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

Vertebral Body Stapling (VBS)

VBS Indications

Based on previous studies,[15–23] VBS works best for patients with idiopathic scoliosis with thoracic curves measuring 25 to 35 degrees and lumbar curves measuring 25 to 45 degrees. These patients should be at least 8 yr of age but still skeletally immature (girls <13 yr of age and boys < 15 yr) with at least 1 year of growth remaining (Risser score 0–1, Sanders digital stage ≤4). Other considerations are curve flexibility with side bending correction to less than 20 degrees, minimal rotation with correction on clinical examination or radiograph, and a true sagittal kyphosis of less than 40 degrees. For a further description of the procedure with illustrations, please refer to the article by Cahill et al.[23]

For best results with VBS, we recommend postoperative nighttime bracing if the curve is greater than 20 degrees on the first erect radiograph. We recommend using a more powerful growth modulation option for larger thoracic curves that measure greater than 35 degrees. This will be covered in the section on vertebral body tethering and anterior scoliosis correction. In geographic areas where regulatory approval has not been received for vertebral body tethering or anterior scoliosis correction, or in underdeveloped countries where the cost of the implant may be an issue, another option for thoracic curves over 35 degrees is a posterior growing hybrid rod construct (rib to spine) across the stapled curve. This posterior system would need lengthening, corresponding to growth, and may be removed at skeletal maturity if desired.

VBS Complications

There are very few complications related to VBS, with the majority related to the approach. We are aware of five of 390 staples (1%) in five of 63 patients (8%) that loosened or backed out, four of which were seen within 2 months of the initial procedure.[23] Loosening was asymptomatic in three of five patients. Two of the five patients underwent revision stapling.

Four of the 63 patients (6%) had broken staples that correlated to a rate of 1% (4/390 staples). All of these staples were in the lumbar spine, and all occurred within 6–12 mo of the initial procedure. Two of the four patients experienced pain, one of whom had the broken staple removed and experienced complete pain relief. Four of 63 (6%) patients experienced overcorrection of a stapled curve (two thoracic curves and two lumbar curves). Three of the four patients underwent staple removal between 1 and 4 yr after the initial stapling procedure. We recommend removing the staples if greater than 10 degrees of overcorrection is noted.

Other complications we encountered in the first 39 patients with staples who had 1 yr or longer follow-up included one postoperative rupture of a pre-existing unrecognized congenital diaphragmatic hernia that required repair, one injury to a segmental spinal vein requiring conversion to a mini-open thoracotomy to ligate the vein (the first case of R.R.B.), one thoracic duct damage resulting in a chylothorax, which was treated with total parenteral nutrition and a chest tube, one mild pancreatitis that resolved with a low-fat diet, and two clinically significant atelectases treated conservatively.[24] We experienced no instances of damage to the great vessels, lung parenchyma, heart, abdominal organs, or kidneys with VBS, making it a safe and reliable option.[23]