Scoliosis is defined as a lateral curvature of the spine. However, this spinal deformity is actually more complex and three-dimensional in nature. In the case of idiopathic (unknown cause) scoliosis, the curvature appears to arise from asymmetrical growth of the spinal column. Essentially, the anterior column (front of the spine) grows more rapidly than the posterior column (back of the spine), creating a buckling effect during rapid growth. This phenomenon leads to a twisting or rotating deformity in the coronal plane (looking at the front of the spine) and a flattening in the Sagittal plane (looking at the child from the side).
Other sources of scoliosis include neuromuscular scoliosis, such that occurs with cerebral palsy, and a malformation of part of the spine during pregnancy, known as congenital scoliosis.
Bracing remains the most effective non-operative treatment for scoliosis, however the results are variable due to severity of the condition, age of the patient and compliance with brace wear. Other methods of conservative care like physical therapy, chiropractic care and traction devices have not been found to be effective in altering the natural progression of the spinal deformity.
Surgical treatment in adolescents who have limited growth remaining and severe scoliosis typically requires spinal instrumentation and fusion – bridging of the bones of the spine. This is highly effective in correcting the curvature and eliminating further progression of the deformity, but unfortunately eliminates growth of the spinal levels that are fused.
Although fusions in adults may not fully relieve symptoms and can create additional problems, this is usually not the case in the treatment of pediatric scoliosis. Advances in pediatric scoliosis surgery have led to a more selective, safe and successful surgery.
Early onset scoliosis, defined as scoliosis that develops before 6 years of age, is one of the most difficult deformities to treat. Often brace wear or casting is not reliable in preventing progression. Additionally, use of the traditional method of surgical treatment is contraindicated as fusion of the majority of spine at this young age would preclude normal chest and lung growth and development.
Several procedures have been introduced in which selective fusion of the spine is combined with instrumentation methods to allow for further growth of the majority of the spine. The most common method of surgery performed to treat early onset scoliosis requires insertion of a distraction instrumentation system. The system typically consists of selective fusion at one level at the top of the scoliosis curve and the second level at the bottom of deformity with rods placed between subcutaneously avoiding fusion in between. The levels fused are not usually the most deformed and rotated levels that occur at the apex of the scoliosis curve. The system requires distraction every 6 months in attempt to mimic natural growth of the non-fused levels beneath the subcutaneous rods.
Unfortunately this procedure requires multiple visits to the operating room. Regardless that many of these procedures are minor and outpatient, they often result in a high rate of complications. Additionally, these repetitive procedures early in life have been found to cause harmful psychosocial influences and childhood anxiety.
A new surgical method has been developed which allows further growth of the majority of the spine and correction of the spine at the same time. In the Shilla procedure, only 2-4 levels of the most deformed segments of the spine, usually at its apex, are fused. This is followed by the placement of long rods on both sides of the spine. At the fusion levels the rods are fixated securely centrally, but attached at the top and bottom of the scoliosis curve to spinal fixation, usually with screws, that do not lock on to the rod. Therefore growth of the spine still occurs, except at the fused apex, guided by the rods like rails of a track. This method of guided growth requires no repetitive distractions, therefore limiting any further surgical procedures.
A recent two-year multicenter study focused on 10 children in which this procedure was performed. The results verified that, after the initial correction, further growth had occurred without the need for multiple surgeries and with minimal complications. If the children were treated with the more traditional distraction procedure, they would have required in total 49 additional surgical procedures.
The following case example is a 3-year-old patient at St. Joseph’s Children’s Hospital who was born with Spina Bifida. After multiple neurosurgical procedures it was evident she was developing a severe and advancing scoliosis, which was affecting her ability to sit and would eventually compromise function of her vital organs. To correct the spinal deformity and avoid subjecting the child to even more surgical procedures, a Shilla procedure was performed. At 18 months postoperative, the child has experienced a major correction of her scoliosis, documented further spinal growth, and has required no further surgical intervention thus far.
Below is a 5-year-old child with infantile idiopathic scoliosis presenting with a progressive severe scoliosis deformity. Left untreated, the deformity could compromise heart and lung function, leading to a life-threatening condition. The Shilla procedure was performed at St. Joseph’s Children’s Hospital, stabilizing as well as correcting the deformity with extended rods to act as rails to guide further growth. At one year postoperative, the child displayed further growth consistent with normal development.
While the introduction of the Shilla procedure is recent, the early results are encouraging. The procedure focuses directly but selectively on the most deformed spinal levels. Properly performed, the Shilla procedure results include limited operative visits and minimal complications, while allowing for further spinal growth. Additionally, the procedure provides the best initial correction of the deformity among current surgical options. This is a procedure that may provide a more favorable outlook for children presenting with this possibly life-threatening spinal deformity.
David Siambanes, DO is the Medical Director at St. Joseph’s Children’s Hospital’s Scoliosis Center. He is board certified in orthopedic surgery and is fellowship trained in pediatric orthopedics. He received his Bachelor of Science in Biology from the University of Illinois and his Doctor of Osteopathic Medicine from the Chicago College of Osteopathic Medicine, Midwestern University. Dr. Siambanes completed fellowships in reconstructive spine surgery from the University of Southern California, and in pediatric orthopedics from Alfred I. duPont Hospital for Children.
For more information on the Scoliosis Center at St. Joseph’s Children’s Hospital in Tampa please visit www.StJosephsChildrens.com. To contact Dr Siambanes please call (813) 554-8983.