most common is right thoracic or double curve with right thoracic & left lumbar
progression is defined as 5 degree change in the curve
factors related to curve progression include a larger magnitude at presentation & also the skeletal maturity where the immature Risser 0 & 1 are more likely to progress
Approach
rule out intraspinal pathology for left thoracic – incidence will be ~20%
on assessment if curve is <25° reassess in 4 months
if curve is 30-40° & the child has significant growth remaining Risser 0,1 brace the child immediately
Contraindications to Bracing
child is skeletally mature
curve is greater than 45°
curve less than 24°
cosmesis is unacceptable
significant thoracic lordosis
Treatment
Non-operative
Milwaukee Brace – cervicothoracolumbosacral
TLSO is used if apex is below T8 & currently the Boston brace with a chest pad is advocated
Child wears the brace 22 hours a day
Follow Q 4 months with an xray in brace
Wean at skeletal maturity by decreasing by 4 hours every 4 months
Operative
Indications
Immature child with a curve of 40-45° on presentation
Curve pattern is identified base on clinical & xray
Single major curve
Double major curve
King & Moe
True double major – fuse both
False double major – implies that the lumbar is flexible & goes away – fuse thoracic
Thoracic Curve
Long thoracic curve
Double thoracic curve – fuse both
All major curves must be fused
Fuse to the end vertebrae of the curve with neutral rotation
Caudal vertebrae must be in the stable zone defined by the line from the spine of S1 which must pass between the pedicles
Avoid fusing to L5 consider L4 fusion
Approach
In general, posterior
Anterior fusion may be indicated in skeletal immature patients, patients with severe – stiff – curves & those whom may get several motion segments saved
Instrumentation
First generation – Harrington Rods – distract the concavity & compress the convexity
Second generation – Luque – segmental fixation with sublaminar wires
Third generation – Cotrel Duboset – multiple hooks & possible pedicle screws
deformity occurs in 3 dimensions & pure distraction leads to hypolordosis & hypokyphosis
3rd generation instrumentation can lead to 3 –D correction via rotation
