian AS. Controversies in Spine Surgery: Is Vertebral Body Tethering Superior to Selective Thoracic Fusion for Adolescent Idiopathic Scoliosis? Clin Spine Surg 2023; 36:291-294. [PMID: 37448175 DOI: 10.1097/bsd.0000000000001484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/17/2023] [Indexed: 07/15/2023]
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O'Donnell JM, Gornitzky AL, Wu HH, Furie KS, Diab M. Anterior vertebral body tethering for adolescent idiopathic scoliosis associated with less early post-operative pain and shorter recovery compared with fusion. Spine Deform 2023; 11:919-925. [PMID: 36809648 PMCID: PMC10261228 DOI: 10.1007/s43390-023-00661-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 02/04/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE While posterior spinal instrumentation and fusion (PSIF) for severe adolescent idiopathic scoliosis (AIS) is the gold standard, anterior vertebral body tethering (AVBT) is becoming an alternative for select cases. Several studies have compared technical outcomes for these two procedures, but no studies have compared post-operative pain and recovery. METHODS In this prospective cohort, we evaluated patients who underwent AVBT or PSIF for AIS for a period of 6 weeks after operation. Pre-operative curve data were obtained from the medical record. Post-operative pain and recovery were evaluated with pain scores, pain confidence scores, PROMIS scores for pain behavior, interference, and mobility, and functional milestones of opiate use, independence in activities of daily living (ADLs), and sleeping. RESULTS The cohort included 9 patients who underwent AVBT and 22 who underwent PSIF, with a mean age of 13.7 years, 90% girls, and 77.4% white. The AVBT patients were younger (p = 0.03) and had fewer instrumented levels (p = 0.03). Results were significant for decreased pain scores at 2 and 6 weeks after operation (p = 0.004, and 0.030), decreased PROMIS pain behavior at all time points (p = 0.024, 0.049, and 0.001), decreased pain interference at 2 and 6 weeks post-operative (p = 0.012 and 0.009), increased PROMIS mobility scores at all time points (p = 0.036, 0.038, and 0.018), and faster time to functional milestones of weaning opiates, independence in ADLs, and sleep (p = 0.024, 0.049, and 0.001). CONCLUSION In this prospective cohort study, the early recovery period following AVBT for AIS is characterized by less pain, increased mobility, and faster recovery of functional milestones, compared with PSIF. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jennifer M O'Donnell
- Department of Orthopaedic Surgery, University of California San Francisco, 505 Parnassus Ave MU 320W, San Francisco, CA, 94143, USA.
| | - Alex L Gornitzky
- Department of Orthopaedic Surgery, University of California San Francisco, 505 Parnassus Ave MU 320W, San Francisco, CA, 94143, USA
| | - Hao-Hua Wu
- Department of Orthopaedic Surgery, University of California San Francisco, 505 Parnassus Ave MU 320W, San Francisco, CA, 94143, USA
| | - Kira S Furie
- University of California San Francisco School of Medicine, San Francisco, CA, 94143, USA
| | - Mohammad Diab
- Department of Orthopaedic Surgery, University of California San Francisco, 505 Parnassus Ave MU 320W, San Francisco, CA, 94143, USA
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Mladenov KV, Pinnschmidt HO, Stücker R. Anterior Vertebral Body Tethering for Skeletally Immature Patients with AIS: Indication for Spinal Fusion at Skeletal Maturity Is Not Obviated in 60% of Cases. J Clin Med 2023; 12:3933. [PMID: 37373628 DOI: 10.3390/jcm12123933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
The role of anterior vertebral body tethering (aVBT) in obviating the need for spinal fusion in patients with AIS remains unclear, and a large amount of variation exists in the data among different studies. The present study aims to investigate and analyze what factors have a potential influence on aVBT outcome. Skeletally immature patients with AIS who underwent aVBT for scoliosis correction were followed up until skeletal maturity. The mean age at the time of surgery was 13.4 ± 1.1, and the mean follow-up time was 2.5 ± 0.5 years. The Cobb angle of the main curve was 46.6 ± 9° at the time of surgery and was significantly corrected to 17.7 ± 10.4° (p < 0.001) immediately postoperatively. A significant loss of correction was observed during the latest follow-up (Cobb angle 33.8 ± 18.7°; p < 0.001). An indication for spinal fusion at skeletal maturity was not obviated in 60% of the patients. The factors identified as having an influence on the outcome were preoperative bone age and the magnitude of the major curve. Patients with advanced bone age and larger curves were more likely to reach an indication for spinal fusion at skeletal maturity. In conclusion, no general recommendation for aVBT can be made for AIS patients. The method can be discussed as a treatment option in skeletally very immature preadolescent patients (Sanders Stadium ≤ 2) with a moderate Cobb angle (≤50°) who failed previous brace therapy.
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Affiliation(s)
- Kiril V Mladenov
- Pediatric Orthopedic Department, Altona Children's Hospital, Bleickenallee 38, D-22763 Hamburg, Germany
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany
| | - Hans O Pinnschmidt
- Center for Experimental Medicine, Institute for Medical Biometry & Epidemiology, University Medical Center Hamburg-Eppendorf, Chrisoph-Probst-Weg 1, D-20246 Hamburg, Germany
| | - Ralf Stücker
- Pediatric Orthopedic Department, Altona Children's Hospital, Bleickenallee 38, D-22763 Hamburg, Germany
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany
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Hammad AM, Balsano M, Ahmad AA. Vertebral body tethering: An alternative to posterior spinal fusion in idiopathic scoliosis? Front Pediatr 2023; 11:1133049. [PMID: 36999081 PMCID: PMC10043194 DOI: 10.3389/fped.2023.1133049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/24/2023] [Indexed: 04/01/2023] Open
Abstract
Introduction Skeletally immature patient with adolescent idiopathic scoliosis (AIS) whose curves continue to progress despite bracing should be treated surgically. Vertebral body tethering (VBT) is a non-fusion, compression-based, growth preserving alternative to posterior spinal fusion (PSF) based on the concept of 'growth modulation' to prevent possible functional complications secondary to fusion while correcting scoliotic deformity. This review aims to shed light on the indications of VBT, short- and medium-term outcomes, describe the surgical technique and associated complications, and to compare its efficacy to that of PSF. Methods A review of peer-reviewed literature on VBT as a surgical technique, its indications, outcomes, complications, and comparison with other surgical interventions to correct AIS was conducted in December 2022. Results Indications remain controversial and mainly include stage of skeletal maturity based on radiographic markers, curve location, magnitude and flexibility, and presence of secondary curve. Assessment of VBT clinical success should not be restricted to improvement in radiographic parameters but should include functional results and patient-centered outcomes, improved body image and pain, and durability of outcomes. In contrast to fusion, VBT seems to be associated with preserved spinal growth, shorter recovery, potentially better functional outcomes, less motion loss but possibly less curve correction. Discussion Yet still, with VBT there exists a risk of overcorrection, construct breakage or failure of procedure which require revision and at times conversion to PSF. Patient and family preferences must be accounted for acknowledging gaps in knowledge, attributes and drawbacks of each intervention.
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Affiliation(s)
- Ahmad M. Hammad
- Department of Orthopedics Surgery, American University of Beirut, Beirut, Lebanon
| | - Massimo Balsano
- Regional Spinal Department, University and Hospital Trust, Verona, Italy
| | - Alaaeldin A. Ahmad
- Department of Pediatric Orthopedic Surgery, Palestine Polytechnic University PPU, Hebron, Palestine
- Correspondence: Alaaeldin A. Ahmad
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