Peter Gabos, MD, a spine surgeon at Nemours/Alfred I. DuPont Hospital for Children in Wilmington, Del., discusses the most exciting trends in scoliosis treatment today.1. Genetic testing. Advancements in genetic research and testing related to scoliosis deformity now allow providers to predict the risk of severe scoliosis in pediatric patients. There are more than 120 genes associated with scoliosis and researchers have identified the predominance of 50 genes that could indicate high or low risks.
"If there are people with low risks, we won't have to follow them as closely as we did in the past," says Dr. Gabos. "If people are at a higher risk, we can brace them earlier and move forward with other treatment options."
ScoliScore is the saliva-based test scoliosis specialists are now using to identify whether patients have a high or low risk of severe scoliosis. When specialists are able to identify low-risk patients, monitoring them less frequently will save healthcare dollars in the long run and catching high risk patients earlier could mean more immediate treatment.
2. Imaging technology. Imaging technology has vastly improved over the past few years to enhance surgical outcomes and decrease radiation exposure. The new EOS machine allows surgeons to take a full length standing front and back image of the spine at the same time and then converts the images into a three-dimensional plane.
"One of the major advantages of this technology for the kids is lower radiation doses," says Dr. Gabos. "We don't know what X-ray exposure will do for kids over their lifetime, but we do know decreasing that is beneficial. We can also generate more complex spine images, which help with treatment."
Another imaging development is the ability to take intraoperative CT scans in a sterile manner. These images enhance spinal implant placement, which leads to better outcomes.
"One of our concerns is the accuracy of implant placement in the spine, especially when pedicle screws are used," says Dr. Gabos. "We can now verify the placement of spinal implants during the surgery by obtaining a three-dimensional CT scan image in the sterile operating room environment o check the length and trajectory of screws before the rods are placed, which greatly impacts the procedure. It's something that's fairly new but becoming increasingly popular."
3. Bracing compliance. Bracing remains one of the most popular and effective treatments for scoliosis, but when the patient isn't compliant they have poor outcomes and could skew research data. A new product installed in the brace now monitors how long patients wear them per day.
"Without this technology, we just have their verbal compliance," says Dr. Gabos. "Now we have an actual way to measure it. This also helps us validate studies on the effectiveness of bracing. We can't tell whether braces are effective if our patients aren't actually wearing them."
4. Screw constructs. While spinal rods have been utilized in spinal surgery for many decades, the more recent advent of pedicle screw fixation has allowed surgeons to gain better anchoring of the rods to the spine and increase the strength and corrective power of the implants. These tools mean surgeons can achieve a better three-dimensional correction of the scoliosis as well as better balance.
"In the past, we anchored the rods to the spine using hooks and wires, which did little to change chest wall deformity," says Dr. Gabos. "Traditionally that led to procedures where the surgeon would remove large portions of the rib cage to decrease rib prominence associated with scoliosis. With the advent of pedicle screw constructs, we get so much de-rotation of the chest wall that these are now rarely done."
In cases of very severe spinal deformity, spine surgeons previously would release the spine through an anterior approach, cutting ligaments in front of the spine prior to performing the posterior procedure. Technological developments in this area now allow surgeons to perform everything through the posterior approach, even in severe cases.
"These procedures allow the patients to return to school, sports and other activities more quickly after surgery," says Dr. Gabos.
5. Surgical technique. Dr. Gabos and his colleagues have pioneered advances in deformity correction, especially related to neuromuscular scoliosis. "We've championed some techniques that allow us to place implants around the pelvis that are much less prominent than in the past, which avoids irritation to the surrounding overlying skin and decrease(S) wound complications," he says.
Dr. Gabos also focuses on advances in growth modulation for very young children with severe scoliosis. These developments include using vertebral expandable prosthetic titanium ribs, and other new growth modulating procedures such as Shilla procedures and anteriorally-based spinal tethers. These newer procedures allow surgeons to gain control of severe curvatures in very young patients, to buy time and growth before a more definitive procedure can be performed.
"Interestingly, we are also seeing a return of the earlier technique of spinal casting," says Dr. Gabos. "It had fallen out of favor, but now surgeons recognize it can be an adjunct to these other treatments and in many cases replaces the need for other growth sparing procedures."
6. Infection control. Complications and infection control are an important part of any surgical procedures, and new techniques have been able to increase patient safety during surgical correction. Less invasive techniques leave the patients less exposed for infection and decreases complications. Dr. Gabos and his team also pioneered additional best practices to further lower these risks.
"We use bone graft to augment fusion in scoliosis surgery, whether it's the patient's own bone or donor bone," says Dr. Gabos. "We started saturating the bone graft in antibiotics prior to placing it into the spine to use the bone graft as a carrier of antibiotics that allows local delivery of the antibiotics to the wound bed."
Using this technique, Dr. Gabos and his colleagues were able to publish a study that included one of the lowest complication rates for these highly complex procedures.
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