This document discusses early onset scoliosis (EOS) and various treatment options. EOS is defined as scoliosis beginning before age 5 or 10. Treatment options include observation, bracing, casting, growing rods, VEPTER, and fusion surgery. Growing rods and VEPTER involve periodic lengthening to allow continued spine and lung growth while correcting the curvature. Magenetically controlled growing rods are a newer option that can be lengthened in the office without surgery. Both have benefits but also risks like infection and premature fusion. The goals are to improve spine and lung development while avoiding early fusion when possible for EOS patients.

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4. Early onset scoliosis (EOS)
 It is defined as scoliosis that starts before
the age of 5th year.
 Some other scientists defined EOS as
scoliosis that starts before the age of 10th
years, regardless the cause of the
deformity.
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5. 5
Allows spine growth and lung
development
EOS is different from late onset
scoliosis

8. Cause of EOS
Congenital
Failure of formation
Failure of segmentation
Mixed
Neuromuscular
Syndromic
e.g. Marfan’s or Morquios
syndromes
Idiopathic
unclassified

9. Vitale classification of EOS

10. Treatment options of EOS
 Standard conservative interventions that include:
• Observation
• Physical therapy
• Bracing
• Casting
 These options are rarely curative and only indicated:
o In mild curves
o To delay early surgery

11. Surgical management of EOS
2-Non-fusion surgery
Results in negative pulmonary
consequences and most
surgeons now use fusion as the
last resort for EOS.
1-Fusion surgery

12. 2-Non-fusion surgery
Distraction based
Growing rods
(spine based)
VEPTR
(rib based )
Magnetically controlled
growing rods
Guided growth
Luque-trolley
Shilla technique
Tension based
Tether
Staples

13. Advantages of non-Fusion options
• When fusion is used the curve of the spine is
improved but growth stops
• Fusionless treatments are important for children
especially those under 10
• Children under 5 still have up to 12.5 cm of vertical
growth
• Lungs do not fully develop till about 8 years old
• Fusion does work for patients who are fully grown

14. Common non fusion methods
Growing rods
• Traditional
growing rods
• Magnetically
controlled
growing rods
VEPTER
• Directly treats
TIS
• Indirectly
treats EOS
Tethering
• Depends on
epiphysiodesis
of the convex
side
Shila technique
 All techniques have their limitations and complications including:
• Rod breakage
• Infection
• Skin problems due to protruding hardware
• Premature fusion

15. Growing Rods
• It was first popularized in 1984 (Moe et al., 1984).
• Since then many generations were popularized:
o The rods are implanted at the index surgery
o Initial lengthening is done.
o May obtain up to 50% correction of the curve.
• This is followed by repeated lengthening every 6 months till
reaching near maturity where definitive fusion can be done
safely.
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16.  Growing rods may be:
• Spine to spine
• Pelvis to spine
• Spine to ribs
• Pelvis to rib
Either of these may be magnetically controlled or Tradional
growing rods.
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17. Growing rods
Indication for growing rods include
- Significant axial spine growth potential
remaining
- Progressive deformity more than 50°
- Spinal deformity that is flexible or can be
made flexible after a limited anterior release

18. Growing rods
-The rods are implanted at the index surgery
and initial lengthening is done which may
obtain up to 50% correction of the curve
-This is followed by repeated lengthening every
6 months till reaching near maturity where
definitive fusion can be done safely

19. Pros and Con of Dual Growing Rod
• One of the most efficient
ways of treating EOS
• Opens up the thorax
preventing many future
pulmonary issues
• Continues to allow for
growth
• Each patient must receive
an invasive surgery every
six months for a span of a
few years (usually till age
10 for girls and age 13 for
boys)
• This leads to more
opportunities to contract
some kind of infection
• Very physically and
psychologically grueling
advantages disadvantages

22. Magnetically controlled growing
rod
This is a newly developed technique the idea
of which depends on
-The (interaction between the internal
implant magnets and external remote
control )
-As other growing rods lengthening is done
periodically

23. Magnetically Controlled Growing Rods
(MCRG)
• Attached in basically the same way as the dual
growing rods
• Lengthened during quick follow-ups in the office
without any invasive surgery every 3-4 months
• This allows for the curve to be managed until their
skeletal structure has matured enough for spinal
fusion
• The EOS is then tracked using radiographs
[6]

25. MCGR
• This technique is new in the United States so
not many hospitals are doing it
• The first one was completed in Washington DC
on a ten year old boy
• The requirements are a skeletal age of 10
years old or younger and a Cobb angle of 50
degrees or greater
• Approved by the FDA in February of 2014

28. Which is better
Many studies compared the effectiveness of
both traditional and magnetic rods

29. Multicenter comparative study results
Major Curve Correction
• Very similar with MCGR and TRG patients
• Overall it was 32% and 33%
Spinal Height(T1-S1)
• MCGR- 8.1mm/year
• TGR- 9.7mm/year
• This is not considered significantly different
Thoracic Height(T1-T12)
• Increase 1.5cm/year in MCGR
• Increase 1.9cm/year in TRG

30. Discussion
MCGR →no proper sagittal plane to contouring
because of the actuator’s position
TRG →better results when looking at numbers but
regarding surgeries and complications are it is not
ideal

31. VEPTR
This procedure treats thoracic insufficiency by
-Lengthening and expanding the constricted
hemithorax
-Allowing growth of the thoracic spine and rib
cage
-Correcting scoliosis with no need for spine
fusion

32. VEPTR
Similar to
Growing rods
preserve
Correction and
lengthened
every 6 months

33. Goals of treatment
-Improve thoracic volume and function
-Establish thoracic symmetry by lengthening the
concave, restricted hemithorax
-Avoid growth-inhibiting procedures
-Maintain these improvements throughout the
patient’s growth
-Correct scoliosis
-Maintain spinal alignment and growth

34. Indications
-Primary Thoracic Insufficiency Syndrome (TIS)
-Progressive thoracic congenital scoliosis with concave
fused ribs
-Progressive thoracic congenital scoliosis with flail
chest due to absent ribs
-Progressive thoracic congenital, neurogenic or
idiopathic scoliosis without rib abnormality

35. Indications
-Hypoplastic thorax syndrome,
-Jeune’s syndrome,
-Jarcho-Levin syndrome,
-Cerebro costal mandibular syndrome,
-Others
-Congenital chest wall defect

36. Indications
-Acquired chest wall defect,
-Chest wall tumor resection
-Traumatic flail chest
-Surgical separation of conjoined twins
-Secondary Thoracic Insufficiency Syndrome due to
lumbar kyphosis (non gibbus)

38. Contraindications
-Inadequate strength of bone (ribs/spine)
-Absence of proximal and distal ribs for attachment
-Absent diaphragmatic function
-Inadequate soft tissue for coverage
-Age beyond skeletal maturity or below 6 months
-Infection at the operative site

39. Construct Options
-Rib-to-Rib

40. -Rib-to-Lumbar Lamina

41. -Rib-to-Ilium

42. Complications of VEPTR
-Brachial plexus problems
-direct trauma or
-impingement from an implant placed too cephalad
-compression of the plexus between upper chest
wall and the clavicle
-Campbell advised the upper rib cradle should remain
medial to the scalene muscles and never cephalad
to the second rib

43. -Chest wall problems
-Chest wall scarring
-ribs autofusion
-Shoulder problems
-Shoulder stiffness
-spontaneous fusion of the scapula to the VEPTR
device and rib cage

44. Take home message
-Distraction based surgery is main stay for
management of EOS
-Many options are available
-No one free from complications
-Every patient should get his optimal option

45. Many thanks
Amer Alkot