title: Apical and intermediate anchors without fusion improve Cobb angle and thoracic kyphosis in early-onset scoliosis.
abstract: BACKGROUND
  The main goal of treatment in early-onset scoliosis is to obtain and maintain curve correction while simultaneously preserving spinal, trunk, and lung growth. This study introduces a new surgical strategy, called the modified growing rod technique, which allows spinal growth and lung development while controlling the main deformity with apical and intermediate anchors without fusion. The use of intraoperative traction at the initial procedure enables spontaneous correction of the deformity and decreases the need for forceful correction maneuvers on the immature spine and prevents possible implant failures. This study seeks to evaluate (1) curve correction; (2) spinal length; (3) number of procedures performed; and (4) complications with the new approach.
  
  
  METHODS
  In the initial procedure, polyaxial pedicle screws were placed with a muscle-sparing technique. Rods were placed in situ after achieving correction with intraoperative skull-femoral traction. The most proximal and most distal screws were fixed and the rest of the screws were left with nonlocked set screws to allow vertical growth. The lengthening reoperations were performed every 6 months.
  
  
  METHODS
  Between 2007 and 2011, we treated 19 patients surgically for early-onset scoliosis. Of those, 16 (29%) were treated with the modified growing rod technique by the senior author (AH); an additional three patients were treated using another technique that was being studied at the time by one of the coauthors (CO); those three were not included in this study. The 16 children included nine girls and seven boys (median, 5.5 years of age; range, 4-9 years), and all had progressive scoliosis (median, 64°; range, 38°-92°). All were available for followup at a minimum of 2 years (median, 4.5 years; range, 2-6 years).
  
  
  RESULTS
  The initial curve Cobb angle of 64° (range, 38°-92°) improved to 21° (range, 4°-36°) and was maintained at 22° (range, 4°-36°) throughout followup. Preoperative thoracic kyphosis of 22° (range, 18°-46°) was maintained at 23° (range, 20°-39°) throughout followup without showing any substantial change. There was a 47 mm (range, 38-72 mm) increase in T1-S1 height throughout followup. The mean number of lengthening operations was 5.5 (range, 4-10). The mean T1-S1 length gain from the first lengthening was 1.18 cm (range, 1.03-2.24 cm) and decreased to 0.46 cm (range, 0,33-1.1 cm) after the fifth lengthening procedure (p = 0.009). The overall complication rate was 25% (four of 16 patients) and the procedural complication rate was 7% (seven of 102 procedures). We did not experience any rod breakages or other complications apart from two superficial wound infections managed without surgery during the treatment period. The only implant-related complications were loosening of two pedicle screws at the uppermost foundation in one patient.
  
  
  CONCLUSIONS
  In this preliminary study, the modified growing rod technique with apical and intermediate anchors provided satisfactory curve control, prevented progression, maintained rotational stability, and allowed continuation of trunk growth with a low implant-related complication rate.
authors: Istanbul Spine Center, Florence Nightingale Hospital, Abide-i Hurriyet Cad. No. 166, Sisli, 34381, Istanbul, Turkey, enercan@yahoo.com.
authors: Meric
authors: M
authors: Enercan
authors: Sinan
authors: S
authors: Kahraman
authors: Erden
authors: E
authors: Erturer
authors: Cagatay
authors: C
authors: Ozturk
authors: Azmi
authors: A
authors: Hamzaoglu
mesh_terms: D001696:Biomechanical Phenomena; D001863:Bone Screws; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007738:Kyphosis / Q000175:diagnosis / Q000601:surgery*; D008168:Lung / Q000254:growth & development; D008297:Male; D011183:Postoperative Complications / Q000209:etiology; D011474:Prosthesis Design; D011859:Radiography; D012600:Scoliosis / Q000175:diagnosis / Q000601:surgery*; D013123:Spinal Fusion / Q000009:adverse effects / Q000295:instrumentation*; D053441:Suture Anchors; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000254:growth & development / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome