What are the preoperative considerations in the surgical treatment of idiopathic scoliosis?

Updated: Dec 02, 2020
  • Author: Charles T Mehlman, DO, MPH; Chief Editor: Jeffrey A Goldstein, MD  more...
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Answer

Preoperative evaluation focuses on specifics of curve location, magnitude, and flexibility. These parameters are used in conjunction with patient maturity factors to determine optimal treatment choice, but definitive studies are not yet available that dictate specific surgical tactics. However, the scoliosis surgeon is aided by commonly applied clinical guidelines that have evolved over time. The goal is always to fuse as little of the spine as possible while adequately treating existing major curvature.

For a thoracic curve (with adequate flexibility) without any significant associated lumbar curvature, the most common surgical approach has not changed since the days of Paul Harrington: posterior spinal fusion with instrumentation. Surgeons may choose from a diverse array of anchors to secure large-diameter rods (usually in the 0.25-in. range) to the spine. These anchors include sublaminar hooks, pedicle hooks, transverse process hooks, sublaminar wires (Luque wires), spinous process wires (Drummond wires), and pedicle screws.

Some surgeons have advocated anterior spinal fusion and instrumentation for such isolated thoracic curves. These have included both open (thoracotomy) and limited-incision (thoracoscopic) techniques.

When the primary problem is a large, stiff thoracic curve (usually not bending less than 50°), a different surgical tactic is usually undertaken in which an anterior release (usually including diskectomy and bone grafting) is performed prior to posterior spinal fusion and instrumentation. Anterior spinal fusion and instrumentation has also been advocated in this situation, provided the patient does not have excessive kyphosis associated with a large thoracic curve.

Large curve patterns that include both thoracic and lumbar deformity continue to challenge scoliosis surgeons. If adequate flexibility and balancing of the lumbar spine is possible, then selective fusion of the thoracic curve is possible. When this is not the case, extensive fusion (at times down to the fourth lumbar segment) may become necessary.


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