REVIEWS IN SPINAL SURGERY

Modern Surgical Management of Early Onset and

Adolescent Idiopathic Scoliosis
Eduardo C. Beauchamp, MD∗
Richard C. E. Anderson, MD ‡ progression while simultaneously correcting the spinal deformity. These principles have
Michael G. Vitale, MD, MPH∗
∗
Department of Orthopedic Surgery,
Columbia University Medical Center/New
York Presbyterian Hospital, New York,
New York; ‡ Department of Neurosurgery,
Columbia University Medical Center/New
York Presbyterian Hospital, New York,
New York
Correspondence:
Eduardo C. Beauchamp, MD,
Department of Orthopedic Surgery,
Columbia University Medical Center, New
York Presbyterian Hospital,
3959 Broadway, 8 North,
New York, NY 10032.
E-mail: eb3138@cumc.columbia.edu
The early principles of spinal fusion in the adolescent population focused on preventing
remained relatively unchanged since their introduction more than a century ago,
but recent improvements in imaging, instrumentation, and corrective techniques have
provided new insight on the diagnosis, management, and postoperative care of this
condition. Treatment options for the management of patients with early onset scoliosis
have also evolved dramatically over the last 2 decades. Further knowledge on the physi-
ology of lung development and the detrimental effects of early fusion in the early onset
scoliosis population has led to the development of growth friendly implants and other
surgical techniques that allow correction of the deformity while maintaining spine, lung,
and chest wall development. The following is an overview of current techniques on the
management of adolescent idiopathic and early onset scoliosis to help provide guidance
on the available surgical alternatives to address these conditions.
KEY WORDS: Pediatric spine deformity, Adolescent idiopathic scoliosis, Early onset scoliosis, Growing rods,
Magnetically controlled growing rods, Compression based techniques, Growth guided techniques
Neurosurgery 0:1–14, 2018 DOI:10.1093/neuros/nyy267 www.neurosurgery-online.com

Received, November 10, 2017.

Accepted, May 21, 2018.
ETIOLOGY AND NATURAL HISTORY
Copyright 
C 2018 by the
Congress of Neurological Surgeons Adolescent idiopathic scoliosis (AIS) is defined
as a coronal curvature of the spine greater
than 10◦ with an onset after 10 years of age.
The diagnosis is made after all other causes
of scoliosis, such as neuromuscular disorders or
congenital vertebral anomalies, have been ruled
out. The prevalence of AIS is estimated to be
3%, and approximately 0.2% to 0.5% of these
patients will require treatment.1-4 Early-onset
scoliosis (EOS) is currently defined as a curvature
of the spine greater than 10◦ from any etiology
developing before 10 years of age.5,6 It is a
heterogeneous condition of significant diversity
ABBREVIATIONS: AIS, adolescent idiopathic
scoliosis; C-EOS, classification of early onset
scoliosis; CT, computed tomography; EOS, early-
onset scoliosis; MCGR, magnetically controlled
growing rods; MRI, magnetic resonance imaging;
TGR, traditional growing rods; TLSO, thoracolum-
bosacral orthosis; VBS, vertebral body stapling;
VBT, vertebral body tethering
with regards to etiology, natural history, and
treatment options. Although the prevalence for
EOS is unknown, idiopathic EOS accounts for
<1% of all scoliosis.7
The natural history and prognosis of EOS
depends predominantly on its etiology and
associated conditions, but if left untreated it
can be associated with significant morbidity
and mortality.8-10 Taking into consideration the
wide spectrum of etiologies and in an effort to
provide an organizing structure, Williams and
Vitale et al11 developed the Classification of
Early Onset Scoliosis (C-EOS; Figure 1). The
C-EOS includes a continuous prefix (age), three
primary variables (etiology, major curve angle,
and kyphosis), and a curve progression modifier.
This classification has been well validated and has
demonstrated excellent prognostic value.11-13
Although significant advances in the under-
standing and treatment of EOS have been made
over the last decade, much work still needs
to be done to determine the extent at which
current interventions help maximize respiratory
function and improve the quality of life in these
patients.

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FIGURE 1. Illustration of the classification of EOS. The patient’s age, etiology,
major coronal Cobb angle, kyphosis, and an optional progression modifier are
taken into consideration. APR = annual progression rate. Reproduced with
permission from Williams BA, Matsumoto H, McCalla DJ, et al: Development
and initial validation of the Classification of Early-Onset Scoliosis (C-EOS).
J Bone Joint Surg Am 2014; 96(16):1359-67.11
EVALUATION
Clinical evaluation of patients with EOS should begin with
a comprehensive medical history including prenatal and birth
history, allergies, previous medical conditions, and a detailed
review of systems. Evaluating neural axis, pulmonary, urogenital,
cardiovascular, musculoskeletal, and gastrointestinal systems is
critical to assess other pathologies associated with EOS that might
influence both operative and nonoperative management of the
spine deformity.14,15-17 If contemplating operative intervention,
careful attention is given to the nutritional and pulmonary status
of the patient. If the child can participate in pulmonary function
testing, these should be performed.
A thorough physical examination should include height,
weight, skin evaluation, range of motion, sensory and motor
function, as well as reflexes in both the upper and lower extrem-
ities. Inspection of the global coronal and sagittal balance is imper-
ative as well as performing an Adams forward bend test to examine
axial rotation of the trunk. Pelvic and shoulder balance as well
as chest wall anomalies should be noted. Pelvic obliquity should
be considered in the evaluation of early onset scoliosis, especially
in patients with neuromuscular scoliosis, since this combination
may lead to spinal imbalance with corresponding dermal pressure
points.18 Many patients with significant coronal deformity may
suffer from rib on pelvis deformity, which can be a source of pain
and discomfort.
IMAGING
It is important to review previous imaging studies, if available,
to have a longitudinal perspective on the natural history of the
deformity and to be able to document progression, particularly
during periods of rapid growth. Consistency in measuring the
curve is paramount in identifying curve progression as positional
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changes are often associated with changes in Cobb angle measure-
ments.19,20 Although full length PA and lateral standing radio-
graphs are preferred, supine or sitting films are appropriate for
more involved patients and those who are still not able to stand
or walk. Supine radiographs are likely to underestimate the
magnitude of the coronal and sagittal deformity compared to
films in the upright position.19-21
Patients with EOS and AIS are exposed to significant amount
of radiation given the increasing number of radiographs needed
throughout their treatment period. EOS-Imaging (EOS Imaging,
Paris, France) is a recent low dose digital imaging system which
has been shown to reduce the radiation exposure by 6 to 9 times
when compared to computed radiography while maintaining
imaging resolution, and up to approximately 45 times less
with the “Micro-Dose” EOS-Imaging, compared to conventional
radiographs (Figure 2).22-24
There are numerous radiographic methods of determining
skeletal maturity, including Risser sign, Tanner–Whitehouse,
Greulich–Pyle atlas, and Sanders classification among others.
The Sanders classification, a simplified variant of the Tanner–
Whitehouse-III RUS method, has shown excellent correlation
with the curve acceleration phase as well as intra- and inter-
observer reliability.25 This classification correlates the different
stages of hand physeal development with the maturity phase prior,
during and after the adolescent growth spurt. It is divided into 8
stages of growth. Stage 1 corresponds to the juvenile slow stage;
Stage 2: Preadolescent slow; Stage 3: Adolescent rapid-early; Stage
4: Adolescent rapid-late; Stage 5: Adolescent steady progression-
early; Stage 6: Adolescent steady progression-late; Stage 7: Early
mature and Stage 8: Mature stage (Figure 3). Stages 1 to 5
occur before iliac apophysis ossification (Risser-1). We find the
Sanders classification most helpful in counseling patients with
coronal curves around 25◦ in whom we are considering bracing.
According to their study, in patients with Lenke curves type 1
and 3,26 a 25◦ curve has close to a 100% ([CI] = 92%-100%)
probability of progressing to more than 50◦ during spinal growth
despite bracing if the patient is Sanders 2. On the other hand,
a patient who is Sanders 4 with a 25◦ curve has close to a
0% (CI = 0%-5%) probability of reaching 50◦ .21 This is our
preferred method for radiographic evaluation of skeletal maturity
due to its strong correlation with the curve acceleration phase.
In their retrospective analysis of 161 patients with a diagnosis of
idiopathic scoliosis, Sitoula et al27 found a strong predictive corre-
lation between initial Cobb angle and Sanders Stage for proba-
bility of curve progression. All of the patients with a Sanders Stage
2 and an initial coronal Cobb angle of 25◦ or greater progressed
to ≥50◦ . Similarly, all of the patients with an initial coronal Cobb
angle of 35◦ or greater and a Sanders Stage 1 or 3 also progressed.
In contrast, no progression to ≥50◦ was observed in patients with
an initial coronal Cobb angle of ≤15◦ or those with Sander Stages
5, 6, or 7 and an initial Cobb angle of ≤30◦ .
Computed tomography (CT) is reserved for the evaluation of
patients with structural abnormalities such as congenital scoliosis
or rib fusions. To minimize radiation exposure, CT is often
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FIGURE 2. Image comparison. A, Standard digital radiograph. B, Standard dose EOS-Imaging (EOS
Imaging). Image resolution is maintained while diminishing radiation exposure.
deferred until the patient is scheduled for surgery. Low dose, age-
appropriate protocols are utilized.
Imaging of the neural axis is most commonly achieved
with magnetic resonance imaging (MRI). Subtle findings in
physical examination, such as absent or asymmetrical abdominal
reflexes, have been proven to be highly suggestive of neural axis
pathology.28,29 Curves that reach 20◦ before 10 years of age have
been shown to have a prevalence of neural axis abnormalities of
approximately 20% (range 17.6%-26%).14,32 Due to this high
incidence, a screening spine MRI is recommended in patients
with EOS and curves greater than 20◦ , even in the absence
of abnormal neurological findings on physical examination.14
Routine MRI evaluation for the AIS population, however, still
remains controversial. This is primarily because of the more
limited availability of MRI (compared with CT and radiographs)
and the relatively low incidence of neural axis anomalies requiring
surgical intervention.33 It is generally accepted that MRI is most
important for AIS patients with atypical curve patterns, such as
left thoracic curves, excessive kyphosis, rapid curve progression,
associated back pain, male gender, neurological deficits, and/or
abnormal reflexes.33-35
Substantial debate exists regarding the neurodevelopmental
effects of sedation on young children. General anesthesia or
sedation is typically required to obtain CT or MRI studies in
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this population. Although potential effects on brain development
after exposing children to single or multiple episodes of sedation
are unknown, current animal studies suggest an elevated risk
of neurodevelopmental disorders in children exposed to general
anesthesia before 3 yr of age, but relatively minimal risk if exposed
to a single general anesthesia event after 3 yr.36-38 To minimize
these risks, we generally wait until after 3 yr of age to obtain these
studies (if possible) and try to coordinate multiple imaging studies
under a single anesthetic exposure.
IMAGING GUIDANCE
The use of pedicle screws for posterior instrumented spinal
fusion is considered the preferred method for deformity
correction in AIS. Pedicle screws have been shown to be a
safe and reliable method of instrumentation in pediatric spine
deformity.39-42 A review of over 19 000 pediatric scoliosis cases
from the Scoliosis Research Society morbidity and mortality
database demonstrated a 0.8% rate of neurological deficit for
AIS.43 Another systematic review on complications of pedicle
screw placement in scoliosis surgery revealed that approximately
4.2% of the pedicle screws are malpositioned.44 This percentage
increased to 15.7% in studies where postoperative CT scans were
obtained. Although free hand technique remains the predominant
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FIGURE 3. Sanders Skeletal Maturity System: Stage 1: All of the digital epiphyses are not covered. Stage 2:
All the digital epiphyses are as wide as the metaphysis, “covered”. Stage 3: The majority of the epiphyses bend
over the metaphyseal edge, or are “capped”. Stage 4: Beginning of closure of the distal phalangeal physes.
Stage 5: All of the distal phalangeal physes are closed while the remaining physes are open and “capped”.
Stage 6: Proximal and middle phalangeal physes are closing. Stage 7: All of the physes, except for the distal
radius and ulna, are closed. Stage 8: All of the physes, including the distal radius, are closed. Reproduced with
permission from Sanders JO, Khoury JG, Kishan S, Browne RH et al. Predicting scoliosis progression from
skeletal maturity: a simplified classification during adolescence. J Bone Joint Surg Am 2008; 90(3):540-
53.25

method for pedicle screw insertion, CT image guidance may
improve accuracy in placement of thoracic pedicle screws, thereby
potentially diminishing vascular or neurological complications.
A recent systematic review demonstrated moderate evidence
of lower breach rate with CT guidance (7.9%) vs free hand
(9.7%-17.1%).45 Conflicting evidence was found regarding the
complication rate between CT navigation vs free hand pedicle
screw insertion. Our preferred method continues to be freehand
technique but we find CT guidance extremely helpful in cases
with complex spinal anatomy and in teaching residents safe
techniques for pedicle screw placement, although the potential
adverse effects of radiation exposure with the CT guided
technique need to be taken into consideration. New technology
in spine surgery, such as robotic assisted pedicle screw placement,
continues to evolve, but further studies about its efficacy and
safety in pediatric spine deformity are needed.
TREATMENT OPTIONS
Treatment options for AIS and EOS include observation,
physical therapy, orthotic management, and surgical inter-
vention. Factors influencing decision making for each treatment
option include age, skeletal maturity and growth potential,
magnitude of curvature and overall balance, underlying diagnosis,
pulmonary status, and concurrent medical comorbidities among
others.
Successful management of scoliosis attempts to correct or
prevent progression of spinal deformity. This is particularly
important in young children with EOS, where significant chest
wall and pulmonary development is taking place. When nonop-
erative management fails in the AIS population, surgical inter-
vention for deformity correction with instrumentation and
definitive fusion is most often recommended. In children with
EOS, however, early fusion across the thoracic spine must
be avoided in order to minimize chest wall constriction and
impairment of cardiopulmonary development during growth.
When surgery is indicated, surgical implants that permit some
spinal growth are preferred. Growth friendly implants for patients
with EOS were classified by Skaggs et al5 into 3 distinct categories,
based on the correction strategy or force exerted by the implants
on the spine: (1) distraction-based, (2) compression-based, and
(3) guided growth systems. The goal of each of these implants is to
provide adequate correction of the spine deformity without spinal

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fusion, thereby permitting lung development as well as chest wall
and spinal growth.
Nonoperative Treatment
Observation is reserved for skeletally mature patients with
nonprogressive and balanced spinal curves. In the EOS
population there are certain pathologies that are less likely to
deteriorate, such as an isolated block vertebra or a hemimetameric
shift, among others. Suggested protocol for follow-up in both
EOS and AIS patients includes obtaining plain radiographs every
6 to 12 month, depending on the phase of growth, and serial
assessment of curve magnitude using Cobb angle and other
standard measurements.
Spinal deformity often remains relatively stable during slow
periods of growth, but may show signs of progression during
accelerated growth phases, such as in infancy or puberty. Obser-
vation is typically pursued until the coronal deformity exceeds 25◦
with more than 10◦ of documented progression.46,47 After this
point, bracing or derotational casting is considered depending on
the patient’s age.
Physical therapy has not been shown to have any influence on
spinal deformity in the EOS population.6 However, in children
with AIS, scoliosis specific exercises, such as the Schroth method
of physical therapy, are increasingly used alone or in combination
with brace treatment to potentially improve spinal deformity
by promoting muscle strengthening and trunk elongation. It is
designed only for flexible curves and limited by the necessity
of patient participation. These exercises can be used in adjunct
to other nonoperative treatments although compliance in this
age group can limit its effectiveness. Currently more evidence is
needed to recommend the use of this therapy as a sole treatment
for mild to moderate AIS.48,49
Bracing/Derotational Casting
Bracing in the AIS population is currently recommended
in skeletally immature patients with curves from 25◦ to 40◦ .
Results of brace treatment in the AIS population have been well
documented in the Bracing in Adolescent Idiopathic Scoliosis
Trial.50 In this prospective multicenter study, skeletally immature
patients from 10 to 15 yr of age with an initial Cobb angle from
20◦ to 40◦ were randomized to brace treatment with a thora-
columbosacral orthosis (TLSO) vs observation. Due to preference
of treatment, significant crossover occurred between groups. This
crossover altered the randomization of the study and an intention-
to-treat as well as an as-treated analysis was conducted. Overall,
the rate of treatment success after bracing (defined as reaching
skeletal maturity without the need for surgical intervention) was
72%, compared with only 48% after observation. They also
demonstrated a brace-dose response with similar success rates
between the observation group (48%) and patients who wore
the brace from 0 to 6 h daily (41%), but significantly higher
success rates in those who wore the TLSO for an average of at least
12.9 h per day (90%-93%).50 The trial had to be stopped before
completion due to the efficacy demonstrated by TLSO treatment.
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Bracing or cast placement in EOS may allow chest wall and
spine growth to continue while maintaining or improving spinal
balance. The effectiveness of bracing alone in the treatment of
EOS is still under debate. In contrast, derotational casting for
infantile idiopathic scoliosis has been shown by multiple studies
to be potentially curative, although its effect and utility for
non-idiopathic scoliosis still remains in question.51-55 Mehta55
described progressive and nonprogressive infantile scoliosis based
on the rib-vertebral angle difference (RVAD) and the phase of the
convex ribs in the apex of the deformity. RVAD is obtained by
measuring the difference in the angles formed by the attachment
of the concave and convex rib in relation to the apical vertebra.
Rib phase is determined by observing the relationship of the rib
head and vertebral body in the apex of the deformity (Phase
1: Rib heads do not overlap the vertebral body. Phase 2: There
is an overlap of the convex rib head and the vertebral body).
Progressive curves presented with an initial RVAD ≥20◦ or a
Phase 2 rib-vertebra relation. The majority of the patients with
and initial RVAD <20◦ and a Phase 1 rib-vertebra relation (83%)
had resolution of their spinal deformity.55 In a study of 55 pts
with progressive infantile scoliosis, Sanders et al53 demonstrated
excellent response to derotational casting, with 89% of these
patients showing a decrease in curve magnitude. Initiation of
derotational casting at a younger age, curve size <60◦ and an
idiopathic etiology carried a better prognosis53 (Figure 4). The
nonidiopathic population in EOS can present with diverse spinal
deformities and structural anomalies which can be less amenable
to bracing or casting.
Halo-Gravity Traction
In cases of severe spinal deformity, both in the adolescent
and early onset population, a period of perioperative halo-
gravity traction may be beneficial in decreasing the magnitude
of the deformity. This period of traction is also favorable in
improving respiratory mechanics and nutritional status, as well
as making the patient a more suitable candidate for surgery.56-58
Length of traction, generally between 2 and 12 weeks, depends
on the overall medical status and the presence of radiographic
evidence of curve improvement. During this period 30% to
44% of deformity correction in both sagittal and coronal
planes can be achieved before growing rod implantation or
definitive fusion57-61 (Figure 5). The most common compli-
cations associated with halo-gravity traction include pin site
infection and pin loosening,61 which can be reduced by increasing
the number of pins during initial application. Patients typically
complain of neck and trapezial soreness that occurs due to
traction weight transmission to the neck musculature. This can be
decreased by progressing slowly with the addition of weights. Our
current protocol is to add 2 pounds of traction in the morning
and 1 pound in the afternoon daily until the traction goal is
reached. Traction goal fluctuates between 30% and 50% total
body weight as tolerated by the patient, with daily neurochecks
as each additional weight is added.
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FIGURE 4. A, PA radiograph of a 19-mo-old male patient with idiopathic early onset scoliosis treated with serial derotational casting for 9 mo and
subsequent bracing. Coronal Cobb angle of 37◦ , RVAD >20◦ , and phase 2 ribs. B, Three months after initial cast placement. C, Nine months after initial
cast placement. D, At 3 yr after initiating derotational casting the coronal curve has remained stable.

OPERATIVE TREATMENT is congenital scoliosis caused by a hemivertebra in which fusion

Posterior Spinal Fusion
Substantial improvements in the surgical treatment of pediatric
spine deformity have been made since the first spine fusion by
Hibbs in 191162 and the initial use of spine instrumentation
by Harrington in 1962.63 Since then, posterior spinal fusion
with instrumentation has been the preferred treatment option in
the surgical management of AIS. Significant advances in instru-
mentation have been made over the last several decades. In
1995 Suk et al40 presented his experience with thoracic pedicle
screw fixation in the management of AIS. This instrumentation
provided remarkable improvement in apical correction, revision
rates, pseudoarthrosis rates, and avoidance of anterior release in
larger curves.41,64-66 Since then, pedicle screw instrumentation
has become the standard of care in the management of AIS.
Historically, early fusions were performed for young patients
with EOS and significant deformity under the assumption that
a short straight spine was preferred over a long crooked one.67
However, there is now consensus that fusing the spine at an early
age and during periods of significant lung development has detri-
mental effects on cardiac and pulmonary physiology.68,69 Karol et
al69 demonstrated pulmonary function test results within 50% to
60% of predicted in 28 patients treated with spinal fusion before
the age of 9. An exception to avoiding early fusion in these patients
of a short segment at an early age, with or without hemivertebra
excision, can be curative and avoid progressive deformity70,71
(Figure 6).
Distraction-Based Techniques
These techniques apply longitudinal force bypassing the apex
of the curve, sometimes fusing only short segments at the end of
the construct and allowing the chest wall and spine to grow while
partially correcting the deformity. These devices are attached to
the spine, ribs or pelvis depending on the patient’s age, bone stock,
ambulation status, and characteristics of the curve. Examples of
these growth friendly implants include traditional growing rods
(TGR), magnetically controlled growth rods (MCGR), and verti-
cally expandable prosthetic titanium rib constructs.
Growing Rod
Harrington initially described the technique of fusionless spine
surgery in children younger than 10 yr with the use of a single
subperiosteal distraction rod. Marchetti and Faldini72 added the
concept of “end fusion” of 2 vertebras at each end followed by
the placement of a subperiosteal rod and sequential lengthening
after 6 months. Moe et al73 then modified this technique by
passing a smooth rod subcutaneously and limiting the subpe-
riosteal dissection to the hook attachment sites at both ends. Since

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FIGURE 5. A, PA radiograph of a 4-yr-old female patient with Syndromic EOS. B, Four weeks after
halo-gravity traction demonstrating a 38% improvement on her coronal Cobb angle.
then, this technique has undergone several modifications but the
underlying principle has remained the same.
Klemme et al74 published their experience on patients treated
with posterior instrumentation without fusion and sequential
distraction. At the time of definite fusion, the curves had
improved an average of 20◦ (67◦ -47◦ ) and the measured growth
of the instrumented but unfused segments averaged 3.1 cm over a
mean treatment period of 3 years. Akbarnia et al75 described the
dual rod technique which is the preferred method today. A single
or dual midline skin incision is performed. Meticulous dissection
is performed with subperiosteal dissection limited to the proximal
and distal anchoring points. Fixation points are obtained at each
end with pedicle screws or hooks. Biomechanical studies have
demonstrated the superior stability and fewer implant related
complications of all screw constructs when compared to screw-
hook or hook-hook fixation in dual growing rods.76-78 Selection
of foundation levels should take into consideration the presence of
pelvic obliquity as well as the magnitude and location of the curve.
Obtaining a solid foundation at the caudal end of the construct is
of utmost importance. Distally, four pedicle screws are generally
placed. Depending on the patient’s age, size, and anatomic varia-
tions, hooks vs pedicle screws are chosen for proximal fixation.
In our experience, adequate proximal fixation should be obtained
over three levels with at least five fixation points.79 Bone autograft
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or allograft is used to augment fusion at both cranial and
caudal foundation sites. Rods are contoured for the sagittal plane
and placed submuscularly without periosteum violation over the
noninstrumented segments. This can be performed by carefully
tunneling the rods underneath the fascia or through direct visual-
ization. In line or side to side tandem connectors are placed
around the straight thoracolumbar junction and cranial and
caudal rods are attached using these connectors. Periodical length-
ening is typically performed every 6 to 12 months depending on
the age, although it has been demonstrated that patients with
dual growing rod constructs who are lengthened frequently (≤ 6
months) may have greater curve correction and overall T1-S1
growth.80
The incidence of neuromonitoring changes has been reported
to be 0.9% during primary growing rod placement or exchange
and 0.5% during lengthening, therefore, routine use of intraop-
erative neuromonitoring during primary surgery or exchange is
currently recommended.81 The complication rate for the growing
rod techniques is high.75,80-82 Bess et al82 reported the Growing
Spine Study Group data on 140 patients who underwent 897
growing rods procedures. In their study, 58% of the patients had
at least one complication. They demonstrated that complication
rates could be reduced by delaying initial implantation (13%
decrease for every additional year in patient age at the beginning
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FIGURE 6. A, PA radiograph of a 7-yr-old patient with a left hemivertebra at the lumbosacral

junction causing right sided trunk shift with a reactive thoracolumbar curve. B, One year postop-
erative image after hemivertebra resection demonstrating resolution of the residual curve and trunk
shift. C, CT reconstruction of the lumbosacral hemivertebra.

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FIGURE 7. A, PA radiograph of a 7-yr-old patient with early onset idiopathic scoliosis. B, Two years postop
PA radiograph after 6 lengthenings with magnetically controlled growing rods.

of treatment), utilizing dual rods, submuscular rod implantation,
and reducing the number of surgical lengthenings.
Magnetically Controlled Growing Rods
Magnetically controlled growing rods allow lengthening proce-
dures without the need of anesthesia or surgical intervention
(Figure 7). The surgical technique and indications for MCGR
and TGR placement are similar. The MCGR device consists of an
implantable rod containing a magnetic actuator that couples with
external magnets on a remote controller converting rotational
motion to longitudinal growth of the rod. Lengthening can
be done in the office setting with no sedation, reducing the
amount of surgical interventions and anesthesia exposure, while
maintaining the benefits of deformity correction and growth
of the spine. Confirmation of the desired lengthening can be
achieved by radiographs or ultrasound, which has recently been
described as an accurate tool reducing the amount of radiation
exposure in the EOS population.83,84 A multicenter study by
Akbarnia et al85 comparing MCGR (n = 12) to TGR (n = 12)
demonstrated similar curve correction (32% in MCGR vs 31% in
TGR; p = .95), incidence of unplanned revisions, T1-S1 growth
(8.1 mm/yr vs 9.7 mm/yr respectively; p = .73) and T1-T12
growth (1.5 mm/yr vs 2.3 mm/yr respectively; p = .83). The
MCGR cohort had a total of 16 surgeries and 137 noninvasive
lengthenings whereas the TGR cohort had 73 total surgeries
including 56 surgical lengthenings.
Reported complication rate for growing spinal implants in the
treatment of patients with early onset scoliosis ranges from 29% to
more than 70%, the most common being implant related compli-
cations.75,81,82,87–89 Even though the use of MCGR may reduce

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the amount of surgical interventions when compared to TGR, its
use does not appear to prevent implant related complications such
as proximal junctional kyphosis, anchor failure, rod breakage, and
failure of device lengthening, among others. In a recent multi-
center retrospective review, Choi et al90 reported on 54 patients
with early onset scoliosis who were treated with MCGR. Twenty-
three patients (42%) had at least one complication. A total of
11% of the patients had at least 1 broken rod while 13% experi-
enced either proximal or distal implant related complications. In
six patients (11%), the rod did not lengthen at least in 1 episode,
but four of these patients lengthened at subsequent office visits
with repeated magnetically controlled noninvasive distraction.
As in many other aspects of medicine, there is typically
an initial higher cost associated with new technology and
implants. MCGR is not an exception. However, given the
reduction in the number of surgical interventions and anesthetic
episodes associated with MCGR, it is likely that the long term
economic outcome with this new device will be to reduce
costs while maintaining safety and clinical results. A recent cost
analysis comparison between MCGR and TGR using a projected
economic model demonstrated cost neutrality between implants
by eliminating TGR surgical lengthenings. This model estimated
the costs for implantation, revisions, lengthenings, equipment
exchanges, and final fusion for the 2 groups over a projected 6 yr
period of care. Over this period, the use of MCGR was associated
with a decrease of approximately 11.2 procedures per patient, 270
fewer deep surgical site infections, and 197 less revisions due to
device failure in over 1000 simulated patients when compared to
TGR.86
Compression-Based Techniques
Based on the Hueter–Volkmann principle, the vertical growth
along the concavity of a scoliotic deformity is known to be
slower than along the convexity, due to compressive forces
inhibiting growth.91 These techniques, which are commonly used
in the treatment of limb malalignment in children, attempt to
modulate growth by applying compressive forces through the
convex vertebral physis. Vertebral stapling or tethers are placed
across the convex growth plates and concave growth proceeds with
an ultimate goal of curve correction and balance. These proce-
dures are generally performed through a thoracoscopic approach
or mini open retroperitoneal approach if below the diaphragm.
Vertebral Body Stapling
Vertebral staples are made of Nitinol, a nickel-titanium alloy
that changes its configuration when in contact with body temper-
atures. Nitinol staples are approved by the US Food & Drug
Administration for upper and lower extremities use, but their
use in the pediatric spine deformity is still off-label. Betz and
colleagues92 reported their experience with anterior vertebral
staples in a retrospective review of 28 patients with idiopathic
scoliosis treated with anterior vertebral body staples and followed
for 2 yr. They defined success as curves that corrected to within
10◦ or decreased by >10◦ from the preoperative measurement.
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Thoracic curves <35◦ had a 77% success rate while those ≥35◦
only a 25%. Lumbar curves demonstrated a success rate of
86.7%. Thoracic curves who reached ≤20◦ of coronal Cobb angle
measurement on the first standing x-ray had an 85.7% success
rate. Suggested criteria for vertebral body stapling (VBS) include
age (<13 yr for girls and <15 yr for boys), Risser grade 0 to 1, at
least 1 yr of remaining growth by wrist bone age or Sanders grade
≤4; flexible thoracic curves 25 to 35◦ (lumbar coronal curves
<45◦ ); minimal rotation along the apex of the deformity and
a thoracic kyphosis <40◦ .85 Bumpass et al93 recently published
their results on 31 patients with curves from 25◦ to 40◦ (Risser
0-2) who were treated with VBS. Success in curve control was
defined as per Betz et al.92 At a minimum of 2 yr of follow-up,
the overall success of curve control in their group was 61%. When
groups were subdivided based on the preoperative coronal curve
magnitude of <35◦ vs ≥35◦ , those with a preoperative Cobb
angle <35◦ had a 75% control rate vs only a 22% in curves
≥35◦ . Thoracic curves ≥35◦ at initial treatment, progressed to
more than 50◦ in 83% of the cases.
Vertebral Body Tethering
With a similar mechanism, tethers consist of bony anchors
attached to flexible cords which provide compressive forces
around the convexity of a curve, potentially correcting the
scoliosis. A theoretical advantage of tethering over VBS is
that tethering provides less restriction of motion in direc-
tions other than lateral bending away from the device, whereas
staples restrict motion in multiple planes, hence potentially
causing a less harmful effect on the overall health of interver-
tebral discs. Vertebral body tethering (VBT) has been studied
in animal models and has shown radiographic evidence of
vertebral deformity correction while maintaining flexibility of
the spine.94,95 Samdani et al96 published the results of 11
patients with AIS and showed a 70% correction on coronal
Cobb angle of the thoracic curve with no major complica-
tions at 2 yr follow-up. They suggest the use of VBT in skele-
tally immature patients (Risser 0-1, Sanders ≤4) with thoracic
curves from 35◦ to 60◦ who demonstrate flexibility to less than
30◦ , whereas thoracic kyphosis >40◦ and a rotational promi-
nence >20◦ were considered absolute contraindications for this
procedure. Crawford and Lenke97 demonstrated an impressive
scoliosis correction in a patient with juvenile idiopathic scoliosis
treated with this technique.
As previously discussed, bracing is helpful in preventing
progression of scoliosis, but in contrast to these compression-
based techniques, it does not provide correction of existing
deformity. Compliance has also been shown to be a signif-
icant problem among patients braced for idiopathic scoliosis.98
Although brace treatment is still the first line treatment in
moderate idiopathic scoliosis, compression based techniques
offer a potential alternative for patients who refuse or are not
compliant with brace wear. The determination of appropriate
indications for these procedures as well as optimal implants
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FIGURE 8. A, PA and lateral radiographs of a 6-yr-old female patient with idiopathic early onset scoliosis treated with a Shilla technique. B, Two months postop. C,
Three years postop demonstrating guided growth through the Shilla construct with conservation of the initial correction.
continues to evolve. Certainly, a thorough discussion with the
families and strict selection criteria should be followed before
suggesting compression based techniques in the early onset or AIS
population.
Growth Guided Techniques
Growth guided techniques aim to preserve growth centers
throughout the spine while correcting the apex of the deformity.
The Luque trolley consists of rods fixed segmentally to the
spine by sublaminar wires in the absence of a fusion. As
growth continues, the rods glide through the sublaminar wires
maintaining spinal correction. This technique is not used
abundantly due to high rates of associated complications, sponta-
neous fusion, and inadequate maintenance of spinal growth.99,100
Ouellet et al101 published a small series of 5 patients treated with a
modern Luque trolley technique in which the cranial and caudal
ends of the construct were instrumented and fused, while only
sliding instrumentation was placed throughout the rest of the
spine using muscle sparing techniques. They showed an average
correction of the coronal Cobb angle for the primary curve from
60◦ to 21◦ and a mean spine growth of 3 cm over 4 yr which
represented 77% of the predicted growth.
With the Shilla technique, a short apical fusion is performed
with additional proximal and distal screws that permit the rods to
slide, thereby directing the growth along the rod trajectory. The
cranial and caudal Shilla screws are placed through the muscle
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MODERN SURGICAL MANAGEMENT OF EOS AND AIS
layer with minimal disruption to the adjacent soft tissue and
periosteum as to minimize the possibility of ankylosis at these
segments. The goal is to correct the apical deformity, rendering
these segments back to neutral in all planes, while permitting and
guiding growth through the remaining instrumented but unfused
spine segments (Figure 8). McCarthy et al102 published their
5 year follow-up on this technique. At 5 years the curves were
reduced from an average of 69◦ to 38.4◦ and the space available
for the lung, determined by the Campbell technique,103 was
increased by an average of 27.7% on the right and 30.5% on the
left hemi-thorax. Complication rate was 73%, the majority being
return to the OR due to implant-related problems. Concerns
about the development of metal ions in the blood and tissues
surrounding these implants have recently emerged.104 Despite
these concerns, the enormous advantage of both of these growth
guidance techniques is that they allow for the surgical treatment
of EOS without the need of repetitive surgical lengthening.
CONCLUSION
The underlying principles in the treatment of both adolescent
and early onset idiopathic scoliosis have remained stable over
decades, but technological advances in imaging as well as new
instrumentation and surgical techniques have provided new
methods for the management of these conditions. As new
technology continues to develop, our understanding on the
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pathophysiology and treatment of early onset and adolescent
scoliosis will continue to evolve.
Disclosures
Dr Vitale reports research grants from Pediatric Orthopaedic Society of
North America, Children’s Spine Foundation; royalties from Biomet, consultant
fees from Stryker, Biomet, and Medtronic. He also holds positions in the
following organizations: Wellinks, Inc. (Chief Medical Officer), Children’s
Spine Foundation (VP, BoD), POSNA (board member), International Pediatric
Orthopaedic Symposium (board member). He also receives travel support from
Biomet. The other authors have no personal, financial, or institutional interest in
any of the drugs, materials, or devices described in this article.
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