Alternatives to Spinal Fusion Surgery in Pediatric Deformity

Randal R. Betz, MD; M. Darryl Antonacci, MD; Laury A. Cuddihy, MD


Curr Orthop Pract. 2018;29(5):430-435. 

In This Article


The standard of care for skeletally immature patients with moderate idiopathic scoliosis between 20 and 45 degrees typically involves observation and bracing with a thoracolumbosacral orthosis (TLSO) to prevent further curve progression.[1] However, bracing is not 100% effective in patients with adolescent idiopathic scoliosis (AIS)[2] and has been shown to work only when the brace is worn for more than 12 hr a day.[2] This may create psychosocial stresses resulting in limited brace wear.[2–12]

In patients with juvenile idiopathic scoliosis (JIS), the success of bracing is even less than that in AIS. Charles et al.[3] reported a 75% fusion rate for patients whose curves were between 21–30 degrees at the onset of puberty and a 100% fusion rate in patients with JIS whose curves were greater than 30 degrees at the onset of puberty regardless of bracing. Harshavardhana and Lonstein[13] recently showed a bracing success rate of only 41% in patients with JIS. Spinal fusion in patients with JIS is problematic because of inhibition of growth over the length of the construct.[14] Spinal fusion for idiopathic scoliosis of any age can be problematic over time, with the development of adjacent level disc degeneration and decreased spinal mobility.[14] As a result, surgeons have turned to alternative surgical approaches to correct the spinal deformity using either growth modulation or remodeling of the spine while preserving motion.

Several procedures are currently being utilized, including vertebral body stapling, vertebral body tethering, anterior scoliosis correction, and posterior periapical concave distraction. Two devices (REFLECT® [Globus Medical] and the ApiFix internal brace system) have CE mark approval for use outside the United States. All of the devices discussed here are used "off label" (or "physician-directed") and are not currently approved by the US Food and Drug Administration (FDA) specifically for correction of scoliosis. The potential advantages of these techniques are curve correction through a minimally invasive approach, a quicker recovery, preservation of motion, and the possibility of any treatment in the future if it becomes necessary.