Non-Fusion Surgical Correction of Thoracic Idiopathic Scoliosis Using a Novel, Braided Vertebral Body Tethering Device: Minimum Follow-up of 4 Years

Posterior spinal fusion versus vertebral body tethering for paediatric scoliosis: a meta-analysis of comparative studies

PURPOSE

Posterior spinal fusion (PSF) is currently the gold standard technique for surgical correction of scoliosis however, there is a growing interest in non-fusion techniques like vertebral body tethering (VBT). The aim of this study is to compare surgical outcomes between PSF and VBT.

METHODS

This systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines with a search of the following databases to identify all comparative studies: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL).

RESULTS

A total of 11 comparative studies with 1112 patients were included. PSF offered significantly greater percentage coronal curve correction postoperatively (P = 0.0001) and at 2 years (P < 0.00001). Time to revision (P = 0.03), number of instrumented levels (P < 0.0001), estimated blood loss (EBL) (P = 0.001), operation duration (OD) (P < 0.00001) and postoperative shoulder height difference (P < 0.00001) were significantly greater in the PSF group. Odds of unplanned surgical revisions were lower in the PSF group (P < 0.0001). Secondary outcome data showed that VBT patients had significantly lower preoperative cobb angles (P < 0.00001), a younger age at surgery (P = 0.002), less postoperative pain (P = 0.002) and lower opioid consumption (P = 0.02). VBT tether breakage events were reported at rates of 13-23%. VBT also offered faster return to sports and greater lumbar flexibility. No significant difference was seen in length of hospital stay (P < 0.05).

CONCLUSION

PSF and VBT are viable treatment options with different pros and cons. Choice of treatment should consider individual patient characteristics and daily requirements.

Correction of L5 Tilt in 2-Row Vertebral Body Tethering Versus Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Single-center retrospective cohort study.

OBJECTIVE

To compare the correction of fractional curve and L5 tilt in 2RVBT versus PSF with LIV in the lumbar spine.

SUMMARY OF BACKGROUND DATA

Vertebral body tethering, an AIS fusion-alternative, avoids rigid constructs, allowing for lower instrumented vertebra (LIV) selection. Single-tether constructs break, but mini-open thoracoscopic assistant double-row vertebral body tethering (2RVBT) reduces this. Limited comparative studies exist with posterior spinal fusion (PSF).

METHODS

Retrospective analysis of AIS correction surgeries with lumbar LIV using preoperative and minimum 2-year postoperative imaging. Patients were divided into 2RVBT or PSF groups. Data included age, Riser, UIV, LIV, instrumented levels, and revision rates. Radiographic analyses included preoperative and postoperative main curve Cobb (MCC), secondary curve Cobb (SCC), fractional curve Cobb (FCC), and L5 tilt.

RESULTS

Ninety-nine patients participated (49 in 2RVBT, 50 in PSF). Preoperatively, secondary CC differed significantly (2RVBT: 44.6±10.4 degrees vs. PSF: 39.5±11.8 degrees, P =0.026), but not L5 tilt, MCC, or FCC. Postoperatively, MCC (2RVBT: 25.7±12.3 degrees vs. PSF: 19.5±7.4 degrees, P =0.003) and SCC (2RVBT: 18.0±8.4 degrees vs. PSF: 14.5±6.6 degrees, P =0.012) varied. Preoperative to postoperative changes in MCC (2RVBT: -32.0±11.3 degrees vs. PSF: -37.2±13.3 degrees, P =0.044) and L5 tilt (-13.8±9.0 degrees vs. PSF: -8.1±6.8 degrees, P =0.001) differed. Revision rates were similar (2RVBT: 2.0%, PSF: 4.0%, P =0.57). In 2RVBT, 3 tethers broke, 1 revision occurred for a broken tether, and 1 pleural effusion needed thoracocentesis. In PSF, 1 superficial infection needed surgery, and 1 revision was for add-on phenomenon. After PSM for Lenke classification, 54 patients remained (27 in each group). At 2 years, 2RVBT showed less MCC correction (-30.8±11.8 degrees vs. -38.9±11.9 degrees, P =0.017), but greater L5 tilt correction (-14.6±10.0 degrees vs. -7.5±6.0 degrees, P =0.003).

CONCLUSIONS

This study with a minimum 2-year radiographic follow-up demonstrates that 2RVBT results in greater L5 tilt correction when compared with posterior spinal fusion after PSM for Lenke classification and similar rates of revision surgery.

LEVEL OF EVIDENCE

Level III.

The Fate of The Broken Tether: How Do Curves Treated With Vertebral Body Tethering Behave After Tether Breakage?

STUDY DESIGN

Retrospective, multicenter.

OBJECTIVE

The aim of this study was to assess curve progression and occurrence of revision surgery following tether breakage after vertebral body tethering (VBT).

SUMMARY OF BACKGROUND DATA

Tether breakage after VBT is common with rates up to 50% reported. In these cases, it remains unknown whether the curve will progress or remain stable.

MATERIALS AND METHODS

Adolescent and juvenile idiopathic scoliosis patients in a multicenter registry with ≥2-year-follow-up after VBT were reviewed. Broken tethers were listed as postoperative complications and identified by increased screw divergence of >5 degrees on serial radiographs. Revision procedures and curve magnitude at subsequent visits were recorded.

RESULTS

Of 186 patients who qualified for inclusion, 84 (45.2%) patients with tether breakage were identified with a mean age at VBT of 12.4±1.4 years and mean curve magnitude at index procedure of 51.8±8.1 degrees. Tether breakage occurred at a mean of 30.3±11.8 months and mean curve of 33.9±13.2 degrees. Twelve patients (12/84, 14.5%) underwent 13 revision procedures after tether breakage, including six tether revisions and seven conversions to fusion. All tether revisions occurred within 5 months of breakage identification. No patients with curves <35 degrees after breakage underwent revision. Revision rate was greatest in skeletally immature (Risser 0-3) patients with curves ≥35 degrees at time of breakage (Risser 0-3: 9/17, 53% vs. Risser 4-5: 3/23, 13%, P =0.01). Curves increased by 3.1 and 3.7 degrees in the first and second year, respectively. By 2 years, 15/30 (50%) progressed >5 degrees and 8/30 (26.7%) progressed >10 degrees. Overall, 66.7% (40/60) reached a curve magnitude >35 degrees at their latest follow-up, and 14/60 (23.3%) reached a curve magnitude >45 degrees. Skeletal maturity did not affect curve progression after tether breakage ( P >0.26), but time to rupture did ( P =0.048).

CONCLUSIONS

While skeletal immaturity and curve magnitude were not independently associated with curve progression, skeletally immature patients with curves ≥35 degrees at time of rupture are most likely to undergo additional surgery. Most patients can expect progression at least 5 degrees in the first 2 years after tether breakage, though longer term behavior remains unknown.

LEVEL OF EVIDENCE

Level III.

Defining the segmental tension generated in a vertebral body tethering system for scoliosis

Vertebral body tethering (VBT) uses a flexible tether affixed across the curve convexity with tension applied at each segment to treat scoliosis. Intraoperative tether tension may be achieved directly with a counter-tensioner or with an extension spring tube. The purpose of this study was to quantify the force generated with and without the extension spring tube using current FDA-approved VBT instrumentation, to understand the variation between surgeons using the same instrumentation, and to define the force range that is generated intra-operatively. Using a benchtop mechanical testing setup to simulate a spinal segment, we affixed the tether and applied tension using a tensioner and counter-tensioner alone (method T1) or by adding an extension spring tube (method T2). Eight orthopedic surgeons used T1 and T2 at six tensioner settings, and one surgeon completed three trials. A two-way ANOVA with a Tukey's HSD post hoc test (p < 0.05) compared the tensioner methods and testing levels. Inter- and intra-rater reliabilities were calculated using intraclass correlation coefficients (ICCs). Methods T1 and T2 exhibited linear tension-setting relationships, with high determination coefficients (R2 > 0.93). T2 consistently produced higher forces (increase of 62.1 N/setting), compared to T1 (increase of 50.6 N/setting, p < 0.05). Inter-rater reliability exhibited excellent agreement (ICC = 0.951 and 0.943 for T1 and T2, respectively), as did intra-rater reliability (ICC = 0.971).

Perioperative Outcomes Related to Thoracic and Lumbar Spine Exposure During Vertebral Body Tethering for Adolescent Idiopathic Scoliosis: A Large, Single-institution Retrospective Review

BACKGROUND

Vertebral body tethering (VBT) is a novel non-fusion technique for the management of scoliosis. Despite growing popularity, data concerning complications and thoracic surgery-related outcomes are lacking.

METHODS

A single-institution retrospective review was conducted of patients who underwent VBT with video-assisted thoracic surgical exposure from 1/1/2015-3/1/2022. Data obtained included demographics, comorbidities, hospital course, and outcomes.

RESULTS

106 patients (81 % female) were identified with a mean age at surgery of 12.7 ± 1.5 (range 9-16). Most patients underwent single curve tethering (n = 93, 87.7 %) with a mean number of vertebral bodies tethered of 8.0 (range 5-13). The mean operative time was 236 ± 96 min (range 129-661) minutes with an estimated blood loss of 165 ± 143 mL (range 20-750) and no patients required allogeneic blood transfusion. The extent of tethering was significantly associated with increased operative time, fluids received, and chest tube output. Excluding instrument-related complications, the complication rate was 13.2 %, mostly occurring within the first 30 days after surgery and pleural effusion being the most common event. Two patients experienced a postoperative hemothorax requiring reoperation. No patients experienced sequelae of spinal cord ischemia secondary to the division of intercostal and/or lumbar vessels during surgical exposure and no deaths occurred.

CONCLUSION

VBT is a seemingly safe alternative to spinal fusion in skeletally immature adolescents, however, there are notable complications of this procedure related to thoracic exposure. Our experience indicates clinically significant pulmonary complications are uncommon and the extent of vertebral body exposure/tethering was strongly associated with operative duration, fluids, and chest tube output.

LEVELS OF EVIDENCE

This original article represents a treatment study of Level IV evidence.

Current Status of Vertebral Body Tethering for Adolescent Idiopathic Scoliosis: An Umbrella Review

Background

Adolescent idiopathic scoliosis (AIS) is a prevalent spinal deformity among teenagers worldwide. Vertebral body tethering (VBT) is an innovative, minimally invasive technique developed to address spinal curvature by modulating vertebral growth. However, the existing body of evidence regarding the effectiveness and safety of VBT in treating AIS is fragmented and requires thorough consolidation and critical assessment.

Methods

Six databases were thoroughly examined, yielding 11 relevant systematic reviews and meta-analyses. The methodological quality of the included studies was evaluated using the Joanna Briggs Institute's critical appraisal checklist. The key findings were encapsulated using a narrative synthesis approach.

Results

The reviews indicated notable improvements in coronal plane radiographic parameters, transverse plane clinical outcomes, and health-related quality of life scores following VBT. Nevertheless, the complication rates associated warrant attention. Additionally, the variability in methodological quality across the included reviews underscores the necessity for more robust and systematic investigations in this domain.

Conclusion

This umbrella review revealed promising results for VBT as a treatment option for AIS. However, further research is needed to address knowledge gaps and limitations, focusing on long-term outcomes, patient selection, standardized techniques, and comparison with traditional treatments.

Anterior vertebral tethering for adolescent idiopathic scoliosis: our initial ten year clinical experience

BACKGROUND

Anterior vertebral tethering (AVT) is a minimally invasive alternative to fusion surgery for adolescent idiopathic scoliosis (AIS) that offers the potential for definitive scoliosis treatment with the possibility of preservation of the growth, motion, function and overall health of the spine. This study represents our first ten years using AVT to treat AIS.

METHODS

In this retrospective review we analyzed our first 74 AIS patients treated with AVT 2010-2020. Multiple Lenke curve types 33-70° were treated with skeletal maturity spanning Risser -1 to 5.

RESULTS

Of 74 consecutive AIS patients treated with AVT, 52 patients (47 female, 5 male) had sufficient 2-year follow-up for inclusion. Forty-six of these 52 patients (88%) with 65 curves (35T, 30TL/L) were satisfactorily treated with AVT demonstrating curve correction from 48.6° pre-op (range 33°-70°) at age 15.1 years (range 9.2-18.8) and skeletal maturity of Risser 2.8 (range -1 to 5) to 23.2° post-op (range 0°-54°) and 24.0° final (range 0°-49°) at 3.3 years follow-up (range 2-10 years). Curve corrections from pre-op to post-op and pre-op to final were both significant (p < 0.001). The 0.8° change from post-op to final was not significant but did represent good control of scoliosis correction over time. Thoracic kyphosis and lumbar lordosis were maintained in a normal range throughout while axial rotation demonstrated a slight trend toward improvement. Skeletal maturity of Risser 4 or greater was achieved in all but one patient. Four of the 52 patients (8%) required additional procedures for tether rupture (3 replacements) or overcorrection (1 removal) to achieve satisfactory treatment status after AVT. An additional 6 of the 52 patients (12%), however, were not satisfactorily treated with AVT, requiring fusion for overcorrection (2) or inadequate correction (4).

CONCLUSIONS

In this study, AIS was satisfactorily treated with AVT in the majority of patients over a broad range of curve magnitudes, curve types, and skeletal maturity. Though late revision surgery for overcorrection, inadequate correction, or tether rupture was not uncommon, the complication of overcorrection was eliminated after our first ten patients by a refinement of indications.

LEVEL OF EVIDENCE

IV.

Vertebral body tethering for adolescent idiopathic scoliosis: a review

PURPOSE

Adolescent Idiopathic Scoliosis (AIS) remains the most common type of pediatric scoliosis, mostly affecting children between ages 10 and 18. Vertebral body tethering (VBT) offers a non-fusion alternative to the gold standard spinal fusion that permits flexibility and some growth within instrumented segments. This article will serve as a comprehensive literature review of the current state-of-the-art of VBT in relation to radiographic and clinical outcomes, complications, and the learning curve associated with the procedure.

METHODS

A systematic literature review was conducted on PubMed, Scopus, and Web of Science from April 2002 to December 2022. Studies were included if they discussed VBT and consisted of clinical studies in which a minimum 2-years follow-up was reported, and series that included anesthetic considerations, learning curve, and early operative morbidity.

RESULTS

Forty-nine studies spanning the period from April 2002 to December 2022 were reviewed.

CONCLUSION

This article illustrates the potential benefits and challenges of the surgical treatment of AIS with VBT and can serve as a basis for the further study and refinement of this technique ideally as a living document that will be updated regularly.

Thoracoscopic Surgery in the Management of Idiopathic Scoliosis: Systematic Literature Review according to the Prisma Protocol

Idiopathic scoliosis is characterized by a three-dimensional deformity of the spine with axial rotation and lateral inclination with an angle greater than 10° according to the Cobb method. Its approach can be conservative or surgical, depending on the degree of angulation, musculoskeletal development and age of the affected child or adolescent, or even depending on the functional impairment resulting from the condition. The aim of this study was to analyze the impact of videoassisted thoracoscopic surgery in the management of idiopathic scoliosis. This is a systematic literature review, built according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and registered with PROSPERO under number CRD42022351466. The search for studies was performed between August 2022 and September of the same year, in bibliographic databases including MEDLINE, The Cochrane Library and Web of Science. The technique is a minimally invasive alternative to thoracotomy that has shown great evolution in recent years. The main advantages include less blood loss during the procedure, shorter hospital stay and improved post-surgical esthetics. One of the disadvantages mentioned by the authors is the greater complexity and technological requirement, longer surgical time and the need for careful selection of patients, according to degrees of vertebral deviation. The use of analgesics and anti-inflammatory drugs had no significant difference between traditional procedures (thoracotomy) or thoracoscopic surgery.

Vertebral body tethering for idiopathic scoliosis: a systematic review and meta-analysis

PURPOSE

Vertebral body tethering (VBT) is a recent procedure to correct and reduce spinal curves in skeletally immature patients with adolescent idiopathic scoliosis (AIS). The purpose of this systematic review and meta-analysis is to determine the expected curve reduction and potential complications for adolescent patients after VBT.

METHODS

PubMed, Embase, Google Scholar and Cochrane databases were searched until February 2022. Records were screened against pre-defined inclusion and exclusion criteria. Data sources were prospective and retrospective studies. Demographics, mean differences in Cobb angle, surgical details and complication rates were recorded. Meta-analysis was conducted using a random-effects model.

RESULTS

This systematic review includes 19 studies, and the meta-analysis includes 16 of these. VBT displayed a statistically significant reduction in Cobb angle from pre-operative to final (minimum 2 years) measurements. The initial mean Cobb angle was 47.8° (CI 95% 42.9-52.7°) and decreased to 22.2° (CI 95% 19.9-24.5°). The mean difference is - 25.8° (CI 95% - 28.9-22.7) (p < 0.01). The overall complication rate was 23% (CI 95% 14.4-31.6%), the most common complication was tether breakage 21.9% (CI 95% 10.6-33.1%). The spinal fusion rate was 7.2% (CI 95% 2.3-12.1%).

CONCLUSION

VBT results in a significant reduction of AIS at 2 years of follow-up. Overall complication rate was relatively high although the consequences of the complications are unknown. Further research is required to explore the reasons behind the complication rate and determine the optimal timing for the procedure. VBT remains a promising new procedure that is effective at reducing scoliotic curves and preventing spinal fusion in the majority of patients.

LEVEL OF EVIDENCE

Systematic review of Therapeutic Studies with evidence level II-IV.

Can anterior vertebral body tethering provide superior range of motion outcomes compared to posterior spinal fusion in adolescent idiopathic scoliosis? A systematic review

PURPOSE

Anterior vertebral body tethering (AVBT) was introduced as a fusionless alternative to treating adolescent idiopathic scoliosis (AIS) while preserving range of motion (ROM). This is the first systematic review to compare the ROM outcomes between AVBT and PSF in treating AIS.

METHODS

We conducted a comprehensive search on PubMed, EMBASE, MEDLINE, and Cochrane Library. Inclusion criteria were patients with AIS treated with AVBT or PSF or both, and clearly defined ROM outcomes; exclusion criteria were scoliosis other than AIS, biomechanical or cadaveric studies, non-English publications, case reports, conference summaries, unpublished literature, commentaries, and reviews. Primary outcome was ROM. Secondary outcomes included Cobb angle correction, quality of life (QOL), complications, and muscle strength and endurance.

RESULTS

Twelve studies were included in this review. We found moderate evidence to support that AVBT results in superior ROM outcomes than PSF while achieving comparable Cobb angle correction with low evidence. The comparison of QOL outcomes between AVBT and PSF remained inconclusive. In addition to the complications noted conventionally in PSF, AVBT could result in over-correction and distal adding-on. We also found very low evidence to support that AIS patients treated with AVBT have superior muscle strength and endurance when compared to those treated with PSF.

CONCLUSIONS

AVBT provides better preservation of ROM and muscle strength postoperatively when compared with PSF, while achieving comparable curve correction. Future studies should explore the spinal growth trajectory to determine the window of opportunity for AVBT in AIS.

Vertebral body tethering in adolescent idiopathic scoliosis with more than 2 years of follow-up- systematic review and meta-analysis

BACKGROUND CONTEXT

Whilst spinal fusion remains the gold standard in the treatment of adolescent idiopathic scoliosis (AIS), anterior vertebral body tethering (AVBT) is gaining momentum with relatively few studies on its efficacy thus far.

PURPOSE

To conduct a systematic review reporting on the early results of AVBT for patients undergoing surgery for AIS. We aimed to systematically evaluate the relevant literature pertaining to the efficacy of AVBT with respect to degree of correction of the major curve Cobb angle, complications and revision rates.

STUDY DESIGN/SETTING

Systematic review.

PATIENT SAMPLE

Of a total of 259 articles, 9 studies met the inclusion criteria and were analysed. Overall, 196 patients of (mean age 12.08 years) underwent an AVBT procedure for correction of AIS with a mean follow-up of 34 months.

OUTCOME MEASURES

Degree of Cobb angle correction, complications and revision rates were used as outcome measures.

METHODS

A systematic review of the literature on AVBT was performed for studies published between Jan 1999-March 2021 applying the PRISMA guidelines. Isolated case reports were excluded.

RESULTS

Overall, 196 patients of (mean age 12.08 years) underwent an AVBT procedure for correction of AIS with a mean follow-up of 34 months. There was a significant correction of the main thoracic curve of scoliosis (mean preoperative Cobb angle 48.5°, post-operative Cobb angle at final follow-up of 20.1°, P = 0.01). Overcorrection and mechanical complications were seen in 14.3% and 27.5% of cases, respectively. Pulmonary complications including atelectasis and pleural effusion were seen in 9.7% of patients. Tether revision was performed in 7.85%, and revision to a spinal fusion in 7.88%.

CONCLUSION

This systematic review incorporated 9 studies of AVBT and 196 patients with AIS. The complication and revision to spinal fusion rates were 27.5% and 7.88%, respectively. The current literature on AVBT is restricted largely to retrospective studies with non-randomised data. We would recommend a prospective, multi-centre trial of AVBT with strict inclusion criteria and standardised outcome measures.

Anterior Vertebral Body Tethering for Skeletally Immature Patients with AIS: Indication for Spinal Fusion at Skeletal Maturity Is Not Obviated in 60% of Cases

The role of anterior vertebral body tethering (aVBT) in obviating the need for spinal fusion in patients with AIS remains unclear, and a large amount of variation exists in the data among different studies. The present study aims to investigate and analyze what factors have a potential influence on aVBT outcome. Skeletally immature patients with AIS who underwent aVBT for scoliosis correction were followed up until skeletal maturity. The mean age at the time of surgery was 13.4 ± 1.1, and the mean follow-up time was 2.5 ± 0.5 years. The Cobb angle of the main curve was 46.6 ± 9° at the time of surgery and was significantly corrected to 17.7 ± 10.4° (p < 0.001) immediately postoperatively. A significant loss of correction was observed during the latest follow-up (Cobb angle 33.8 ± 18.7°; p < 0.001). An indication for spinal fusion at skeletal maturity was not obviated in 60% of the patients. The factors identified as having an influence on the outcome were preoperative bone age and the magnitude of the major curve. Patients with advanced bone age and larger curves were more likely to reach an indication for spinal fusion at skeletal maturity. In conclusion, no general recommendation for aVBT can be made for AIS patients. The method can be discussed as a treatment option in skeletally very immature preadolescent patients (Sanders Stadium ≤ 2) with a moderate Cobb angle (≤50°) who failed previous brace therapy.

Back pain in adolescent idiopathic scoliosis: A comprehensive review

Purpose

Adolescent idiopathic scoliosis (AIS) is a common spinal deformity that affects millions of children worldwide. A variety of treatment algorithms exist for patients based on radiographic parameters such as the Cobb angle and the Risser stage. However, there has been a growing focus on nonradiographic outcomes such as back pain, which can cause functional disability and reduced quality of life for patients. In spite of this, back pain in AIS is poorly characterized in the literature. We aimed to summarize various factors that may influence back pain in AIS and the impact of different treatment methods on pain reduction.

Methods

A comprehensive systematic review was undertaken using the PubMed and Cochrane database. Keywords that were utilized and combined with "Adolescent Idiopathic Scoliosis" included, "back pain," "treatment," "biomechanics," "biochemistry," "epidemiology," and "biopsychosocial." The literature was subsequently evaluated and deemed relevant or not relevant for inclusion.

Results

A total of 93 articles were ultimately included in this review. A variety of contradictory literature was present for all sections related to epidemiology, underlying biomechanics and biochemistry, biopsychosocial factors, and treatment methodologies.

Conclusion

Back pain in AIS is common but remains difficult to predict and treat. The literature pertaining to causative factors and treatment options is heterogeneous and inconclusive. Longer-term prospective studies combining biopsychosocial intervention in conjunction with existing curve correction techniques would be meaningful.

Vertebral body tethering: An alternative to posterior spinal fusion in idiopathic scoliosis?

INTRODUCTION

Skeletally immature patient with adolescent idiopathic scoliosis (AIS) whose curves continue to progress despite bracing should be treated surgically. Vertebral body tethering (VBT) is a non-fusion, compression-based, growth preserving alternative to posterior spinal fusion (PSF) based on the concept of 'growth modulation' to prevent possible functional complications secondary to fusion while correcting scoliotic deformity. This review aims to shed light on the indications of VBT, short- and medium-term outcomes, describe the surgical technique and associated complications, and to compare its efficacy to that of PSF.

METHODS

A review of peer-reviewed literature on VBT as a surgical technique, its indications, outcomes, complications, and comparison with other surgical interventions to correct AIS was conducted in December 2022.

RESULTS

Indications remain controversial and mainly include stage of skeletal maturity based on radiographic markers, curve location, magnitude and flexibility, and presence of secondary curve. Assessment of VBT clinical success should not be restricted to improvement in radiographic parameters but should include functional results and patient-centered outcomes, improved body image and pain, and durability of outcomes. In contrast to fusion, VBT seems to be associated with preserved spinal growth, shorter recovery, potentially better functional outcomes, less motion loss but possibly less curve correction.

DISCUSSION

Yet still, with VBT there exists a risk of overcorrection, construct breakage or failure of procedure which require revision and at times conversion to PSF. Patient and family preferences must be accounted for acknowledging gaps in knowledge, attributes and drawbacks of each intervention.

Vertebral Body Tethering in AIS Management-A Preliminary Report

Vertebral Body Tethering (VBT) is a recently developed surgical technique for the treatment of progressive and severe scoliosis in patients with significant growth potential. It has been used since the first exploratory series, which showed encouraging results on the progressive correction of the major curves. This study reports on a retrospective series of 85 patients extracted from a French cohort, with a follow-up at a minimum of two years after a VBT with recent screws-and-tether constructs. The major and compensatory curves were measured pre-operatively, at the 1st standing X-ray, at 1 year, and at the last available follow-up. The complications were also analyzed. A significant improvement was observed in the curve magnitude after surgery. Thanks to growth modulation, both the main and the secondary curves continued to progress over time. Both the thoracic kyphosis and lumbar lordosis remained stable over time. Overcorrection occurred in 11% of the cases. Tether breakage was observed in 2% of the cases and pulmonary complications in 3% of the cases. VBT is an effective technique for the management of adolescent idiopathic scoliosis patients with residual growth potential. VBT opens an era of a more subtle and patient-specific surgical management of AIS that considers parameters such as flexibility and growth.

Meta-analysis on the efficacy and safety of anterior vertebral body tethering in adolescent idiopathic scoliosis

PURPOSE

In this meta-analysis, we analyzed the efficacy and safety of anterior vertebral body tethering in patients with adolescent idiopathic scoliosis.

METHODS

We performed a literature search and analyzed the following data: baseline characteristics, efficacy measures (corrections of the main thoracic curve, proximal thoracic curve, and thoracolumbar curve, thoracic kyphosis, lumbosacral lordosis, rib hump, lumbar prominence and SRS-22 scores, and complications. Analyses were performed with Cochrane's Review Manager version 5.4.

RESULTS

Twelve studies met the inclusion criteria. Significant corrections of the main thoracic (MD 22.51, 95% CI 12.93 to 32.09) proximal thoracic (MD 10.14°, 95% CI 7.25° to 13.02°), and thoracolumbar curve (MD 12.16, 95% CI 9.14 to 15.18) were found. No statistically significant corrections were observed on the sagittal plane assessed by thoracic kyphosis (MD - 0.60°, 95% CI - 2.45 to 1.26; participants = 622; studies = 4; I2 = 36%) and lumbosacral lordosis (MD 0.19°, 95% CI - 2.16° to 2.54°). Significant corrections were identified for rib hump (MD 5.26°, 95% CI 4.19° to 6.32°) and lumbar prominence (MD 1.20°, 95% CI 0.27° to 2.13°) at final follow-up. Significant improvements of total SRS-22 score (MD - 0.96, 95% CI - 1.10 to - 0.83) were achieved at final follow-up. The most common complication was overcorrection (8.0%) and tether breakage (5.9%), with a reoperation rate of 10.1%.

CONCLUSIONS

Anterior vertebral body tethering is effective to reduce the curve in the coronal plane and clinical deformity. Maximum correction is achieved at one year. The method should, however, be optimized to reduce the rate of complications.

Minimum 3-year experience with vertebral body tethering for treating scoliosis: A systematic review and single-arm meta-analysis

PURPOSE

Over the past 12 years, vertebral body tethering (VBT) has been gradually promoted for treating scoliosis, but there are few published studies, with only short-term follow-up. This study aimed to systematically review VBT efficacy and safety for treating scoliosis.

METHODS

PubMed, Web of Science, Embase, and the Cochrane Library were searched for studies on VBT treatment of scoliosis published up to November 2021. Two researchers independently screened the literature, extracted data, and assessed the risk of bias in included studies. Data on clinical efficacy, unplanned reoperations, and complications were extracted. The meta-analysis was performed with R 4.1.0.

RESULTS

Twenty-six studies involving 1045 patients were included in the meta-analysis. The correction rate of major curve immediately post-operation was 46.6% ± 13.8% (16%-69%) and that at final follow-up was 53.2% ± 17.9% (16%-79%). The single-arm meta-analysis results of all included studies showed that VBT was effective in general. The overall clinical success rate was 73.02% (95% confidence interval [CI]: 68.31%-78.05%). The pooled overall unplanned reoperation rate was 8.66% (95% CI: 5.53%-13.31%). The overall incidence rate of complications was 36.8% (95% CI: 23.9%-49.7%). The subgroup analysis based on follow-up time indicated that patients with follow-up time >36 months had increased clinical success rate, unplanned reoperation rate, and incidence rate of complications compared with those with <36 months' follow-up time. The preliminary results showed that after 36 months of follow-up, only 7.17% (95% CI: 4.81%-10.55%) of patients required posterior spinal fusion (PSF) surgery and nearly 93% of patients avoided spinal fusion surgeries.

CONCLUSIONS

The current evidence from at least 3-year follow-up in different countries indicates that VBT is an effective surgical approach for treating scoliosis, with 73.88% of patients achieving clinical success. Nevertheless, about one in seven patients (15.8%) required unplanned reoperations, but only 7.17% required PSF. About half (52.17%) of the patients experienced complications. Due to the limitation of the study number and quality, our conclusion may be biased and requires verification by further studies with longer follow-up times.

The preliminary outcomes of vertebral body tethering in treating adolescent idiopathic scoliosis: a systematic review

PURPOSE

VBT is a novel alternative to spinal fusion surgery to treat skeletally immature AIS and was approved to correct idiopathic scoliosis in August 2019 by US Federal Drug Administration (FDA). To systemically review the preliminary outcomes of vertebral body tethering (VBT) in treating adolescent idiopathic scoliosis.

METHODS

The electronic databases PubMed, EMBASE, and Web of Science were queried up to January 2022 for articles regarding VBT. Basic characteristics of patients, changes of radiographic parameters in coronal and sagittal planes, and clinical outcomes of surgical treatment of VBT including complication and revision rates were summarized.

RESULTS

Twenty five studies met the inclusion criteria. Most studies (23/25) included patients with only skeletal immaturity. The average % correction of the main/tethered curve at final follow-up, and % correction of thoracic kyphosis at final follow-up were reported to be 15.6-106.5% and - 31.8 to 20.0%, respectively. The most common complications for VBT were tether breakage (n = 145;21.3%), pulmonary complications (n = 49; 6.9%), and overcorrection (n = 30; 4.2%). The revision rate was 13.1%.

CONCLUSION

VBT could effectively and safely correct spinal deformity in skeletally immature patients with AIS and preserve the motion and growth of the spine. However, VBT has a relatively high complication and revision rates. Therefore, surgeons should cautiously consider VBT for treating AIS. Future research efforts are needed to lower the complication and revision rates. Whatever, VBT is still in its infancy and may have a promising future as a non-fusion solution for AIS.

Intervertebral Disk Health Following Vertebral Body Tethering for Adolescent Idiopathic Scoliosis: A Preliminary Study

BACKGROUND

Interest in vertebral body tethering (VBT) as an alternative to posterior spinal fusion for adolescent idiopathic scoliosis (AIS) continues to grow. The purpose of this study was to prospectively assess intervertebral disk health on magnetic resonance imaging (MRI) at 1 year following VBT in AIS patients.

METHODS

AIS patients were enrolled in a prospective surgeon-sponsored Food and Drug Administration (FDA) Investigational Device Exemption (IDE) Study and underwent MRI at 1-year following VBT. All spanned disks and the untethered disks immediately adjacent to the upper instrumented vertebra and lowest instrumented vertebra levels were evaluated according to Pfirrmann grading criteria. Associations between patient factors and preoperative and postoperative disk health and patient-reported outcomes were evaluated.

RESULTS

Twenty-two patients were enrolled with a postoperative MRI (25 curves, 188 disks), and 7 patients (7 curves) had both preoperative and postoperative MRIs (67 disks). The mean age was 12.7 years. Most were Risser 0 (65%) and either Sanders Skeletal Maturity Score 3 (35%) or 4 (53%). In the 7 patients with preoperative and postoperative MRI, the mean Pfirrmann grade of the disks spanned by the tether was 1.88 preoperatively and 2.31 postoperatively ( P =0.0075). No statistically significant differences in preoperative versus postoperative Pfirrmann grade were identified in the disks adjacent to the upper or lower instrumented vertebrae. No association was found between patient-reported outcomes and Pfirrmann grade.

CONCLUSION

At 1 year postoperatively, increased degenerative changes in disks spanned by the tether was identifiable on MRI without evidence of adjacent segment disk disease. These changes were not associated with patient-reported outcomes.

LEVEL OF EVIDENCE

Level III.

Radiographic Results after Vertebral Body Tethering

Vertebral body tethering (VBT), otherwise known as fusion-less anterior scoliosis correction (ASC), is a new and increasingly interesting therapeutic option for selected scoliosis patients. The available data on this surgical technique are still limited and guidelines on patient selection or surgical timing are not available. The aim of this study was to conduct a systematic review of the available literature on VBT. The analysis was performed in accordance with the PRISMA Statement. Nine studies with data from 175 patients were available. On average, 7.3 vertebrae were instrumented. Surgical time was 230 min and the estimated blood loss 153 ml. The mean correction on the coronal plane was 52%, and there was no significant change in sagittal parameters. The revision rate was 18.9%. The methodological quality assessment with the Coleman score gave unsatisfactory results, so that available data are not sufficient to propose general indications or guidelines to perform VBT.

To tether or fuse? Significant equipoise remains in treatment recommendations for idiopathic scoliosis

PURPOSE

Vertebral body tethering (VBT) continues to grow in interest from both a patient and surgeon perspective for the treatment of scoliosis. However, the data are limited when it comes to surgeon selection of both procedure type and instrumented levels. This study sought to assess surgeon variability in treatment recommendation and level selection for VBT versus posterior spinal fusion (PSF) for the management of scoliosis.

METHODS

Surgeon members of the Pediatric Spine Study Group and Harms Study Group were queried for treatment recommendations and proposed upper instrumented vertebra (UIV) and lower instrumented vertebra (LIV) selection for PSF and VBT based on 17 detailed clinical vignettes. Responses were subdivided in each clinical vignette according to surgeon experience and treatment recommendations with assessment of intra-rater reliability. Binomial distribution tests were used to establish equipoise, selecting p < 0.10 to indicate the presence of a treatment choice with consensus set > 70% agreement. For treatment choice, responses were assessed first for consensus on the decision to proceed with PSF or VBT.

RESULTS

Thirty-five surgeons with varied experience completed the survey with 26 surgeons (74%) completing the second follow-up survey. Overall, VBT was the recommended treatment by 47% of surgeons, ranging by clinical vignette. Consensus in treatment recommendation was present for 6 clinical vignettes including 3 for VBT and 3 for PSF, with equipoise present for the remaining 11. Of the 17 vignettes, 12 demonstrated moderate intra-observer reliability including the 3 consensus vignettes for VBT. Sanders stage ≤ 3 and smaller curve magnitude were related with VBT recommendation but neither age nor curve flexibility significantly influenced the decision to recommend VBT. Surgeons with high VBT volume, ≥ 11 VBT cases/year, were more likely to recommend VBT than those with low volumes (0-10 cases per year (p < 0.0001)). High VBT volume surgeons demonstrated consensus in VBT recommendation for Lenke 5/6 curves (75% mean recommendation). High VBT volume surgeons had a significantly higher VBT recommendation rate for Lenke 1A, 2A curves (71.8% vs 48.0%, p = 0.012), and Lenke 3 curves (62% vs 26.9%, p = 0.023). Equipoise was present for all vignettes in low volume surgeons. In addition, high VBT volume surgeons trended toward including more instrumented levels than low VBT volume surgeons (7.17 vs 6.69 levels).

CONCLUSION

Significant equipoise is present among pediatric spine surgeons for treatment recommendations regarding VBT and PSF. Surgeon-, patient-, and curve-specific variables were identified to influence treatment recommendations, including surgeon experience, curve subtype, deformity magnitude, and skeletal maturity. This study highlights the need for continued research in identifying the optimal indications for VBT and PSF in the treatment of pediatric spinal deformity.

When successful, anterior vertebral body tethering (VBT) induces differential segmental growth of vertebrae: an in vivo study of 51 patients and 764 vertebrae

PURPOSE

This study aimed to determine (1) does vertebral body tethering (VBT) produce differential growth modulation in individual vertebrae in patients with idiopathic scoliosis, (2) does VBT change disc shape, and (3) does VBT affect total spine length?

METHODS

Patients with idiopathic scoliosis treated with VBT of the main thoracic curve and minimum 2-year follow-up were included. Vertebrae and discs were categorized as uninstrumented proximal thoracic, instrumented main thoracic, or uninstrumented thoracolumbar-lumbar. The left- and right-sided heights of each vertebra and disc were measured on subsequent radiographs to assess for differential growth. T1-T12 thoracic and T1-S1 thoracolumbar growth velocities were compared with standardized reference data.

RESULTS

Fifty-one patients (764 vertebrae and 807 discs) were analyzed. The average major curve magnitude improved from 46° ± 11° to 17° ± 11° at 2-year follow-up. Differential growth was observed in MT vertebrae, in which the left/concave side grew 2.0 ± 2.2 mm compared with 1.5 ± 2.3 mm on the right/convex (tethered) side (p < 0.001). Differential height changes were observed for all discs, but were most pronounced in instrumented MT discs, in which the right/convex sides decreased by an average of 1.2 mm each, compared with no significant height change on the left/concave side. Total spinal growth velocities were not significantly different from standard reference data.

CONCLUSION

Vertebral body tethering limits convex spinal growth as designed while permitting concave growth. Curve correction results from differential vertebral growth and decreased convex disc height. Overall spinal growth continues at the expected rate.

LEVEL OF EVIDENCE

Level IV case series.

Pulmonary Complications after Vertebral Body Tethering: Incidence, Treatment, Outcomes and Risk Factor Analysis

Introduction: Vertebral body tethering (VBT) is gaining popularity for the management of selected AIS patients. The most frequent non-mechanical complications after VBT are pulmonary complications, with a reported incidence of up to 8% for recurrent pleural effusion. However, only trace data have been published on this topic. We aimed to analyze the incidence, timing, treatment, outcomes and risk factors of pulmonary complications after VBT. Materials and Methods: All patients who underwent VBT between September 2018 and September 2022 were retrospectively reviewed. The rate of pulmonary complications was analyzed and the symptoms, timing of onset, treatment and outcomes were recorded. An analysis of demographic, radiographic, surgical and pulmonary function data was conducted to explore possible risk factors for pulmonary complications. Results: Data from 140 patients were available: 14 experienced a pulmonary complication 1 day to 6 weeks after VBT, with 9 presenting a recurrent pleural effusion. A total of 13 patients required invasive treatment. All recovered without sequelae. The risk factor analysis did not result in any significant observations. However, 11/14 patients had had a diaphragm split. Conclusion: Pulmonary complications were observed in 10% of patients. The timing, symptoms and required treatment were heterogeneous. Pleural effusion seems to be more common after diaphragm crossing, but evidence is not yet conclusive.

Anterior vertebral body tethering for idiopathic scoliosis in growing children: A systematic review

BACKGROUND

The management of idiopathic scoliosis (IS) in skeletally immature patients should aim at three-dimensional deformity correction, without compromising spinal and chest growth. In 2019, the US Food and Drug Administration approved the first instrumentation system for anterior vertebral body tethering (AVBT), under a Humanitarian Device Exception, for skeletally immature patients with curves having a Cobb angle between 35° and 65°.

AIM

To summarize current evidence about the efficacy and safety of AVBT in the management of IS in skeletally immature patients.

METHODS

From January 2014 to January 2021, Ovid Medline, Embase, Cochrane Library, Scopus, Web of Science, Google Scholar and PubMed were searched to identify relevant studies. The methodological quality of the studies was evaluated and relevant data were extracted.

RESULTS

Seven clinical trials recruiting 163 patients were included in the present review. Five studies out of seven were classified as high quality, whereas the remaining two studies were classified as moderate quality. A total of 151 of 163 AVBT procedures were performed in the thoracic spine, and the remaining 12 tethering in the lumbar spine. Only 117 of 163 (71.8%) patients had a nonprogressive curve at skeletal maturity. Twenty-three of 163 (14.11%) patients required unplanned revision surgery within the follow-up period. Conversion to posterior spinal fusion (PSF) was performed in 18 of 163 (11%) patients.

CONCLUSION

AVBT is a promising growth-friendly technique for treatment of IS in growing patients. However, it has moderate success and perioperative complications, revision and conversion to PSF.

Vertebral Body Tethering: Indications, Surgical Technique, and a Systematic Review of Published Results

Vertebral body tethering (VBT) represents a new surgical technique to correct idiopathic scoliosis using an anterior approach, spinal instrumentation with vertebral body screws, and a cable compressing the convexity of the curve. According to the Hueter-Volkmann principle, compression reduces and distraction increases growth on the growth plates. VBT was designed to modulate spinal growth of vertebral bodies and hence, the term ‘growth modulation’ has also been used. This review describes the indications and surgical technique of VBT. Further, a systematic review of published studies was conducted to critically evaluate the results and complications of this technique. In a total of 23 included studies on 843 patients, the preoperative main thoracic curve corrected from 49 to 23 degrees in a minimum 2 year follow-up. The complication rate of VBT was 18%. The results showed that 15% of VBT patients required reoperations for pulmonary or tether-related issues (10%) and less than 5% required conversion to spinal fusion. While the reported median-term results of VBT appear promising, long-term results of this technique are currently lacking.

Anterior vertebral body tethering for thoracic idiopathic scoliosis leads to asymmetric growth of the periapical vertebrae

PURPOSE

To evaluate 3D growth of the periapical vertebrae and discs in the 2 years after anterior vertebral body tether (AVBT) placement in patients with idiopathic scoliosis (IS).

METHODS

Patients with IS treated with AVBT, ≥ 2 years of follow-up, and 3D spine reconstructions created from simultaneous, biplanar radiographs were studied. Patients were divided into two groups: progressive scoliosis correction (PC) or no/limited correction (NPC). The average of the 3 apical vertebral and disc heights and angular measures were made. The rate of change for each measure (mm/mo, °/mo) from first erect to 2-year follow-up was compared between groups.

RESULTS

Fourteen (Risser 0, Sanders 2-3) patients aged 11.4 ± 1.4 years with right thoracic scoliosis of 52 ± 9° were included. There were 7 patients per group (6F, 1M). Mean follow-up was 3.6 ± 1.1 (range 2-5) years. PC left-sided vertebral height increased 0.13 mm/months compared to 0.05 mm/mo in the NPC group (p = 0.001). Right (tethered side) vertebral growth was not different (PC: 0.07 mm/mo, NPC: 0.05 mm/mo, p = 0.2). Coronal vertebral wedging occurred at - 0.11°/mo compared to - 0.02°/mo for the PC and NPC groups, respectively (p = 0.004). Coronal disc angulation change was - 0.12°/mo in the PC group and - 0.04°/mo in the NPC group (p = 0.03), and was associated with loss of right disc height (PC: - 0.06 mm/mo) with little effect on the left disc height (PC: -0.01 mm/mo).

CONCLUSIONS

AVBT in immature patients with thoracic scoliosis can asymmetrically modulate growth of the periapical vertebrae and discs. Progressive reduction in scoliosis after AVBT was associated with greater concave growth rates in the vertebrae and loss of disc height on the convex side.

The Role of Vertebral Body Tethering in Treating Skeletally Immature Scoliosis

This is a critical analysis of a study by Hoernschemeyer et al, "Anterior Vertebral Body Tethering for Adolescent Scoliosis with Growth Remaining: A Retrospective Review of 2 to 5-Year Postoperative Results" (J Bone Joint Surg Am, 2020;102[13]:1169-1176), that assessed the clinical and radiographic outcomes of vertebral body tethering (VBT) in the treatment of adolescent scoliosis. The authors demonstrated successful treatment in 74% of patients, based on radiographic outcomes and avoidance of subsequent posterior spinal fusion. Nearly a quarter of patients required revision surgery. Almost half suffered a broken tether, although the effects of such complications are not fully understood. The study provided valuable information for determining which patients are reasonable candidates for VBT and emphasizes several questions surrounding this novel technology that remain unanswered. This analysis discusses the study's strengths and weaknesses, suggests potential directions of future research, and examines the potential indications for VBT.

Anterior Vertebral Body Tethering for Treatment of Idiopathic Scoliosis in the Skeletally Immature: Results of 112 Cases

STUDY DESIGN

Prospective case series.

OBJECTIVE

Determine the efficacy of anterior vertebral body tethering (AVBT) in skeletally immature patients.

SUMMARY OF BACKGROUND DATA

The value of AVBT is currently unclear given the paucity of available data.

METHODS

Consecutive skeletally immature patients with idiopathic scoliosis were treated with AVBT between 2012 and 2018 by one of two surgeons working at two independent centers and followed up for >2 years. Data were collected prospectively and supplemented retrospectively where necessary. Outcomes were measured preoperatively, at first erect radiograph (FE), 1-year postoperatively and at most recent follow up (FU).

RESULTS

One hundred twelve patients underwent 116 primary tethering procedures (108 thoracic and eight lumbar tethers). Four patients had primary tethering of both lumbar and thoracic curves. At surgery mean age was 12.7 ± 1.4 years (8.2-16.7) and Risser 0.5 ± 0.9 (0-3). Follow up was mean 37 ± 9 months (15-64). Preoperative mean coronal Cobb angle of the 130 tethered curves was 50.8° ± 10.2 (31-81) and corrected significantly to 26.6° ± 10.1 (-3-61) at FE radiograph (P < 0.001). Further significant improvement was seen from FE to 1-year, to mean 23.1° ± 12.4 (-37-57) (P < 0.001). There was a small but significant increase between 1-year and FU to 25.7° ± 16.3 (-32-58) (P < 0.001), which appeared to reflect tether breakage. Untethered minor curves were corrected from 31.0° ± 9.5 (3-57) to 20.3° ± 10.3 (0-52) at FU (P < 0.001). Rib hump was corrected from 14.1 ± 4.8 (0-26) to 8.8° ± 5.4 (0-22) at FU (P < 0.01). Twenty-five patients (22%) had 28 complications. Fifteen patients (13%) requiring 18 revision operations including six completed and one awaited fusions.

CONCLUSION

AVBT of immature cases is associated with satisfactory deformity correction in the majority of cases. However, complication and revision rates suggest the need for improved implants and patient selection. Long-term follow-up remains crucial to establish the true efficacy of this procedure.Level of Evidence: 3.

Rate of Scoliosis Correction After Anterior Spinal Growth Tethering for Idiopathic Scoliosis

BACKGROUND

The purpose of the present study was to evaluate associations between changes in segmental vertebral coronal angulation (screw angulation) and overall height after anterior spinal growth tethering for the treatment of idiopathic scoliosis and to compare the rates of coronal angulation change using the preoperative Sanders stage.

METHODS

Patients with idiopathic scoliosis who underwent anterior spinal growth tethering between 2012 and 2016 and had ≥2 years of follow-up were retrospectively studied. We calculated each segment's screw angulation rate of change (degrees/month) and each patient's height velocity (cm/month) between each of the visits (3 to 12 visits/patient) and divided the visits into 4 groups by postoperative duration (<1 year, 1 to 2 years, >2 to 3 years, >3 years). Patients were divided into 2 groups according to the preoperative Sanders stage. Generalized estimating equations and repeated-measures correlation were utilized for analyses with non-independent samples.

RESULTS

We analyzed 23 patients (16 female, 7 male) with a mean age (and standard deviation) of 12.2 ± 1.6 years who had right thoracic idiopathic scoliosis (mean, 53° ± 8°). All patients were immature at the time of surgery (Risser stage 0 or 1, Sanders stage 2 or 3). The mean duration of follow-up was 3.4 ± 1.1 years (range, 2 to 5 years). The rate of change for each segment's screw angulation after anterior spinal growth tethering was -0.16°, -0.14°, -0.05°, and 0.03° per month (with negative values indicating a reduction in scoliosis) for <1 year, 1 to 2 years, >2 to 3 years, and >3 years, respectively (p ≤ 0.001), and the mean height velocity was 0.65, 0.57, 0.30, and 0.19 cm per month for <1 year, 1 to 2 years, >2 to 3 years, and >3 years, respectively (p < 0.001). Changes in screw angulation correlated with height increases after anterior spinal growth tethering (r = -0.46, p < 0.001). Scoliosis correction for patients in the Sanders stage-2 group continued for 3 years (0.23°, 0.23°, and 0.09° per level per month for the first 3 years, respectively) and occurred at more than twice the rate for patients in the Sanders stage-3 group, for whom scoliosis correction ceased 2 years postoperatively (0.11° and 0.09° per level per month for the first 2 years, respectively).

CONCLUSIONS

Scoliosis correction was associated with overall height changes and occurred primarily within 2 to 3 years after surgery in this cohort of largely Risser stage-0 patients. The correction rate was 2.8° per segment per year for the first 2 years in the Sanders stage-2 group, compared with 1.2° per segment per year for the Sanders stage-3 group. Surgical timing that considers the patient's skeletal maturity is an important factor in generating proper postoperative correction after anterior spinal growth tethering.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk of early complication following anterior vertebral body tethering for idiopathic scoliosis

PURPOSE

The purpose of this study was to determine peri-operative morbidity associated with anterior vertebral body tethering (aVBT) for idiopathic scoliosis.

METHOD

Of 175 patients treated with aVBT, 120 patients had 2 year follow up and were included in this study. Prospectively collected clinical and radiographic data was analyzed retrospectively.

RESULTS

Pre-operatively, the mean patient age was 12.6 year (8.2-15.7 year), Risser 0-3, with main thoracic scoliosis 51.2° (40-70°). Immediately post-operative, scoliosis improved to 26.9° (6-53°; p < 0.05), at 1-year post-operative was 23.0° (- 11 to 50°; p < 0.01 vs immediate post-op) and at 2-year post-operative was 27.5° (- 5 to 52; p = 0.64 vs immediate post-op). Pre-operative T5-T12 kyphosis was 16.0° (- 23 to 52°), post-operative was 16.9° (- 7 to 44°), at 1-year was 17.5° (- 14 to 61°) and at 2-year was 17.0° (- 10 to 50°; p = 0.72 vs pre-op). All patients underwent thoracoscopic approach, EBL 200 ml (20-900 ml), surgical time 215.3 min (111-472 min), anesthesia time 303.5 min (207-480 min), ICU stay of 0.2 day (0-2 days), and post-operative hospital stay 4.5 days (2-9 days). During the in-hospital peri-operative period, there were no unplanned return to the operating room (UPROR) and there was a 0.8% rate of complication: one pneumothorax requiring reinsertion of chest tube. By 90 days post-operative, there was no UPROR and a 5% rate of complication. Five additional patients developed complications after discharge: one CSF leak treated with blood patch injection in the clinic and resolved, two pleural effusions requiring chest tubes, one superficial wound infection and one pneumonia treated with outpatient antibiotics. By 1-year post-op, there was a 1.7% rate of UPROR and 8.3% rate of complication. Four additional patients developed complications beyond 90 days: two upper limb paresthesia required outpatient medical management, one CSF leak which initially treated blood patch injection in the clinic initially which then required UPROR, and one compensatory lumbar curve add on that was treated with extension of the tether. By 2-years post-op, there was a 6.7% rate of UPROR and 15.8% rate of complication. 9 additional complications developed after 1 year. One curve progression, one keloid scar, one right leg weakness, 4 cable failures and 2 curve overcorrections.

CONCLUSION

This large, multicenter series of aVBT demonstrated a 15.8% complication rate and a 6.7% UPROR rate at 2 year post-operatively. This early study during the learning curve of aVBT found higher rates of CSF leaks and overall complications than would be expected for PSFI at 1 year post-operatively and a higher rate of overall complications and of UPROR than would be expected for PSFI at 2 year post-operatively. As is common with new procedures, the complication rate may fall with further experience.

Intra-operative forecasting of growth modulation spine surgery outcomes with spatio-temporal dynamic networks

PURPOSE

In adolescent idiopathic scoliosis (AIS), non-invasive surgical techniques such as anterior vertebral body tethering (AVBT) enable to treat patients with mild and severe degrees of deformity while maintaining lower lumbar motion by avoiding spinal fusion. However, multiple features and characteristics affect the overall patient outcome, notably the 3D spine geometry and bone maturity, but also from decisions taken intra-operatively such as the selected tethered vertebral levels, which makes it difficult to anticipate the patient response.

METHODS

We propose here a forecasting method which can be used during AVBT surgery, exploiting the spatio-temporal features extracted from a dynamic networks. The model learns the corrective effect from the spine's different segments while taking under account the time differences in the initial diagnosis and between the serial acquisitions taken before and during surgery. Clinical parameters are integrated through an attention-based decoder, allowing to associate geometrical features to patient status. Long-term relationships allow to ensure regularity in geometrical curve prediction, using a manifold-based smoothness term to regularize geometrical outputs, capturing the temporal variations of spine correction.

RESULTS

A dataset of 695 3D spine reconstructions was used to train the network, which was evaluated on a hold-out dataset of 72 scoliosis patients using the baseline 3D reconstruction obtained prior to surgery, yielding an overall reconstruction error of [Formula: see text]mm based on pre-identified landmarks on vertebral bodies. The model was also tested prospectively on a separate cohort of 15 AIS patients, demonstrating the integration within the OR theatre.

CONCLUSION

The proposed predictive network allows to intra-operatively anticipate the geometrical response of the spine to AVBT procedures using the dynamic features.

Complications, Reoperations, and Mid-Term Outcomes Following Anterior Vertebral Body Tethering Versus Posterior Spinal Fusion: A Meta-Analysis

Background

Anterior vertebral body tethering (AVBT) is a growth-modulation technique theorized to correct adolescent idiopathic scoliosis (AIS) without the postoperative stiffness imposed by posterior spinal fusion. However, data are limited to small series examining short-term outcomes. To assess AVBT's potential as a viable alternative to posterior spinal fusion (PSF), a comprehensive comparison is warranted. The purpose of this meta-analysis was to compare postoperative outcomes between patients with AIS undergoing PSF and AVBT. Our primary objective was to compare complication and reoperation rates at available follow-up times. Secondary objectives included comparing mid-term Scoliosis Research Society (SRS)-22 scores, and coronal and sagittal-plane Cobb angle corrections.

Methods

We performed a systematic review of outcome studies following AVBT and/or PSF procedures. The inclusion criteria included the following: AVBT and/or PSF procedures; Lenke 1 or 2 curves; an age of 10 to 18 years for >90% of the patient population; <10% non-AIS scoliosis etiology; and follow-up of ≥1 year. A single-arm, random-effects meta-analysis was performed. Deformity corrections, complication and reoperation rates, and postoperative SRS-22 scores were recorded.

Results

Ten AVBT studies (211 patients) and 14 PSF studies (1,069 patients) were included. The mean follow-up durations were similar for both groups. Pooled complication rates were 26% for AVBT versus 2% for PSF, and reoperation rates were 14.1% for AVBT versus 0.6% for PSF with nonoverlapping confidence intervals (CIs). The pooled reoperation rate among studies with follow-up times of ≥36 months was 24.7% in AVBT versus 1.8% in PSF. Deformity correction, clinical outcomes, and mid-term SRS-22 scores were similar.

Conclusions

Our study showed greater rates of complications and reoperations with AVBT compared with PSF. Reoperation rates were significantly greater in AVBT studies with longer follow-up (≥36 months). Deformity correction, clinical outcomes, and mid-term SRS-22 scores were similar. While a potential fusionless treatment for AIS merits excitement, clinicians should consider AVBT with caution. Future long-term randomized prospective studies are needed.

Level of Evidence

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Anterior Vertebral Body Tethering for Adolescent Idiopathic Scoliosis: Early Results and Future Directions

Anterior vertebral body tether (AVBT) is a nonfusion surgical procedure for correction of scoliosis in skeletally immature individuals. With US Food and Drug Administration approval in 2019, AVBT technology is spreading and early to midterm reports are being published. Early clinical reports are promising while precise indications, outcomes, complication profiles, and best practices are being established. Patients who are skeletally immature and wish to avoid a fusion surgery may benefit from this procedure. This article highlights the translational science foundation, early to midterm clinical reports, and future directions for this growing technique in pediatric spinal deformity surgery.

Cost-Utility Analysis of Anterior Vertebral Body Tethering versus Spinal Fusion in Idiopathic Scoliosis from a US Integrated Healthcare Delivery System Perspective

Purpose

Anterior vertebral body tethering (VBT) is a non-fusion, minimally invasive, growth-modulating procedure with some early positive clinical outcomes reported in pediatric patients with idiopathic scoliosis (IS). VBT offers potential health-related quality of life (HRQoL) benefits over spinal fusion in allowing patients to retain a greater range of motion after surgery. We conducted an early cost-utility analysis (CUA) to compare VBT with fusion as a first-choice surgical treatment for skeletally immature patients (age >10 years) with moderate to severe IS, who have failed nonoperative management, from a US integrated healthcare delivery system perspective.

Patients and Methods

The CUA uses a Markov state transition model, capturing a 15-year period following index surgery. Transition probabilities, including revision risk and subsequent fusion, were based on published surgical outcomes and an ongoing VBT observational study (NCT02897453). Patients were assigned utilities derived from published patient-reported outcomes (PROs; SRS-22r mapped to EQ-5D) following fusion and the above VBT study. Index and revision procedure costs were included. Probabilistic (PSA) and deterministic sensitivity analyses (DSA) were performed.

Results

VBT was associated with higher costs but also higher quality-adjusted life years (QALYs) than fusion (incremental costs: $45,546; QALYs gained: 0.54). The subsequent incremental cost-effectiveness ratio for VBT vs fusion was $84,391/QALY gained. Mean PSA results were similar to the base case, indicating that results were generally robust to uncertainty. The DSA indicated that results were most sensitive to variations in utility values.

Conclusion

This is the first CUA comparing VBT with fusion in pediatric patients with IS and suggests that VBT may be a cost-effective alternative to fusion in the US, given recommended willingness-to-pay thresholds ($100,000–$150,000). The results rely on HRQoL benefits for VBT compared with fusion. For improved model accuracy, further analyses with longer-term PROs for VBT, and comparative effectiveness studies, would be needed.

Anterior vertebral body tethering shows mixed results at 2-year follow-up

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To report 2-4-year outcomes of anterior vertebral body tethering (AVBT) for adolescent idiopathic scoliosis (AIS). AVBT is a relatively new procedure to correct AIS spine curvature and few outcomes studies have been published.

METHODS

Patients from 2015 to 2017 with 2-year follow-up were included. Successful outcomes were defined as curves 35° or less without revision surgery. We also compared outcomes between thoracic and lumbar ABVT.

RESULTS

There were 19 AVBTs in 17 patients, 13 thoracic and 6 lumbar. Nine curves (47%) in nine patients (53%) were successful. Preoperative kyphosis averaged 26° in the successful group and 14° in the unsuccessful group (P = 0.0337). Immediate correction for lumbar ABVTs (76%) was greater than thoracic ABVTs (43%) (P = 0.0140). Correction per level per month was greater in lumbar ABVTs (2.9° vs. 0.1°) (0.0440). Preoperative Sanders Maturity Scale (SMS) was 3.7 for successful cases and 2.5 for unsuccessful cases (P = 0.0232). Final SMS was 7.7 for successful cases and 5.7 for unsuccessful cases (P = 0.0518). All successful cases and 50% of unsuccessful cases were mature at final follow-up (P = 0.0294). There were four (24%) revision procedures, and three involving lumbar AVBTs. There were nine (47%) broken tethers.

CONCLUSIONS

Despite several final curves > 35°, four revisions, and nine broken tethers, the majority of patients (53%) were considered successful. Lumbar ABVTs correct more intraoperatively and faster postoperatively. Patients who are tethered during or slightly after the curve acceleration phase of growth may have more successful outcomes than patients tethered prior to the curve acceleration phase. AVBT requires further study with longer outcomes to define best practices for indications, level selections, and surgical techniques.

LEVEL OF EVIDENCE

IV.

Image-Guided Tethering Spine Surgery With Outcome Prediction Using Spatio-Temporal Dynamic Networks

Recent fusionless surgical techniques for corrective spine surgery such as Anterior Vertebral Body Growth Modulation (AVBGM) allow to treat mild to severe spinal deformations by tethering vertebral bodies together, helping to preserve lower back flexibility. Forecasting the outcome of AVBGM from skeletally immature patients remains elusive with several factors involved in corrective vertebral tethering, but could help orthopaedic surgeons plan and tailor AVBGM procedures prior to surgery. We introduce an intra-operative framework forecasting the outcomes during AVBGM surgery in scoliosis patients. The method is based on spatial-temporal corrective networks, which learns the similarity in segmental corrections between patients and integrates a long-term shifting mechanism designed to cope with timing differences in onset to surgery dates, between patients in the training set. The model captures dynamic geometric dependencies in scoliosis patients, ensuring long-term dependency with temporal dynamics in curve evolution and integrated features from inter-vertebral disks extracted from T2-w MRI. The loss function of the network introduces a regularization term based on learned group-average piecewise-geodesic path to ensure the generated corrective transformations are coherent with regards to the observed evolution of spine corrections at follow-up exams. The network was trained on 695 3D spine models and tested on 72 operative patients using a set of 3D spine reconstructions as inputs. The spatio-temporal network predicted outputs with errors of 1.8 ± 0.8mm in 3D anatomical landmarks, yielding geometries similar to ground-truth spine reconstructions obtained at one and two year follow-ups and with significant improvements to comparative deep learning and biomechanical models.

Safety and efficacy of anterior vertebral body tethering in the treatment of idiopathic scoliosis

AIMS

Spinal fusion remains the gold standard in the treatment of idiopathic scoliosis. However, anterior vertebral body tethering (AVBT) is gaining widespread interest, despite the limited data on its efficacy. The aim of our study was to determine the clinical efficacy of AVBT in skeletally immature patients with idiopathic scoliosis.

METHODS

All consecutive skeletally immature patients with idiopathic scoliosis treated with AVBT enrolled in a longitudinal, multicentre, prospective database between 2013 and 2016 were analyzed. All patients were treated by one of two surgeons working at two independent centres. Data were collected prospectively in a multicentre database and supplemented retrospectively where necessary. Patients with a minimum follow-up of two years were included in the analysis. Clinical success was set a priori as a major coronal Cobb angle of < 35° at the most recent follow-up.

RESULTS

A total of 57 patients were included in the study. Their mean age was 12.7 years (SD 1.5; 8.2 to 16.7), with 95% being female. The mean preoperative Sanders score and Risser grade was 3.3 (SD 1.2), and 0.05 (0 to 3), respectively. The majority were thoracic tethers (96.5%) and the mean follow-up was 40.4 months (SD 9.3). The mean preoperative major curve of 51° (SD 10.9°; 31° to 81°) was significantly improved to a mean of 24.6° (SD 11.8°; 0° to 57°) at the first postoperative visit (45.6% (SD 17.6%; 7% to 107%); p < 0.001)) with further significant correction to a mean of 16.3° (SD 12.8°; -12 to 55; p < 0.001) at one year and a significant correction to a mean of 23° (SD 15.4°; -18° to 57°) at the final follow-up (42.9% (-16% to 147%); p < 0.001). Clinical success was achieved in 44 patients (77%). Most patients reached skeletal maturity, with a mean Risser score of 4.3 (SD 1.02), at final follow-up. The complication rate was 28.1% with a 15.8% rate of unplanned revision procedures.

CONCLUSION

AVBT is associated with satisfactory correction of deformity and an acceptable complication rate when used in skeletally immature patients with idiopathic scoliosis. Improved patient selection and better implant technology may improve the 15.8% rate of revision surgery in these patients. Further scrutiny of the true effectiveness and long-term risks of this technique remains critical. Cite this article: Bone Joint J 2020;102-B(12):1703-1708.