Scoliosis Research Society (SRS)
Scoliosis Research Society (SRS)
An International Organization Dedicated to the Education, Research and Treatment of Spinal Deformity
Our Mission is to Foster Optimal Care for All Patients with Spinal Deformities
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Infantile Scoliosis

Instrumentation and Fusion

Definitive spinal fusion is performed to stop growth of the spine and thus achieve permanent correction. This treatment becomes appropriate when the patient has achieved sufficient spinal length and thoracic width and depth. It is important to determine that the growth stoppage will not in itself produce thoracic insufficiency. Timing of the procedure is controversial, but in general, patients who have reached age 10 have completed the greatest part of their thoracic growth, and thus are candidates for definitive fusion to finish their scoliosis treatment.

Posterior fusion provides permanent stabilization in the corrected position and is achieved by removing the joints between the vertebrae to be fused. These are usually all the vertebrae which are involved in the curve. Bone graft - either from the pelvis, ribs, or from the bone bank (allograft) - is placed in each joint space which has been removed. Over time (4-6 months), the graft adheres to the vertebral bone, and the operated portion of the spine heals into a solid block of bone which cannot bend, thus eliminating further progression of the curve. Typically in a child who has reached an appropriate age for definitive fusion, instrumentation will also be placed when the fusion is performed. The instrumentation rigidly fixes the spine internally, so that the corrected position is carefully preserved while the fusion takes place over the 4-6 month period. This rigid fixation is achieved by screws, hooks, and wires ("anchors") attached to the spine, usually at multiple sites along the curve, and then rods are attached to the anchors to stiffen the entire area. Depending on the flexibility of the curve and any preceding treatment (such as traction), there may be additional correction of the deformity achieved by the application of the instrumentation. However, the primary goal of the surgery is to stop the curve from progressing further, resulting in definitive stabilization. Additional correction is an added benefit but not the primary concern. Often the patient does not need a cast or brace if the internal instrumentation is felt to be adequate at the time of surgery.

Depending on the surgeon's determination of how much growth the patient might have remaining, an anterior (front) fusion of the spine may also be appropriate. This is done either through an incision in the patient's side or rib cage, or through small incisions between the ribs, aided by a camera (thoracoscopic fusion). This will prevent curve progression after posterior (rear) fusion due to continued growth of the vertebrae. Known as the "crankshaft phenomenon", curves sometimes continue to grow by rotating around the original surgical fusion. This is known to happen when children under the age of ten undergo fusion surgery and can be prevented by performing an anterior fusion at the same time (or shortly before or after) the definitive posterior operation.

The decision to undergo the additional surgery required to prevent crankshaft curve progression is dependent on the age of the child at the time surgery is selected. Delaying definitive surgery is the best option if that delay can be accomplished while maintaining control of the curve by non-operative means.