Perioperative Complications and Health-related Quality of Life Outcomes in Severe Pediatric Spinal Deformity.

STUDY DESIGN: Prospective multicenter cohort study. OBJECTIVE: To evaluate perioperative complications and mid-term outcomes for severe pediatric spinal deformity. SUMMARY OF BACKGROUND DATA: Few studies have evaluated the impact of complications on health-related quality of life (HRQoL) outcomes in severe pediatric spinal deformity. METHODS: Patients from a prospective, multicenter database with severe pediatric spinal deformity (minimum of 100 degree curve in any plane or planned vertebral column resection (VCR)) with a minimum of 2-years follow-up were evaluated (n=231). SRS-22r scores were collected preoperatively and at 2-years postoperatively. Complications were categorized as intraoperative, early postoperative (within 90-days of surgery), major, or minor. Perioperative complication rate was evaluated between patients with and without VCR. Additionally, SRS-22r scores were compared between patients with and without complications. RESULTS: Perioperative complications occurred in 135 (58%) patients, and major complications occurred in 53 (23%) patients. Patients that underwent VCR had a higher incidence of early postoperative complications than patients without VCR (28.9% vs. 16.2%, P =0.02). Complications resolved in 126/135 (93.3%) patients with a mean time to resolution of 91.63 days. Unresolved major complications included motor deficit (n=4), spinal cord deficit (n=1), nerve root deficit (n=1), compartment syndrome (n=1), and motor weakness due to recurrent intradural tumor (n=1). Patients with complications, major complications, or multiple complications had equivalent postoperative SRS-22r scores. Patients with motor deficits had lower postoperative satisfaction subscore (4.32 vs. 4.51, P =0.03), but patients with resolved motor deficits had equivalent postoperative scores in all domains. Patients with unresolved complications had lower postoperative satisfaction subscore (3.94 vs. 4.47, P =0.03) and less postoperative improvement in self-image subscore (0.64 vs. 1.42, P =0.03) as compared to patients with resolved complications. CONCLUSION: Most perioperative complications for severe pediatric spinal deformity resolve within 2-years postoperatively and do not result in adverse HRQoL outcomes. However, patients with unresolved complications have decreased HRQoL outcomes.

Re-evaluating consensus and uncertainty among treatment options for early onset scoliosis: a 10-year update.

PURPOSE: Consensus and uncertainty in early onset scoliosis (EOS) treatment were evaluated in 2010. It is currently unknown how treatment preferences have evolved over the past decade. The purpose of this study was to re-evaluate consensus and uncertainty among treatment options for EOS patients to understand how they compare to 10 years ago. METHODS: 11 pediatric spinal surgeons (similar participants as in 2010) were invited to complete a survey of 315 idiopathic and neuromuscular EOS cases (same cases as in 2010). Treatment options included the following: conservative management, distraction-based methods, growth guidance/modulation, and arthrodesis. Consensus was defined as ≥ 70% agreement, and uncertainty was < 70%. Associations between case characteristics and consensus for treatments were assessed via chi-squared and multiple regression analyses. Case characteristics associated with uncertainty were described. RESULTS: Eleven surgeons [31.7 ± 7.8 years of experience] in the original 2010 cohort completed the survey. Consensus for conservative management was found in idiopathic patients aged ≤ 3, whereas in 2010, some of these cases were selected for surgery. There is currently consensus for casting idiopathic patients aged 1 or 2 with moderate curves, whereas in 2010, there was uncertainty between casting and bracing. Among neuromuscular cases with consensus for surgery, arthrodesis was chosen for patients aged 9 with larger curves. CONCLUSION: Presently, preferences for conservative management have increased in comparison to 2010, and casting appears to be preferred over bracing in select infantile cases. Future research efforts with higher levels-of-evidence should be devoted to elucidate the areas of uncertainty to improve care in the EOS population. LEVEL OF EVIDENCE: Level V.

Delayed diagnosis of a flexion-distraction spinal injury and occult small bowel injury in a pediatric trauma patient: Importance of recognizing the abdominal "seatbelt sign".

Spine trauma in the pediatric population can present with occult spinal and visceral injuries, presenting unique diagnostic challenges. Subtle imaging findings, as well as difficulty in patient participation with history and examination can contribute to a delayed or missed diagnosis. This in turn can be detrimental to recovery, leading to significant delay in care, additional morbidity, and cost. We present the case of an 11-year-old female patient with a delayed diagnosis of an unstable three-column lumbar spine injury as well as an occult small bowel injury that evaded diagnosis despite multiple hospitalizations and a plethora of imaging and treatment modalities. This led to several extended hospital stays and numerous interventions and surgeries to treat her injuries. We present this case to highlight the sequela of such an injury, and to broaden awareness across specialties of an injury pattern which requires a heightened index of suspicion to detect.

Preconception, Antepartum, and Peripartum Care for the Woman With a Spinal Cord Injury: A Review of the Literature.

IMPORTANCE: Spinal cord injury (SCI) may result in temporary or permanent loss of sensory, motor, and autonomic function, presenting unique medical and psychosocial challenges in women during their childbearing years. OBJECTIVE: The aim of this study was to review the literature and describe the spectrum of pregnancy considerations, complications, and evidence-based obstetric practices in women with SCI. EVIDENCE ACQUISITION: A literature search was undertaken using the search engines of PubMed and Web of Science using the terms "spinal cord injury" or "spinal cord complications" and "pregnancy outcomes" or "pregnancy complications." The search was limited to the English language, and there was no restriction on the years searched. RESULTS: The search identified 174 abstracts, 50 of which are the basis for this review. Pregnancy in women who have experienced an SCI requires a multidisciplinary approach. Common complications during pregnancy include recurrent urinary tract infection, upper respiratory tract infection, hypertension, venous thromboembolism, and autonomic dysreflexia (AD), which is a potentially life-threatening complication. Obstetricians should avoid potential triggers and be familiar with acute management of AD. Postpartum complications include difficulty initiating and maintaining breastfeeding and increased risk of postpartum depression and other mental health issues. CONCLUSIONS AND RELEVANCE: Obstetricians caring for women with an SCI must be familiar with the unique challenges and complications that may occur during pregnancy and puerperium. RELEVANCE STATEMENT: An evidence-based literature review of the care of pregnant women with spinal cord injury.

Characterizing Use of Growth-friendly Implants for Early-onset Scoliosis: A 10-Year Update.

BACKGROUND: Growth-friendly treatment of early-onset scoliosis (EOS) has changed with the development and evolution of multiple devices. This study was designed to characterize changes in the use of growth-friendly implants for EOS from 2007 to 2017. METHODS: We queried the Pediatric Spine Study Group database for patients who underwent index surgery with growth-friendly implants from July 2007 to June 2017. In 1298 patients, we assessed causes of EOS; preoperative curve magnitude; age at first surgery; patient sex; construct type; lengthening interval; incidence of "final" fusion for definitive treatment; and age at definitive treatment. α=0.05. RESULTS: From 2007 to 2017, the annual proportion of patients with idiopathic EOS increased from 12% to 33% (R=0.58, P=0.006). Neuromuscular EOS was the most common type at all time points (range, 33% to 44%). By year, mean preoperative curve magnitude ranged from 67 to 77 degrees, with no significant temporal changes. Mean (±SD) age at first surgery increased from 6.1±2.9 years in 2007 to 7.8±2.5 years in 2017 (R=0.78, P<0.001). As a proportion of new implants, magnetically controlled growing rods increased from <5% during the first 2 years to 83% in the last 2 years of the study. Vertically expandable prosthetic titanium ribs decreased from a peak of 48% to 6%; growth-guidance devices decreased from 10% to 3%. No change was seen in mean surgical lengthening intervals (range, 6 to 9 mo) for the 614 patients with recorded lengthenings. Final fusion was performed in 88% of patients who had undergone definitive treatment, occurring at a mean age of 13.4±2.4 years. CONCLUSIONS: From 2007 to 2017, neuromuscular EOS was the most common diagnosis for patients treated with growth-friendly implants. Patient age at first surgery and the use of magnetically controlled growing rods increased during this time. Preoperative curve magnitude, traditional growing rod lengthening intervals, and rates of final fusion did not change. LEVEL OF EVIDENCE: Level II.

Accuracy of the Spinal Pain Diagram Is Influenced by Patient Health Literacy in Completion of the Scoliosis Research Society30 Questionnaire.

The Scoliosis Research Society Questionnaire (SRS30) was designed to measure healthrelated quality of life in scoliosis patients. Patients with low health literacy may need specific guidance when providing feedback on the SRS30 so that reliable and valid results are collected for clinical decision making. The purpose of this research study was to investigate the health literacy demands of the Scoliosis Research Society Questionnaire (SRS30) and to determine if health literacy best practices mitigate errors for patients with low health literacy. Readability assessment, focus groups and structured interviews were used. Results indicated that patients with low health literacy perceived health literacy best practices as helpful in completing the SRS30 drawing. Additionally, patients with inadequate health literacy had a higher proportion of errors in pain location on the drawing (p = 0.0325) compared to patients with adequate health literacy. (Journal of Surgical Orthopaedic Advances 29(1):3942, 2020).

Positioning and baby devices impact infant spinal muscle activity.

Infant positioning in daily life, particularly in relation to active neck and back muscles, may affect spinal development, psychosocial progression, and motor milestone achievement. Yet the impact of infant body position on muscle activity is unknown. The objective of this study was to evaluate neck and back muscle activity of healthy infants in common positions and baby devices. Healthy full-term infants (n = 22, 2-6 months) participated in this experimental study. Daily sleep and positioning were reported by caregivers. Cervical paraspinal and erector spinae muscle activity was measured using surface electromyography (EMG) in five positions: lying prone, lying supine, held in-arms, held in a baby carrier, and buckled into a car seat. Mean filtered EMG signal and time that muscles were active were calculated. Paired t-tests were used to compare positions to the prone condition. Caregivers reported that infants spent 12% of daily awake time prone, 43% in supine-lying baby gear, and 44% held in-arms or upright in a baby carrier. Infants exhibited highest erector spinae activity when prone, and lowest cervical paraspinal muscle activity in the car seat. No differences were found between in-arms carrying and babywearing. This first evaluation of the muscle activity of healthy infants supports the importance of prone time in infants' early spinal development because it promotes neck and back muscle activity. Carrying babies in-arms or in baby carriers may also be beneficial to neck muscle development, while prolonged time spent in car seats or containment devices may be detrimental to spinal development.

Curve Modulation and Apex Migration Using Shilla Growth Guidance Rods for Early-onset Scoliosis at 5-Year Follow-up.

BACKGROUND: The Shilla procedure was designed to correct and control early-onset spinal deformity while harnessing a child's remaining spinal growth. It allows for controlled axial skeletal growth within the construct, avoiding the need for frequent surgeries to lengthen implants. We hypothesized that curve characteristics evolve over time after initial apex fusion and placement of the Shilla implants. The purpose of this study was to identify trends in curve evolution after Shilla implantation and understand how these changes influence ultimate outcome. METHODS: A single-center, retrospective review of all patients with Shilla implants in place for ≥5 years yielded 21 patients. Charts and radiographs were reviewed to compare coronal curve characteristics preoperatively, postoperatively, and at last follow-up to note changes in the apex of the primary curve. Also noted were the development of adjacent compensatory curves, the overall vertical spinal growth, and the need for definitive spinal fusion once skeletal maturity was reached. RESULTS: Of the 21 patients, the curve apex migrated caudally in 12 patients (57%) and cephalad in 1 patient (5%), with a mean migration of 2.7 vertebral levels. Two patients (10%) developed new, significant compensatory curves (1 caudal and 1 cephalad). All patients demonstrated spinal growth in T1-S1 length following index surgery (mean, 45 mm). At skeletal maturity, 10 patients underwent definitive posterior spinal fusion and instrumentation, and 3 underwent implant removal alone. CONCLUSIONS: This study constitutes the longest follow-up of Shilla patients evaluating curve and implant behavior. Results of this review suggest that the apex of the fused primary curve shifts in approximately 62% of patients, with nearly all of these (92%) involving a distal migration. Compensatory curves did develop after Shilla placement as well. Overall, these findings represent adding-on distal to the apex after Shilla instrumentation rather than a crankshaft phenomenon about the apex. A better understanding of spinal growth mechanics and outcomes after Shilla placement may improve our ability to appropriately select patients and instrumentation levels. LEVEL OF EVIDENCE: Level III.

Growth-Friendly Spine Surgery in Escobar Syndrome.

BACKGROUND: The aims of this study were to characterize the spinal deformity of patients with Escobar syndrome, describe results of growth-friendly treatments, and compare these results with those of an idiopathic early-onset scoliosis (EOS) cohort to determine whether the axial stiffness in Escobar syndrome limited correction. METHODS: We used 2 multicenter databases to review the records of 8 patients with EOS associated with Escobar syndrome who had at least 2-year follow-up after initiation of growth-friendly treatment from 1990 to 2016. An idiopathic EOS cohort of 16 patients matched for age at surgery (±1 y), postoperative follow-up (±1 y), and initial curve magnitude (±10 degrees) was identified. A randomized 1:2 matching algorithm was applied (α=0.05). RESULTS: In the Escobar group, spinal deformity involved 7 to 13 vertebrae and ranged from no vertebral anomalies in 3 patients to multiple segmentation defects in 6 patients. Mean age at first surgery was 5 years (range, 1.4 to 7.8 y) with a mean follow-up of 7.5 years (range, 4.0 to 10 y). Mean major curve improved from 76 degrees at initial presentation, to 43 degrees at first instrumentation, to 37 degrees at final follow-up (both P<0.001). Mean pelvic obliquity improved from 16 degrees (range, 5 to 31 degrees) preoperatively to 4 degrees (range, 0 to 8 degrees) at final follow-up (P=0.005). There were no differences in the mean percentage of major curve correction between the idiopathic EOS and Escobar groups at the immediate postoperative visit (P=0.743) or final follow-up (P=0.511). There were no differences between the cohorts in T1-S1 height at initial presentation (P=0.129) or in growth per month (P=0.211). CONCLUSIONS: Multiple congenital fusions and spinal curve deformity are common in Escobar syndrome. Despite large areas of congenital fusion, growth-friendly constructs facilitate spinal growth and improve curve correction. These results are comparable to those in idiopathic EOS. LEVEL OF EVIDENCE: Level III-case-control study.

Expansion Thoracoplasty as a Life-Saving Procedure in an Adolescent With Severe Spinal Deformity and Sacral Agenesis.

STUDY DESIGN: Case report. OBJECTIVES: To describe use of expansion thoracoplasty (ET) for severe thoracic insufficiency syndrome (TIS) in an adolescent with severe spinal deformity. BACKGROUND: ET is typically performed in young patients with TIS to increase chest cavity volume, improve alveolar expansion, and potentially improve alveolar proliferation. ET has not been well-described in adolescent patients with TIS. METHOD: A mature adolescent with previously treated myelokyphosis and sacral agenesis developed severe TIS with dependence on supplemental oxygen and noninvasive ventilation. She was treated with two-stage bilateral ET and vertical expandable prosthetic titanium rib (VEPTR) placement. Yearly pulmonary function testing (PFT) was performed over 7 years of follow-up. RESULTS: Significant clinical pulmonary improvement was achieved and maintained at final follow-up, as the patient no longer required supplemental oxygen. Percentage predicted forced vital capacity (FVC) improved from 29% to 36%; percentage predicted forced expiratory volume-1 second (FEV1) improved from 30% to 36%. CONCLUSIONS: This case demonstrates that improvement and stabilization of respiratory function can be achieved with instrumented ET in a skeletally mature adolescent with severe TIS and spinal deformity.

Cost analysis of a growth guidance system compared with traditional and magnetically controlled growing rods for early-onset scoliosis: a US-based integrated health care delivery system perspective.

PURPOSE: Treating early-onset scoliosis (EOS) with traditional growing rods (TGR) is effective but requires periodic surgical lengthening, risking complications. Alternatives include magnetically controlled growing rods (MCGR) that lengthen noninvasively and the growth guidance system (GGS), which obviate the need for active, distractive lengthenings. Previous studies have reported promising clinical effectiveness for GGS; however the direct medical costs of GGS compared to TGR and MCGR have not yet been explored. METHODS: To estimate the cost of GGS compared with MCGR and TGR for EOS an economic model was developed from the perspective of a US integrated health care delivery system. Using dual-rod constructs, the model estimated the cumulative costs associated with initial implantation, rod lengthenings (TGR, MCGR), revisions due to device failure, surgical-site infections, device exchange, and final spinal fusion over a 6-year episode of care. Model parameters were from peer-reviewed, published literature. Medicare payments were used as a proxy for provider costs. Costs (2016 US$) were discounted 3% annually. RESULTS: Over a 6-year episode of care, GGS was associated with fewer invasive surgeries per patient than TGR (GGS: 3.4; TGR: 14.4) and lower cumulative costs than MCGR and TGR, saving $25,226 vs TGR. Sensitivity analyses showed that results were sensitive to changes in construct costs, rod breakage rates, months between lengthenings, and TGR lengthening setting of care. CONCLUSION: Within the model, GGS resulted in fewer invasive surgeries and deep surgical site infections than TGR, and lower cumulative costs per patient than both MCGR and TGR, over a 6-year episode of care. The analysis did not account for family disruption, pain, psychological distress, or compromised health-related quality of life associated with invasive TGR lengthenings, nor for potential patient anxiety surrounding the frequent MCGR lengthenings. Further analyses focusing strictly on current generation technologies should be considered for future research.

Radiographic Outcomes of Shilla Growth Guidance System and Traditional Growing Rods Through Definitive Treatment.

STUDY DESIGN: Retrospective review of a multicenter database. OBJECTIVES: To compare the radiographic outcomes of patients who had undergone the Shilla Growth Guidance System (SGGS) and traditional growing rod (GR) treatment for management of early-onset scoliosis (EOS) through definitive treatment. SUMMARY OF BACKGROUND DATA: The efficacy of surgical treatment of EOS can only be determined after definitive treatment has been completed. We wanted to review our experience with the SGGS and GR for management of EOS through definitive treatment. METHODS: Patients who had surgical treatment with SGGS or GR and had undergone definitive treatment were included. The patients were matched by age, preoperative curve magnitude, and diagnosis. The study population consisted of 36 patients (18 in each group) whose mean age at initial surgery was as follows: SGGS, 7.9 years; and GR, 7.7 years (not significant [NS]). Length of follow-up after initial surgery was 6.1 years for SGGS and 7.4 years for GR (NS). Definitive treatment was posterior spinal fusion (15 SGGS, 17 GR), implant removal (3 SGGS), or completion of lengthenings (1 GR). RESULTS: The preoperative curve was 61 degrees for SGGS and 65 degrees for GR (NS). After index surgery, the major curve decreased to 24 degrees (-37 degrees) for SGGS and 38 (-27 degrees) for GR (p < .05). At last follow-up, the major curve was 34 degrees (44%) for SGGS and 36 degrees (45%) for GR (NS). The initial T1-T12 length for SGGS was 188 mm and for GR, 181 mm; at last follow-up, SGGS was 234 mm (46 mm increase) and GR was 233 mm (52 mm increase) (NS). CONCLUSION: Our analysis shows the final radiographic outcomes (and changes) and complications (implant-related and infection) between the SGGS and GR groups were not statistically different. The main difference between the two groups was the threefold difference in overall surgeries.

A Comparison of SHILLA GROWTH GUIDANCE SYSTEM and Growing Rods in the Treatment of Spinal Deformity in Children Less Than 10 Years of Age.

BACKGROUND: The purpose of this study was to compare the outcomes of the SHILLA GROWTH GUIDANCE SYSTEM and "intermittent distraction growing rod" (IDGR) in the treatment of children (less than 10 y of age) with progressive spinal deformity. This was a multicenter retrospective study of the SHILLA used as an alternative treatment to IDGR to support an HDE submission for Food and Drug Administration approval. METHODS: Inclusion criteria were progressive scoliosis in a patient less than 10 years of age at index procedure. The study population consisted of 19 SHILLA and 6 IDGR patients whose mean age was 6.1 and 5.8 years, respectively. Group demographics were similar between the 2 groups. RESULTS: The initial major curve magnitude was 70.3 degrees for SHILLA and 68.3 degrees for IDGR, which decreased postoperatively to 22.4 degrees (68.1% improvement) and 32.2 degrees (52.9% improvement). During the first 4 years the correction for SHILLA varied from 40.5% to 53.4% and for IDGR from 40.9% to 56.9%. At last follow-up, T1-S1 length was 32.9 cm for SHILLA (4.2 increase from preoperation) and 34.0 cm (5.0 cm increase from preoperation) for IDGR. Average growth per month from T1-S1: SHILLA 0.14 cm, IDGR 0.11 cm. Sagittal T2-T12 preoperatively was 36.3 degrees for SHILLA and 30.0 degrees for IDGR. There were 29 reoperations in 12 of the 19 SHILLA patients (63.2%) and 40 reoperations in all 6 of the IDGR patients (100%) related to the index procedure. CONCLUSIONS: The SHILLA GROWTH GUIDANCE SYSTEM compares favorably with traditional IDGR constructs in terms of correction of the major curve, spinal length and growth, and maintenance of sagittal alignment. The >4-fold decrease in additional surgeries makes the SHILLA an attractive alternative to minimize comorbidities associated with additional surgeries. LEVELS OF EVIDENCE: Level III.

Utility of an allograft tendon for scoliosis correction via the costo-transverse foreman.

Current convex tethering techniques for treatment of scoliosis have centered on anterior convex staples or polypropylene tethers. We hypothesized that an allograft tendon tether inserted via the costo-transverse foramen would correct an established spinal deformity. In the pilot study, six 8-week-old pigs underwent allograft tendon tethering via the costo-transverse foreman or sham to test the strength of the transplanted tendon to retard spine growth. After 4 months, spinal deformity in three planes was induced in all animals with allograft tendons. In the treatment study, the allograft tendon tether was used to treat established scoliosis in 11 8-week-old pigs (spinal deformity > 50°). Once the deformity was observed (4 months) animals were assigned to either no treatment group or allograft tendon tether group and progression assessed by monthly radiographs. At final follow-up, coronal Cobb angle and maximum vertebral axial rotation of the treatment group was significantly smaller than the non-treatment group, whereas sagittal kyphosis of the treatment group was significantly larger than the non-treatment group. In sum, a significant correction was achieved using a unilateral allograft tendon spinal tether, suggesting that an allograft tendon tethering approach may represent a novel fusion-less procedure to correct idiopathic scoliosis. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:183-192, 2017.

Final Fusion After Growing-Rod Treatment for Early Onset Scoliosis: Is It Really Final?

BACKGROUND: Final fusion is thought to be the end point for patients with early onset scoliosis following treatment with the use of growing rods. But is it? The purpose of this study was to determine the incidence and cause of any reoperation after final fusion. METHODS: A multicenter database of patients with early onset scoliosis was retrospectively analyzed to identify patients treated with growing rods with a minimum of 2 years of follow-up after final fusion. All reoperations were recorded. Reoperation was defined as a return to the operating room for any complication related to the final fusion surgery or etiology of the spinal deformity. RESULTS: One hundred (84%) of 119 patients met the inclusion criteria: for 38 of the patients, the etiology of scoliosis was neuromuscular; for 31, syndromic; for 22, idiopathic; and for 9, congenital. The mean age at final fusion was 12.2 years (range, 8.5 to 18.7 years). The mean follow-up after final fusion was 4.3 years (range, 2 to 11.2 years). Twenty (20%) of the patients had 30 complications requiring reoperation (57 procedures). There was a mean of 1.5 complications per patient after final fusion. Eight patients with neuromuscular scoliosis, 8 with syndromic, 4 with idiopathic, and no patient with congenital scoliosis required reoperation. Nine (9%) of the patients experienced infection (33 reoperation procedures); 6 (6%) had instrumentation failure (8 procedures); 5 (5%) had painful or prominent instrumentation (6 procedures); 3 (3%) each had coronal deformity (3 procedures), pseudarthrosis (3 procedures), or sagittal deformity (3 procedures); and 1 (1%) had progressive crankshaft chest wall deformity requiring a thoracoplasty (1 procedure). CONCLUSIONS: A higher-than-anticipated percentage of patients treated with growing rods required unplanned reoperation following final fusion. Long-term follow-up after final fusion is necessary to determine true final results. Patients and parents need to be counseled regarding the possibility of further surgery after final fusion. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

New developments in the treatment of early-onset spinal deformity: role of the Shilla growth guidance system.

Early-onset scoliosis is a complex condition with multiple facets. The goal of treating any spinal deformity is to improve the condition of the patient with the least intervention necessary. A system that allows for continuation of natural spinal growth while correcting the deformity should be the goal of treating this complex condition. The SHILLA growth guidance system allows for continued growth of the pediatric spine while correcting and guiding the apex and guiding the future growth of the curvature. The system involves selective fusion across the apex of the curvature, and minimally invasive instrumentation is then used above and below the apex to allow for continued growth of the spine. A review of recent literature on the SHILLA growth guidance system shows promising results. Early animal models showed continued growth across unfused levels with minimal facet articular damage. Comparative studies to traditional growing rods showed significantly less total surgeries along with comparable correction and longitudinal growth. The SHILLA growth guidance system is a good option for this complex patient group. Results are comparable with other growing constructs with significantly less operative interventions. The SHILLA system allows for natural growth of the pediatric spine while correcting the scoliotic deformity in a minimally invasive method. The goal of this article is to present a comprehensive review of the SHILLA system surgical technique and the associated literature concerning this topic.

Shilla Growth Guidance for Early-Onset Scoliosis: Results After a Minimum of Five Years of Follow-up.

BACKGROUND: The Shilla growth guidance technique was developed to allow growth during treatment of a child's spinal deformity without requiring repeated surgery for lengthening procedures. Dual stainless-steel rods are fixed posteriorly to the corrected apex via pedicle screws with a limited fusion at the apex and are combined with sliding pedicle screws to allow vertebral growth in a cephalad and caudad direction. METHODS: A retrospective study of the original forty patients treated with the Shilla method for a severe deformity of a growing spine was performed to determine the efficacy of the procedure. RESULTS: The etiology of the spinal deformity in the forty patients was idiopathic in nine, congenital in one, neuromuscular in sixteen, and syndromic in fourteen. The average age at the index surgery was six years and eleven months, and the average duration of follow-up for the thirty-three eligible patients was seven years (range, four years and nine months to ten years and nine months). The curves averaged 69° (range, 40° to 115°) preoperatively and 38.4° (range, 16° to 74°) at the time of the most recent follow-up or prior to definitive spinal instrumentation and fusion. Complications included secondary infections (six patients), alignment issues (eight patients), and implant-related problems (twenty-four patients), with some patients experiencing more than one complication. CONCLUSIONS: The Shilla growth guidance technique is a method of scoliosis treatment that allows spinal growth while controlling the deformity without scheduled repeated surgical procedures. The complication rate is high (73%) but acceptable, and children with a wide variety of diagnoses can be safely treated with the Shilla procedure.