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Thread: Tethering in scoliosis management post sci

  1. #1

    Tethering in scoliosis management post sci

    Dr. Wise, KLD or anyone else that has information on this procedure, I would love to hear your opinion. IT has been recommended for a friend's son here in shriners philadelphia and in time-my daughter Noirin. From reading between lines seems it has just been done so far on idiopathic scoliosis and not yet on SCI.It is an endoscopic procedure and through the thorax-lateral entry and i suppose the main concern is on lungs. THe boy is T11 whereas noirin is T1 and had pneumothorax at time of accident.
    I realize long term results are not available and spinal fusion may still be required. His age is 10 and cobb angle 40 degrees.
    WE are both concerned about hospitalization period as live out of the country and rehab needs after and ability to fly home. we are due to meet anesthetist and maybe ortho again and can email concerns so questions may be answered but would love to hear other opinions. thanks, Sonia.

  2. #2
    I asked Dr Wise to comment on your posting
    pbr

  3. #3
    Quote Originally Posted by noirin's mum View Post
    Dr. Wise, KLD or anyone else that has information on this procedure, I would love to hear your opinion. IT has been recommended for a friend's son here in shriners philadelphia and in time-my daughter Noirin. From reading between lines seems it has just been done so far on idiopathic scoliosis and not yet on SCI.It is an endoscopic procedure and through the thorax-lateral entry and i suppose the main concern is on lungs. THe boy is T11 whereas noirin is T1 and had pneumothorax at time of accident.
    I realize long term results are not available and spinal fusion may still be required. His age is 10 and cobb angle 40 degrees.
    WE are both concerned about hospitalization period as live out of the country and rehab needs after and ability to fly home. we are due to meet anesthetist and maybe ortho again and can email concerns so questions may be answered but would love to hear other opinions. thanks, Sonia.
    noirun's mum,

    I have not heard of endoscopic untethering of the spinal cord. As you probably know, endoscopy is used extensively at some centers to remove herniated discs and to do thoracic sympathectomies. These are all surgeries where the target of the surgery can be exposed and accessible to endoscopic surgery. I cannot imagine that they are referring to intradural untethering because this means going through bone, cutting the dura, and the removing adhesions from within the dura. There is no room for an endoscopic tube. Perhaps they are referring to extradural adhesions?

    I have the greatest respect for Shriner's doctors and their good intentions. I suggest that you find out what the objective of the surgery is, why they are using this approach as opposed to a direct surgical exposure, and what their results are to date. While they may not have long term followup, it would be important to know what complications they have and what improvements have resulted from the surgery.

    Wise.

  4. #4

    Non fusi√≥n v√*a tethering for scoliosis correction

    Quote Originally Posted by Wise Young View Post
    noirun's mum,

    I have not heard of endoscopic untethering of the spinal cord. As you probably know, endoscopy is used extensively at some centers to remove herniated discs and to do thoracic sympathectomies. These are all surgeries where the target of the surgery can be exposed and accessible to endoscopic surgery. I cannot imagine that they are referring to intradural untethering because this means going through bone, cutting the dura, and the removing adhesions from within the dura. There is no room for an endoscopic tube. Perhaps they are referring to extradural adhesions?

    I have the greatest respect for Shriner's doctors and their good intentions. I suggest that you find out what the objective of the surgery is, why they are using this approach as opposed to a direct surgical exposure, and what their results are to date. While they may not have long term followup, it would be important to know what complications they have and what improvements have resulted from the surgery.

    Wise.
    Dr Wise

    Thank you for your answer however this procedure is to correct the scoliosis by tethering the spine. Apparently this procedure has been tried in non SCI patients but not in SCI patients before. I have attached a paper we found on non fusion treatment of the spine.

    Any advice on questions to ask the Doctors tomorrow would be great

  5. #5

    Vertebral Body Tethering fusionless option for scoliosis

    Dr Wise / SCI Nurse / Anyone who has knowledge of an Thoracosopic / Endoscopia approach

    I have attached the presentation they gave me about the VBT procedure. I can see if offers a number of advantages by being a less invasus procedure and offers the possibility of retaining currently flexibility which would be lossed with a spinal fusion.

    However in Sean's case they have to detach the diaphragm during the procedure which will result in loss of lung capacity. A spinal fusion does not need to do this. I am afraid of the long term consequences of loss of lung capacity. We have just interested Sean in Wheelchair Basketball and tennis, will this stop him doing this? As he gets older will he be more susceptible to respiratory complications in later life?

    This procedure also involves deflating a lung and alot of radiation again what are the possible consequences?

    Also there is the added complication of having to travel internationally and should complications arise there is no help at home and involves a long flight for corrective surgery.

    There is a small window where VBT is viable ie the scoliosis curve below a certain angle and sufficient growth. The progression of Sean's curve would means that a spinal fusion could be necessary within a year and a half if it continues to progress at current rate. So hopefully this brace will be more successful in prolonging the progression of the curve.

    I hope somebody can advise me and that this might be of interest to other parents of SCI children who faces the bleak prospect of choosing a spinal fusion for their kids

  6. #6
    Hi Dr Young, Just noticed you are online at the minute so was hoping you may get a chance to comment on the updated info that Sean's mum has attached to the tethering procedure i asked you about for scoliosis. With thanks, sonia.

  7. #7
    Quote Originally Posted by soimumireland View Post
    Dr Wise

    Thank you for your answer however this procedure is to correct the scoliosis by tethering the spine. Apparently this procedure has been tried in non SCI patients but not in SCI patients before. I have attached a paper we found on non fusion treatment of the spine.

    Any advice on questions to ask the Doctors tomorrow would be great
    soimumireland,

    Thank you for including the paper. I misunderstood the procedure from your description. The paper explained it all. The procedure is a fusionless treatment of scoliosis through the use of vertebral staples or bone anchors with ligament tethers. It is an elegant method to correct scoliosis, . The short-term results look very good and the review (which was published in 2007) pointed out that long-term followup results were not yet available.

    I therefore did a search of more recent literature to see if there are any more recent reports of longer term followup results of fusionless procedures. While the method is still relatively new and few orthopedic surgeons have large series of cases with long-term followups, it is very clear that the best scoliosis surgeons today are moving to these procedures using stapling, anchoring with ligament tethering for softer curves, and growing expansion rods that grew with the child.

    In my opinion, these new procedures using stapling, tethering, and expansion rods are more much better than the rigid rods and wires that I was used to in the 1970's and 1980's. They are also better than the wedge resections that had been used to correct curvatures in the 1990's. In the end, these procedures leave the spinal column flexible and takes into account the growth of the child. Even though long-term followup studies are not available yet, I believe that the results will be far better than older methods.

    Wise.

  8. #8
    THanks so much DR Wise for going to the effort of looking at recent data.It is comforting to get this information.
    I hope you don't mind but i wonder can you comment on the possible difficulties of having a thoracic endoscopic procedure done to a child with an SCI as opposed to idiopathic.
    I suppose our main concerns are in relation to lung function as the lung needs to be deflated and the diaphragm detached. Does the scarring in a pneumothorax received at time of accident affect things and how about reduced lung capacity to start with. mY daughter has a T1 injury and 50% lung capacity.
    Sonia.

  9. #9
    Quote Originally Posted by noirin's mum View Post
    THanks so much DR Wise for going to the effort of looking at recent data.It is comforting to get this information.
    I hope you don't mind but i wonder can you comment on the possible difficulties of having a thoracic endoscopic procedure done to a child with an SCI as opposed to idiopathic.
    I suppose our main concerns are in relation to lung function as the lung needs to be deflated and the diaphragm detached. Does the scarring in a pneumothorax received at time of accident affect things and how about reduced lung capacity to start with. mY daughter has a T1 injury and 50% lung capacity.
    Sonia.
    The endoscopic approach should greatly reduce mortality and recovery time after surgery. Surgery time should be shorter and blood loss should be minimal. Of course, a child with only 50% lung volume would have a greater risk than a child with full lung capacity. However, due to the endoscopy, there will be less manipulation of the lung and therefore less compromise of her lung function during surgery. So, in theory, I don't think that the risk is that much higher.

    Do you know whether the surgeons are planning a wedge resection? I had not realized that Noirin already has a 50% reduction in lung capacity due to her scoliosis, suggesting that she has a substantial fixed curve. A wedge resection may partly straighten her spine and perhaps give her more lung capacity in the future.

    Let me emphasize that my initial reservations resulted from my misunderstanding that you were referring to use of endoscopy to untether the spinal cord. I couldn't imagine how this would be done and had never heard of this procedure being used to untether the spinal cord of a child with scoliosis. In my opinion, this development is a great boon for the treatment of children with progressive scoliosis. The curvature can be addressed much earlier.

    Wise.

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