Surgery for scoliosis is usually recommended for:
- Growing children whose curve has gone beyond 40 degrees. (There is debate about whether all children with curves of 40 degrees should have surgery.)
- Children whose skeletons have fully matured, and who have a curve greater than 50 degrees.
There are 4 main goals of scoliosis surgery:
- Straighten the spine as much as possible by correcting the deformity.
- Balance the torso and pelvic areas.
- Stop progression of the curve and maintain the correction long term.
- Reduce pain symptoms and the risks for future heart and lung complications.
Surgery is performed to accomplish these goals:
- Fusing (joining together) the vertebrae along the curve.
- Supporting these fused bones with instrumentation (steel rods, hooks, and other devices) attached to the spine.
- Or surgery can be done to provide guided growth to the spine. This newer technique does not lead to fusion of a large segment of the spine, but it does control or limit growth where the curve is.
Different instruments, procedures, and surgical approaches are used to treat scoliosis. All of the operations require meticulous skill and should be performed by a surgeon specializing in spine surgery.
The cause of scoliosis often determines the type of procedure. Other determinants include:
- The location of the curve (thoracic, thoracolumbar, or lumbar).
- Whether there are single, double, or triple curves, and the degree of rotation.
- The size of the curve.
You should always ask the surgeon and hospital about their experience with the specific procedures being considered.
Scoliosis surgery can take from 4 to 12 hours to perform. The child stays in the hospital for around 5 days, followed by 3 to 6 weeks of recovery time at home.
Tell your child's surgeon what medicines your child is taking. This includes medicines, supplements, or herbs you bought without a prescription.
Before the operation your child will:
- Have a complete physical exam by the surgeon.
- Learn about the surgery and what to expect.
- Learn how to do special breathing exercises to help the lungs recover after surgery.
- Be taught special ways to do everyday things after surgery to protect the spine. This includes learning how to move properly, changing from one position to another, and sitting, standing, and walking. Your child will be told to use a "log-rolling" technique when getting out of bed. This means moving the entire body at once to avoid twisting the spine.
The surgeon or nurse may talk with you about having your child store some of his or her blood about a month before the surgery. This is so that your child's own blood can be used if a transfusion is needed during surgery.
During the 2 weeks before the surgery:
- If your child smokes, they need to stop. People who have spine fusion and keep smoking do not heal as well.
- Two weeks before surgery, the surgeon may ask you to stop giving your child medicines that make it harder for the blood to clot. These include aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve).
- Ask which medicines you should still give your child on the day of the surgery.
- Let the health care team know right away when your child has any cold, flu, fever, herpes breakout, or other illness before the surgery.
On the day of the surgery:
- You will likely be asked not to give your child anything to eat or drink 6 to 12 hours before the procedure.
- Give your child any medicines the doctor told you to give with a small sip of water.
- The provider will tell you when to arrive at the hospital. Be sure to arrive on time.
The surgeon will make at least one surgical cut to get to your child's spine. This cut may be in your child's back, chest, or both places. The surgeon may also do the procedure using a special video camera.
The basic surgical approaches are:
- Posterior approach. The surgeon reaches the spine by making a cut in the back. This is usually the standard approach.
- Anterior approach. The surgeon makes a cut through the chest wall (called a thoracotomy), deflates a lung, and removes a rib. The rib may be used during the operation to support the spine, or it may be repositioned and later used for bone grafting during spinal fusion.
- Combined anterior-posterior approach. The combination approach uses an anterior approach first, which allows better correction of the problems. The fusion part of the operation is done with the posterior approach. This method may correct large rigid curves and specific severe curves in the thoracic spine.
- Video-Assisted Thoracoscopic Surgery (VATS). This method uses a video-assisted anterior approach and specialized spinal instrumentation. The procedure is complicated and surgeons must be specially trained to perform it. It is generally reserved for specific types of curvatures. Children must wear a brace for 3 months following surgery.
Spinal Fusion Procedure
Most scoliosis operations involve fusing the vertebrae. The instruments and devices used to support the fusion vary.
Before surgery, your child will receive general anesthesia. This will make your child unconscious and unable to feel pain during the operation.
In the spinal fusion procedure, the surgeon will:
- Raise flaps to expose the backs of the vertebrae that lie along the curve.
- Remove the bony outgrowths along the vertebrae that allow the spine to twist and bend.
- Lay matchstick-sized bone grafts vertically across the exposed surface of each vertebra so that they touch the adjoining vertebrae.
- Fold the flaps back to their original position, covering the bone grafts.
These grafts will regenerate, grow into the bone, and fuse the vertebrae together. Bone grafts will help keep the spine in the correct position.
Surgery for scoliosis involves correcting the curve (although not all the way) and fusing the bones in the curve together.
Bone grafts can be acquired from:
- Autograft. A bone graft from the child's own hip, rib, spine, or other bone area in the body. Autografts work well, but because they require an additional incision and surgery, they cause more pain during the post-surgical recovery process.
- Allograft. A bone taken from a cadaver. Allografts are usually from a bone bank. These types of grafts can sometimes increase the risk for infection.
- Synthetic grafts. A graft made from biologically-manufactured human bone protein, may be another option.
During surgery, the surgeon will use steel rods attached to the spine by hooks, screws, or wires to straighten your child's spine and support the bones of the spine.
There are various types of instrumentation procedures. They include the Texas-Scottish-Rite Hospital instrumentation or pedicle screws procedure.
The metal instruments are usually left in the body after the bone fuses together. In certain circumstances, a rod may need to be removed.
In addition to allergic reactions to anesthesia, infection, pain, and other standard surgical risks, specific complications associated with scoliosis surgery may include:
- Blood loss that requires a transfusion.
- Nerve injury causing muscle weakness or paralysis (very rare).
- Gallstones or pancreatitis (inflammation of the pancreas).
- Intestinal obstruction (blockage).
- Lung problems up to 1 week after surgery. Breathing may not return to normal until 1 to 2 months after surgery.
Problems that may develop in the future include:
- Fusion does not heal. This can lead to a painful condition in which a false joint develops at the site. This condition is called pseudarthrosis.
- The parts of the spine that are fused can no longer move. This puts stress on other parts of the back. The extra stress can cause back pain and make the disks break down (disk degeneration).
- A metal hook placed in the spine may move a little. Or a metal rod may rub on a sensitive spot. Both can cause some pain.
- New spine problems may develop, especially in children who have surgery before their spine has stopped growing.
- Some children may later need a corrective procedure called revision or salvage surgery. This is usually performed to correct a failure of the previous procedure or address issues with disk degeneration or curvature progression at fusion site.
Recovery and Outcomes
Your child's spine should look much straighter after surgery. There will still be some curve. It takes at least 3 months for the spinal bones to fuse together well. It will take 1 to 2 years for them to fuse completely. Children can resume many physical activities in the weeks and months after surgery, but will need to wait until the spine is fully healed before participating in contact sports.
Fusion stops growth in the spine. This is not usually a concern because most growth occurs in the long bones of the body, such as the leg bones. Children who have this surgery will probably gain height from both growth in the legs and from having a straighter spine.
Your child will be given pain medication in the hospital and will be discharged with a prescription for pain medicines that can be taken for a few weeks. When prescription pain medication is stopped, the child can be given acetaminophen (Tylenol) to cope with pain. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil), are not recommended because they may increase the risks for bleeding.
The health care team will give instructions to the parents about how to lift and move the child. For some types of procedures, the child may need to temporarily wear a brace to help prevent rotating movements that could delay recovery. During the initial weeks of recovery, the child should avoid movements that involve bending, lifting, or twisting.
Your child may need to see a physical therapist to receive an individualized exercise program that includes exercises for stretching and strengthening. An occupational therapist can provide exercises for activities of daily life, such as techniques for tying shoes, dressing, and bathing.
Children can usually return to school about 1 month after spinal fusion surgery.
Other Types of Surgery
Growing Rod Technique
This technique is used for very young children in whom bracing has not helped. Instead of doing spinal fusion, a rod is surgically inserted into the child's back. The child will have surgery every 6 months to extend the rod so that the spine can continue to grow. Some growing rod techniques use a single rod, while others use 2 rods.
Vertebral Body Stapling and Vertebral Body Tethering
Surgeons do these procedures using an anterior approach surgery without fusion. Vertebral body stapling is an experimental technique that may prevent curve progression in some young people with curves of less than 50 degrees. It involves stapling the outer curve on the side of the spine facing the chest, which helps stabilize and reduce progression of the inner curve. The procedure uses a special metal device that is clamp-shaped at body temperature. The device can be straightened when subjected to cold temperatures and inserted into the spine. When warmed up, the staple returns to its clamp shape and supports the spine.
An FDA-approved tether device is used in the newer vertebral body tethering system (VBT) surgery. VBT is a minimally invasive procedure that employs a flexible rope-like device connected to each vertebra by screws and pulled tight alongside the spine. The tension applied to the tether during surgery partially corrects the curve. With time, the tether helps slow growth on the curve side and promote growth on the opposite side.
Scoliosis Surgery in Adults
In most cases of adult scoliosis, nonsurgical care is preferred, if possible. This can include patient education, exercises, and medical treatments. Braces are not useful, and surgery is usually recommended only as a last resort. In general, pain is the most common reason for scoliosis surgery in adults. A procedure such as diskectomy (removal of a diseased disk) may be performed, followed by spinal fusion and instrumentation. However, adults have increased risks for complications of spinal fusion surgery.