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STUDY DESIGN: Retrospective review.

OBJECTIVES: To report the feasibility, safety, and utility of vertebral body stapling without fusion as an alternative treatment for adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA: The success rate of brace treatment of adolescent idiopathic scoliosis ranges from 50% to 82%. However, poor self-image and brace compliance are issues for the patient. An alternative method of treatment such as a motion-preserving vertebral body stapling to provide curve stability would be desirable.

METHODS: We retrospectively reviewed 21 patients (27 curves) with adolescent idiopathic scoliosis treated with vertebral body stapling. Patients were immature as defined by Risser sign <or=2.

RESULTS: The concept of vertebral body stapling of the convex side of a patient with adolescent idiopathic scoliosis is feasible. The procedure was safe, with no major complications and three minor complications. One patient had an intraoperative segmental vein bleed resulting in an increased estimated blood loss of 1500 cc as compared to the average estimated blood loss of 247 cc for all patients. One patient had a chylothorax and one pancreatitis. No patient has had a staple dislodge or move during the follow-up period (mean 11 months, range 3-36 months), and no adverse effects specifically from the staples have been identified. Utility (defined as curve stability) was evaluated in 10 patients with stapling with greater than 1-year follow-up (mean 22.6 months) and preoperative curve <50 degrees. Progression of >or=6 degrees or beyond 50 degrees was considered a failure of treatment. Of these 10 patients, 6 (60%) remained stable or improved and 4 (40%) progressed. One of 10 (10%) in the stapling group had progressed beyond 50 degrees and went on to fusion. Six patients required stapling of a second curve, three as part of the primary surgery, and three as a second stage, because a second untreated curve progressed. The results need to be considered with caution, as the follow-up is still short.

CONCLUSIONS: The data demonstrate that vertebral body stapling for the treatment of scoliosis in the adolescent was feasible and safe in this group of 21 patients. In the short-term, stapling appears to have utility in stabilizing curves of progressive adolescent idiopathic scoliosis.

Originally published by:Spine (Phila Pa 1976). 2003 Oct 15;28(20):S255-65.

Betz RR, Kim J, D'Andrea LP, Mulcahey MJ, Balsara RK, Clements DH.

Shriners Hospitals for Children, Philadelphia, PA 19140, USA. This e-mail address is being protected from spambots. You need JavaScript enabled to view it

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Thirty-nine consecutive patients have had vertebral body stapling of 52 curves (26 patients with one curve stapled and 13 with two). For the group with patients who were 8 years or older with less than 50 degrees preoperative curve and a minimum 1-year followup, coronal curve stability was 87% when defined by progression less than or equal to 10 degrees . Fusion was necessary in two patients. No curves less than 30 degrees at the time of stapling progressed greater than or equal to 10 degrees . Major complications occurred in one patient (2.6%, diaphragmatic hernia) and minor complications occurred in five patients (13%). Further followup of the patient cohort and further research into efficacy and indications are warranted.

Originally published by:

Clin Orthop Relat Res. 2005 May;(434):55-60.

Betz RR, D'Andrea LP, Mulcahey MJ, Chafetz RS.

Shriners Hospitals for Children, Philadelphia, PA, USA. This e-mail address is being protected from spambots. You need JavaScript enabled to view it

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STUDY DESIGN: Absolute and relative growth modulation of apical spinal segments were measured during creation and correction of an experimental scoliosis in a goat model.

OBJECTIVE: To differentiate relative and absolute changes in growth on the concavity and convexity of an experimental scoliosis treated with anterior vertebral stapling.

SUMMARY OF BACKGROUND DATA: The creation and correction of vertebral wedge deformities have been previously described in a rat tail model using external fixation as well as in a goat model using anterior vertebral body stapling.

METHODS: Progressive, structural, scoliotic curves convex to the right in the thoracic spine were created in 14 Spanish Cross-X female goats using a posterior asymmetric tether. After 7-13 weeks, all tethers were removed, and goats were randomized into stapled (n = 8) and untreated (n = 6) groups. Stapled goats underwent anterior vertebral stapling with 4 shape memory alloy staples (Medtronic Sofamor Danek, Memphis, TN) along the convexity of the maximal curvature. All goats were observed for an additional 7-13 weeks. There were 12 additional goats matched for age, sex, and weight used as growth controls throughout the study. Serial radiographs were used to document progression or correction of the maximal scoliotic deformity, and changes in relative and absolute growth at the apical spinal segment T9-10 (2 adjacent vertebrae and the intervening disc).

RESULTS: All tethered goats had progressive, structural, scoliotic curves of significant magnitude during the tethering period (average 61.4 degrees, range 49 degrees to 73 degrees) (P = 0.001). There was 1 goat from each group eliminated from the study because its apical spinal segment did not match the T9-10 level used to establish normal growth in controls. During the treatment period, stapled goats had a correction of -6.9 degrees (P = 0.03), whereas untreated goats had little change (-1.4 degrees). Apical spinal segment wedging progressed in all tethered goats, from 11.1 degrees to 22.4 degrees, during the tethering period (P = 0.001). During the treatment period, wedging corrected -2.2 degrees (range 22.5 degrees to 20.3 degrees) in the stapled goats but progressed +3.5 degrees (range 22.3 degrees to 25.8 degrees) in the untreated goats (P < 0.05). Apical spinal segment growth in all tethered goats was decreased on the concavity by 78% and increased on the convexity by 33% when compared to growth controls (P < 0.001). During the treatment period, growth on the concavity of the apical spinal segment of the stapled goats was decreased by 10% but increased in the untreated goats by 37% when compared to growth controls. On the convexity, apical spinal segment growth at T9-10 was decreased in the stapled goats by 18% and increased in the untreated goats by 29% when compared to growth controls (P < 0.04). CONCLUSIONS: Data in this study show the ability to modulate relative and absolute growth, according to the Hueter-Volkmann law, at the apical spinal segment of a progressive experimental scoliosis. However, anterior vertebral stapling, although able to control progressive wedging and scoliosis at the apical spinal segment, was not able to reverse fully the Hueter-Volkmann effect.

Originally published by:Spine (Phila Pa 1976). 2006 Jul 15;31(16):1776-82.

Braun JT, Hines JL, Akyuz E, Vallera C, Ogilvie JW.

Department of Orthopaedics, University of Utah, School of Medicine, Salt Lake City, UT, USA. This e-mail address is being protected from spambots. You need JavaScript enabled to view it

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The recent investigations of convex anterior vertebral body stapling have offered promising early results with use of improved implants and techniques. The use of a shape memory alloy staple tailored to the size of the vertebral body, the application of several staples per level, the instrumentation of the Cobb levels of all curves, and the employment of minimally invasive thoracoscopic approaches all offer substantial improvements over previous fusionless techniques. Patient selection may also play a role in the current success of these fusionless treatments, with perhaps the ideal candidates for this intervention possessing smaller and more flexible curves. Long-term results of the effects on the instrumented motion segments and adjacent spine are not yet available.

Originally published by:

Orthop Clin North Am. 2007 Oct;38(4):541-5, vii.

Guille JT, D'Andrea LP, Betz RR.

Division of Spinal Disorders, Brandywine Institute of Orthopaedics, 600 Creekside Drive, Suite 611, Pottstown, PA 19464, USA. This e-mail address is being protected from spambots. You need JavaScript enabled to view it

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Progressive scoliosis in the growing child poses a unique challenge. The surgeon aims to attain maximal curve correction while maintaining spinal and thoracic growth. Nonoperative treatments include bracing and serial casting (both with questionable results). The classic surgical treatment has been spine fusion with less than optimal results. This has resulted in the development of fusionless interventions for children with scoliosis. These include growing rods, intervertebral body stapling, and the vertical expandable prosthetic titanium rib. Each of these offers unique advantages and disadvantages.  

Originally published by:

Neurosurg Clin N Am. 2007 Oct;18(4):697-705.

Torre-Healy A, Samdani AF.

Spine Division, Drexel University Medical School, Philadelphia, 2900 Queen Lane, Philadelphia, PA 19102, USA.

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Endoscopic vertebral body stapling is an innovative technique intended to treat adolescent idiopathic scoliosis, but the optimal instrumentation design is not yet established. The objective was to simulate the immediate correction obtained from two stapling configurations. A parametric finite element model of a typical right thoracic scoliotic spine (Cobb 21 degrees ) was developed using geometrical and mechanical data from the literature. Staple insertion and closing were modeled. The intra-operative lateral decubitus and standing positions were taken into account. Two implant configurations, varying the number of staples per vertebra, were simulated. The major correction (9 degrees ) came by simulating the intra-operative posture. The immediate Cobb angle correction due to the staples alone was less then 1 degrees for both configurations. However, the staples helped maintain the correction obtained by the intra-operative posture when the post-operative standing position was simulated. Next steps are to validate the model using surgical cases, implement growth modulation modeling, improve lateral decubitus modeling, and analyze different vertebral stapling strategies for different scoliotic curves.

Originally published by:

Lalonde NM, Aubin CE, Pannetier R, Villemure I.

Ecole Polytechnique de Montréal, Canada.

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Scoliosis is a condition affecting the neuro-muscular system that has long challenged health care professionals worldwide. The current treatment options or lack of any treatment for most families dealing with an early detection of this disease can be very frustrating. In most cases children diagnosed with scoliosis are told they have it and the healthcare team will monitor it to see if it gets worse. This would be similar to having a doctor tell you that you have a highly progressive cancer but we will wait until it spreads before we can do anything for you. Statistically, scoliosis is progressive in most cases.

So where does this leave children with scoliosis diagnosed below 25 degrees commonly referred to as early detection? The general medical approach is to wait until the curve reaches 25 degrees at which time the orthopedic specialist will recommend bracing. The most common form of bracing is a hard brace which is to be worn on average 22 hours daily until skeletal maturity or until the curve advances to 40 degrees at which point they will push for surgical intervention.

What medical practitioners typically don't tell you is that once the curve reaches 25 degrees the likelihood of progression is 68% even with most bracing attempts. So that leaves nearly 70% of the families with a highly progressive disease that ends up involving surgical intervention, a highly invasive surgery with significant post surgical ramifications. I don't know about you, but if my daughter was offered this solution as the only option, I would be very frustrated, scared, and disappointed in our healthcare system for not coming up with a better alternative to effectively combat scoliosis early on before it reaches critical levels where bracing and surgery becomes the only option.

A non-profit organization dedicated to finding a cure for scoliosis has developed a system that can effectively reduce and stabilize scoliosis without bracing or surgery. In fact, the majority of the scoliosis cases treated by this alternative methodology have been the result of patient's facing surgery where bracing attempts have failed to stop progression. This means a huge portion of scoliosis cases that have been reduced and stabilized using these new protocols have been above the 40 degree level. This spinal rehabilitation program was originally designed to correct scoliosis. Correction, meaning take scoliosis generally above 30 degrees Cobb angle and correct it to what is considered non-scoliosis level generally 10 degrees or less.

The majority of cases over 30 degrees have not corrected to this ideal 10 degrees or less range. The average reduction in Cobb angle measurement is 30-50% using what's called "MIX FIX SET" methodology. Now this is in no way a failure because a non-surgical non-bracing method which has the consistent ability to reduce and stabilize this highly progressive disease is a tremendous accomplishment and will most likely revolutionize the treatment of adolescent idiopathic scoliosis. Several news stations nationally as well as magazines have done stories and interviews with patients who have undergone this program of scoliosis care. It is considered a major success if you are able to stop scoliosis curve progression let alone reduce the actual curve measurement without the use of bracing, casting, or surgery.

Families with early detection of scoliosis can be proactive. The status quo of watching and waiting for the inevitable train wreck is no longer your only option. Doctors have developed a scoliosis treatment option that is ideal for curves under 30 degrees. The reason for the lack of a complete correction with curves above 30 degrees is due to the inherent nature of scoliosis as a feed forward mechanism. Meaning once the curve progresses to 30 or above, the "crankshaft phenomenon" kicks in, which creates massive rotation coupled with lateral flexion and compression. This phenomenon is very difficult to undo in fact, invasive surgery can not even fully correct this mechanism. When a scoliosis reaches the 30 degree mark, the crankshaft mechanism begins, and the chance of progression skyrockets. This is also why a 50 degree scoliosis may reduce to 30 degrees using this alternative method, which is fantastic, but the scoliosis still remains alive. It has not been fully corrected and therefore has the innate potential to want to continue to grow.

By attacking the scoliosis before it reaches this pivotal point of 30 degrees you can typically correct the scoliosis. You can in most cases eliminate the scoliosis with non scoliosis measurements of 10 degrees or less, thus defeating the disease rather than merely taming it. Imagine having the opportunity to fix the problem before it spirals out of control giving you the freedom to go about your life without having to constantly worry about what the scoliosis is doing or what it will become. This scoliosis program has the potential to become the first line of defense against childhood scoliosis. At some point this technology will be the standard recommendation and hopefully replace the current "watch and wait" do nothing recommendation currently in place for children diagnosed with scoliosis below 25 degrees. Doctors through research and new technology have the potential to "cure" this disease, but it must start from a solid program of early detection and referral to the appropriate treatment facility rather than a watch and wait system that is antiquated and dangerous.