When it comes to scoliosis in very young children, things are changing in the world of pediatric orthopedics. The traditional treatment with spinal fusion, casting, and bracing is being replaced by growing rods and devices that help the chest wall expand with good spinal alignment.
Those are the main points taken from an on-line survey completed by 195 pediatric orthopedic surgeons who are members of the Pediatric Orthopaedic Society of North America (POSNA).
Early onset scoliosis (EOS) is a challenging problem. Rapidly progressive spinal curves in young children (age five years old and younger) can compromise lung development. When curvature of the spine measures 20 degrees, the ribs start to rotate.
With large curves (60 degrees or more), spinal alignment is severely compromised and along with it, the chest. Decreased chest space for the lungs and other organs in the chest and abdomen get compressed or squashed together. Movement, function, and growth of the organs are all affected. At that point, the health and in some cases, even the life of the child is in danger.
Treatment varies depending on two major factors: the age of the child and the type of clinic or hospital where treatment is delivered. For example, children under the age of two are more likely to be treated conservatively (nonoperative care). This is true even if there is a severe curve. But by age five, surgeons choose surgery more often to treat severe curves.
Children receiving care at a pediatric orthopedic specialty hospital are more likely to be placed in a series of casts designed to gradually straighten the spine as much as possible. Care received at a university-based or private pediatric hospital is more likely to be with bracing.
Some of the treatment choices do depend on the equipment present in various settings. Casting tables, halo traction, and customized devices that help regulate the amount of traction force applied aren't always available. Most of the surgeons who responded to this survey had the necessary equipment and made use of it.
Many surgeons today have taken advanced training in the use of growing rod technology. Just as the name implies, growing rods placed along the spine straighten the curve and can then be lengthened as the child grows. Growing rod techniques are a great improvement for young, growing children over the previous approach of fusion, which can stop growth.
Only about 20 per cent of the membership of this group responded to the survey. That's only one out of every five pediatric orthopedic surgeons. The responses to questions asked may be biased by those who chose to participate.
For those who did reply, the most common treatment approach to early onset scoliosis was bracing (89 per cent), followed by casting (62 per cent), and growing rods (64 per cent). Chest expansion devices (39 per cent) and halo traction (27 per cent) were clearly used much less often.
The intent of treatment for early onset scoliosis (EOS) is to keep the spine as straight as possible using nonoperative approaches until fusion can be done. Serial casting works better for younger children. Older children may need halo-gravity traction first before casting.
Growing spine- and chest-wall surgeries do involve surgery but still make it possible to delay fusion while the child is growing. The authors summarize all of their findings by saying that there aren't enough studies to truly show what works best for each level of severity of scoliosis.
Surgeons may be basing their treatment choices on what is available at their particular center. The gradual move toward greater use of surgery over the last 10 to 15 years may be swinging back toward conservative care.
It may turn out that casting and bracing are more effective and less problematic because complications from growing and expansion techniques can result in worse outcomes. Each child should be evaluated individually and decisions made in the best way possible with the information currently available.
Reference: Nicholas D. Fletcher, MD, et al. Current Treatment Preferences for Early Onset Scoliosis: A Survey of POSNA Members. In Journal of Pediatric Orthopaedics. April/May 2011. Vol. 31. No. 3. Pp. 326-330.