Is Brace Treatment Effective?
One of the biggest differences between congenital and idiopathic deformities is that braces are ineffective in congenital deformities. To re-establish balance, sometimes the body forms a second curve above and/or below the curves that were caused by congenital abnormalities. These curves may show a progression over time, and even exceed the severity of the initial curves. Braces may be used in these patients for controlling or delaying the progression of the secondary curve.
When is Surgery Necessary? Is There an Age Limit?
The only effective treatment is to slow down or stop the asymmetric growth of the abnormal vertebra. This is most frequently accomplished by limited spinal fusion. It may be necessary to perform surgery at a young age to control a progressive deformity. Parents understandably fear that fusion may prevent trunk growth as growth of the fused part is stopped. Although true to a certain extent, trunk height may not be regained by correcting a deformity after growth ends. Besides, delaying surgical treatment just because of this fear may result in future significant health problems.
While surgery can be carried out at any age, it may be delayed until the patient is age 1 or older. After this age, if a surgical procedure is mandatory it should be performed without further delay. Despite early surgery, if the curve is not adequately treated with the initial operation, further procedures may be necessary. In actively growing children, fusion from both the front and back may be needed to manage the curve. These methods are applicable to both scoliosis and kyphosis. Either autograft (from the patient) or allograft (from a donor) bone, bone substitutes, or a multitude of these sources may be employed.
If associated problems in other organs arise, address themseparately. Spinal cord-related issues, however, should be treated simultaneously with spinal curves. Some spinal cord abnormalities do not require surgical treatment while others may—either before or during surgical treatment of the curve.
Treatment Options
- Controlled Observation: This involves physical examination and X-rays at certain intervals—including post-surgery—and continous observation without any specific treatment until skeletal maturity occurs.
- Surgical treatment: Most contemporary treatment methods in growing children involve trying to gain control of the curve without a spinal fusion or fusion of only a limited area.
- Limited fusion operations:
- Hemivertebrectomy: In some conditions, the curve may be eliminated by removal of the abnormal vertebra. (Figure 4). Although this operation can be performed by approaching only from the back, some surgeons prefer to approach from both the back and front. After surgery, a trunk cast is applied for three to six months.
- Management of the curve with growing rods: In very small children, correction can be achieved by screws placed above and below the curve and connected to each other with rods. A periodic lengthening is then made every six months to control the curve. Finally, a fusion procedure is applied when skeletal maturity is reached. This preserves and provides growth of the lungs and thoracic cage to normal dimensions.
- Magnetically controlled growing rods, which we recently began to use, can be lengthened in the clinic without the need for repeated operations.
- Operation for Expanding the Thoracic Cage (VEPTR): Some patients with congenital scoliosis have associated rib abnormalities and inadequate chest development. Rods placed into the thoracic cage in these children enable both correction of the thoracic cage abnormality and control of the curve without a fusion. Peridodic lengthening every six months may be necessary in these patients.
- Instrumentation and fusion, Osteotomies: The most difficult congential scoliosis types to treat are neglected curves above 70-80 degrees. In such curves, removal of the deformed spine or correction without removal and fixation of the vertebra with titanium rods and screws are possible.
Consider numerous factors when selecting the best procedure for you or your child. Discuss available options with your orthopedic surgeon.
Summary
Congenital spinal deformities occur due to asymmetric growth of the abnormal vertebrae present from birth. Although some of affected individuals will not have a severe curve, curves in other individuals may reach significant levels when not diagnosed or treated appropriately. Generally, it’s necessary to observe the behavior of the deformity over a time. When the deformity progresses, the only effective treatment is surgery.
Numerous surgical options exist. Surgery is performed when a decision is made to control the curve, and this decision can be made when the child is very small. The widespread notion that a child should be operated on during maturity is absolutely wrong. This may cause the curve to severely progress to a point where it is no longer operable. Today, spinal surgery can be applied to children as young as 1 years old.
All patients with congenital spinal deformities should be, at least, under supervision until growth is complete.