October 7, 2009

Casting May Trump Surgery for Infantile Scoliosis

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When children are diagnosed with progressive infantile scoliosis, a rare and potentially fatal form of spinal curvature that is also known as early-onset scoliosis, their first course of treatment is often bracing. If that fails, they generally have metal rods surgically implanted in their backs, later followed by spinal fusion. These children face risks of surgical complications, and their backs and chests may be stiff for life.

New research from the University of Rochester Medical Center (URMC), New York, challenges that treatment protocol and may lead doctors to eschew implantable devices for tweaks on an old technology—serial casting. According to URMC, this method of casting may have fewer and less serious potential complications and, while it does require multiple episodes of anesthesia and ventilation, it requires no surgery. In fact, with the right training and equipment, the casting can be performed during outpatient procedures.

“Best of all, we can cure some children with progressive infantile scoliosis—something we can’t do with surgery and devices,” said James O. Sanders, MD, chief of pediatric orthopedics at the URMC’s Golisano Children’s Hospital and lead author of the research published in the September 2009 Journal of Pediatric Orthopedics. “If we cast these children before their curvatures become severe and before they turn 2, our chances of avoiding surgery and potentially curing them are much better.”

The study followed 55 patients with progressive infantile scoliosis at Shriners Hospitals for Children in three cities—Erie, Pennsylvania; Salt Lake City, Utah; and Chicago, Illinois. Pediatric orthopedic specialists used a method of casting called EDF (extension, derotation, and flexion) that capitalizes on children’s rapid growth to untwist and un-curve their spines over time. The method uses a specialized table and casts with strategically placed holes. Sanders and URMC colleague Paul Rubery, MD, an orthopedic surgeon, are two of only a handful of surgeons nationwide who use this method with the goal of curing, not just delaying surgery.

Children are given anesthesia and ventilated during the casting because the pressure on the chest during the procedure can make breathing difficult. The cast may extend over the shoulders like a tank-top and down to the pelvis, but large holes are left open between to relieve pressure on the chest and abdomen while preventing the ribs from rotating. The entire procedure can take less than an hour. Depending on the child’s age and the severity of the curvature, the series of casts (removed and refitted every eight to 12 weeks) could be completed in about two years.

Although the casts can be restrictive and cause some initial trouble with mobility, Sanders said parents are almost always surprised by how quickly their children adapt and how little having a cast changes their lives. Children can’t swim or be immersed in water, but they are otherwise unrestricted in their activities.

Current treatments, such as the vertical expandable prosthetic titanium rib (VEPTR), which is attached to the inside of the ribs and adjusted over time; and growing rods, which are inserted near the spine and lengthened over time, are aimed at delaying spinal fusion. They are not meant to be a cure for the disease, and they present a whole host of potential complications, such as infection, pulling loose, and causing stiffness in the chest and back.

“Casting remains the only method which can cure some of these curves,” Sanders said.

Unfortunately, casting doesn’t cure all curvatures, and some children may still require growing rods or the VEPTR. Among children in this study, a little more than 10 percent saw their curves worsen and needed surgery. Sanders said his future research will focus on finding the best treatment options for these children, for older children, and for those with large curvatures.

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