Baron S. Lonner

Background: We describe key pearls and principles of a mini-open, thoracoscopically-assisted vertebral body tethering case for double-major scoliosis with 2 distinct anterior approaches: thoracic and thoracoabdominal. Description: The thoracic curve is addressed through a mini-thoracotomy combined with thoracoscopic portals utilizing single-lung ventilation to provide clear visualization. Key steps include precise fluoroscopic marking of vertebral levels, muscle-sparing entry between the ribs, controlled pleural entry and mobilization, and careful management of segmental vessels. Vertebral body screws are placed under direct and fluoroscopic guidance with strict adherence to orthogonal trajectories and avoidance of disc violation. Tether placement proceeds segment-by-segment, maximizing correction at the apex while maintaining appropriate laxity distally to prevent overcorrection. Major tethering principles include maintaining colinear screw alignment to prevent tether kinking and utilizing bicortical fixation when anatomy permits. These principles ensure uniform force transmission and minimize stress concentrations within the tether construct, optimizing tether durability. The lumbar curve is accessed through a thoracoabdominal exposure that includes mobilization of the diaphragm with cuffed detachment and blunt retroperitoneal dissection to safely identify the iliopsoas muscle and sympathetic chain. Double-screw constructs are used at most accessible lumbar levels, with priority given to the apical region to enhance durability under higher mechanical loads. Screws are positioned posteriorly within the vertebral body to help maintain lumbar lordosis and are inserted with a controlled trajectory to achieve bicortical fixation while avoiding a posterior cortical breach and maintaining a safe distance from the spinal canal. Two tethers are applied (first posterior, then anterior) to distribute corrective forces and reduce peak tether strain, balancing correction with load-sharing. Adherence to these principles optimizes lordosis preservation, construct longevity, and safe modulation during growth. Alternatives: The primary alternative treatment is posterior spinal fusion (PSF), the current standard surgical treatment for adolescent idiopathic scoliosis ¹ . PSF generally provides greater and more predictable curve correction, particularly for thoracic-major curves, but sacrifices motion across the fused spinal segments. Rationale: This surgical technique is appropriately applied in skeletally immature patients with flexible double-major adolescent idiopathic scoliosis who are undergoing vertebral body tethering through combined thoracic and thoracoabdominal anterior approaches ^1–7 . A representative scenario is a patient with a right thoracic and a left lumbar curve demonstrating ≥50% correction of both curves on preoperative bending radiographs, indicating sufficient flexibility for growth modulation. Ideal candidates typically have Cobb angles between 40° and 65° and are skeletally immature (Risser 0 to 2, Sanders 3 to 4). The principles demonstrated are particularly relevant when treating double-curve deformities that require 2 distinct anterior exposures, wherein precise screw alignment, safe vessel and soft-tissue management, and differential tether tensioning are critical to predictable growth modulation. In the thoracic spine, this technique is useful when placing vertebral body screws through a mini-thoracotomy with thoracoscopic assistance, wherein colinear screw alignment and segmental tensioning are necessary to avoid tether kinking and maintain physiologic thoracic kyphosis. In the lumbar spine, thoracoabdominal exposure requires diaphragm mobilization and screws are posteriorly positioned; dual-screw constructs and staged posterior-then-anterior tethering help preserve lumbar lordosis and improve construct durability. These use cases emphasize scenarios in which precise fluoroscopic planning, harmonious screw trajectories, and controlled tether laxity are essential to avoid overcorrection, minimize mechanical stress on the tether, and achieve durable correction through guided spinal growth. Expected Outcomes: In appropriately selected adolescents with double-curve adolescent idiopathic scoliosis, bilateral vertebral body tethering can provide meaningful correction of both curves while preserving spinal motion ^1–3 . Outcomes appear more favorable for thoracolumbar-major curves than thoracic-major curves, but patients should be counseled regarding risks of tether breakage, overcorrection, loss of correction, and potential revision or fusion. Long-term durability remains uncertain. Important Tips: Maintain optimal orthogonal fluoroscopic views throughout screw placement. Align screw tulips colinearly to avoid tether shear forces. Leave controlled laxity distally in patients with substantial remaining growth. Use bicortical fixation posteriorly in the lumbar spine for reliable fixation. Avoid placing screws too anteriorly or posteriorly, which increases the risk of a visceral or canal breach. Avoid overtensioning end segments, which increases the risk of overcorrection. Avoid grasping or damaging the tether with instruments. Avoid insufficient thoracotomy and/or portal placement, which can lead to poor exposure and suboptimal screw trajectory. Acronyms and Abbreviations: VBT = vertebral body tethering

Background: Understanding outcomes of spinal fusion (SF) in children with cerebral palsy (CP) beyond the short term is important to determine efficacy and durability. This study examined complications, unplanned returns to the operating room (UPROR), and radiographic and clinical outcomes after SF in children with CP. Methods: Patients with GMFCS IV or V CP who had been followed for a minimum of 5 years after SF were identified in a prospective multicenter database and analyzed. The major Cobb angle and pelvic obliquity (PO) were recorded. Data regarding complications and any UPROR were collected prospectively. The Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire was completed preoperatively and at 2 and 5 years postoperatively. Data were analyzed using a generalized estimating equation (GEE), repeated-measures analysis of variance (RM-ANOVA), and the Kaplan-Meier method. Results: One hundred and eighty-nine patients (mean age, 13.4 ± 2.7 years; 94 male and 95 female; 45% White, 24% Hispanic, 16% Black, and 4% Asian as self-reported) were included in the study. The preoperative Cobb angle (82.8° ± 23.0°) was improved at 2 years (29.9° ± 16.2°; p < 0.001), and the improvement was maintained at 5 years (30.2° ± 17.0°; p = 0.284). The preoperative PO (27.4° ± 15.6°) was improved at 2 years (9.7° ± 9.1°; p < 0.001), and the improvement was maintained at 5 years (9.9° ± 9.8°; p = 0.997). There were 46 patients (24.3%) with major complications and 25 patients (13.2%) who required UPROR, mostly within the first year. The probability of remaining free of major complications and of having no UPROR at 5 years was >75% and >87%, respectively. Improvements in CPCHILD scores were observed at 2 years and remained improved at 5 years compared with baseline. RM-ANOVA demonstrated no significant differences in the change in scores over time in patients with complications or UPROR compared with those who did not. Those with complications or UPROR showed no evidence of a major decline in CPCHILD scores. Conclusions: SF resulted in durable radiographic correction and sustained improvements in caregiver-reported quality of life over a minimum of 5 years. Patients with major complications or UPROR showed no deterioration in CPCHILD scores. These findings support SF as an effective treatment option for appropriately selected patients with GMFCSIV or V CP. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Study Design: Original research, cross-sectional study. Objectives: Evaluate preferences of patients, caregivers, and patient-caregiver dyads for non-fusion vs fusion surgery. Methods: A survey-based discrete choice experiment included patients 12-15 years of age with idiopathic scoliosis and their caregivers. Preference weights were estimated for 2 types of attributes that differed between fusion and non-fusion surgery: treatment outcomes (ie, appearance, confidence in planned correction, spinal motion, device failure, reoperation, and recovery period) and procedure-type requirements associated with each surgery type. Correlations between preference weights for patients, caregivers, and dyads were calculated to assess preference concordance between cohorts. Results: A total of 344 respondents (124 patients, 92 caregivers, and 128 patient/caregiver dyads) completed the survey. Appearance was the most important treatment outcome for the average respondent in all cohorts. For patients, the least important treatment outcome was recovery time, whereas reoperation rate was the least important treatment outcome for caregivers and dyads. After controlling for treatment outcomes, patients and patient-caregiver dyads preferred the procedure-type requirements associated with fusion surgery, while caregivers preferred the procedure-type requirements associated with non-fusion surgery. Preferences of respondents who completed the survey prior to surgery were similar to those who completed the survey after surgery. Patient and caregiver preferences were more similar to the preferences of dyads than to each other. Conclusions: Patients and patient-caregiver dyads preferred the procedure-type requirements associated with fusion surgery, while caregivers preferred the procedure-type requirements associated with non-fusion surgery. Appearance was the most important treatment outcome for patients, caregivers, and patient-caregiver dyads.

Background: Delayed-onset neurologic changes (DONCs) following spinal deformity surgery are poorly understood and are often devastating. Methods: A retrospective review of cases from 12 hospitals was performed. The clinical and radiographic parameters of patients who experienced a new DONC after spinal deformity correction were evaluated. Results: Eighteen patients, with a mean preoperative major Cobb angle of 75° ± 24°, were included. The mean age at surgery was 13 ± 2 years, and 6 patients (33%) were male. Seven patients had temporary intraoperative neuromonitoring changes. Fourteen patients (78%) had neurologic changes within 24 hours postoperatively (range, 3 to 24 hours). Of 16 patients with blood pressure data, 8 (50%) had at least 1 documented episode of hypotension surrounding the change in neurologic status. No misaligned implants were seen on axial imaging. Fourteen patients (78%) were treated with vasopressors. Sixteen patients (89%) returned to the operating room, and 11 patients (61%) underwent implant removal. Seven patients (39%) sustained a spinal cord infarct, with only 1 (6%) experiencing recovery beyond an ASIA (American Spinal Injury Association Impairment Scale) score of B. Ten (91%) of the 11 patients without an infarct demonstrated recovery (5 patients with an ASIA score of D and 5 with a score of E). Conclusions: A DONC is a rare complication of spinal deformity surgery. This study represents the largest documented series of DONCs and highlights the multifactorial and still poorly understood nature of this condition. The primary modifiable risk factor may be hypotension in the postoperative period: 50% of patients had a mean arterial pressure below the 5th percentile for their height, as documented around the time of the neurologic change. Eighty-six percent of patients with a spinal cord infarct had minimal neurologic recovery, whereas nearly all of the patients without an infarct did recover function. The management of this condition may include elevation of blood pressure with temporary implant removal. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Purpose Vertebral body tethering (VBT) is a non-fusion surgical option for adolescent idiopathic scoliosis (AIS) that requires a postoperative (PO) chest tube. This study evaluates whether 48 h of PO TXA reduces chest tube (CT) drainage and retention compared to 24 h of TXA following VBT for AIS. Methods Consecutively treated patients with a diagnosis of AIS who underwent VBT were assessed. Thirty-eight patients who received 48 h of PO IV TXA (48-TXA) were compared to 35 VBT patients who received 24 h of PO IV TXA (24-TXA) and 48 patients who did not receive TXA (non-TXA). TXA use in thoracic CT and thoracolumbar CT drainages were also assessed separately. Group comparisons were performed using one-way ANOVA and Chi-square tests. Results There were no significant differences in demographics between groups. TXA significantly reduced CT drainage (p < 0.001) and retention (p < 0.001), with no differences between 24-TXA and 48-TXA (p = 0.88). Sub-analyses showed that both 24-TXA and 48-TXA reduced thoracic CT drainage (p = 0.002, p = 0.02) and retention time (p = 0.04, p = 0.007) compared to non-TXA, respectively. For thoracolumbar CT, differences were observed only between 24-TXA and non-TXA (p = 0.01, p = 0.03). TXA was an independent predictor of reduced CT drainage (p < 0.001) and retention (p < 0.001). Hospital stay, ICU stay, and complications didn’t differ between TXA groups (p > 0.9, p = 0.4), respectively. Conclusions Intravenous TXA reduces CT drainage and retention after VBT for AIS for thoracic CTs. There was no additional benefit of 48-TXA over 24-TXA in decreasing overall drainage and CT retention time.

Background: The gold standard treatment for adolescent idiopathic scoliosis (AIS) is posterior spinal fusion (PSF). However, long-term consequences of PSF can include reduced spinal flexibility, back pain, and intervertebral disc degeneration. Vertebral body tethering (VBT) is a non-fusion alternative that preserves motion. We investigated the outcomes of VBT for the treatment of thoracolumbar (TL) major AIS in the largest single-surgeon series with a minimum 2-year follow-up (FU). Methods: We performed a retrospective single-center review. Inclusion criteria were AIS, Lenke 5/6 curvature, and skeletally immature Variables were compared using Student’s t-tests, Wilcoxon rank sum tests, Chi-square, and Fisher’s exact tests. Results: A total of 37 consecutive patients, age 14.1 ± 1.6 years, 86.5% F, 35.9 ± 11.5-month FU, were examined. Overall, 27 patients (73%) had Lenke 5 and 10 (27%) had Lenke 6 curvatures. Instrumentation of the TL curve alone was performed in 59.5%, and thoracic (T) and TL in 40.5% of patients. Overall, 45.9% of patients had two tethers placed in the TL spine; no patients had double tethers placed at the main thoracic curves. The TL (51 ± 8° to 20 ± 11°; p < 0.0001) and T (37 ± 13° to 17 ± 10°; p < 0.0001) curvatures improved from baseline to the latest FU. Overall, 89% of patients achieved major Cobb < 35°; the three patients who did not experienced at least one cord breakage or required PSF. T5-T12 kyphosis increased (p = 0.0401) and lumbar lordosis was maintained (p = 0.9236). Both the TL inclinometer (16 ± 4º to 4 ± 2°; p < 0.0001) and T (6 ± 4° to 4 ± 3°; p = 0.0036) measurements improved. There was a 49% tether breakage rate as follows: 60% for single-cord TL constructs and 35% for double cords (p = 0.0991). There was an 8.1% re-operation rate as follows: one conversion to T PSF and revision of the TL tether; one release of the T tether and revision of the TL tether; one screw revision for radiculopathy. One patient was re-admitted for poor pain control. Conclusions: Patients with TL major curvature treated with VBT experienced a high rate of clinically successful outcomes with maintenance of lumbar lordosis and relatively low complication rates at the latest FU.

Purpose Posterior spinal fusion (PSF) is the current gold standard in surgical treatment for adolescent idiopathic scoliosis. Vertebral body tethering (VBT) is a fusionless alternative. Shoulder balance is an important metric for outcomes and patient satisfaction. Here we compare shoulder balance outcomes between PSF and VBT. Methods In this retrospective review, the pre-operative and post-operative absolute radiographic shoulder height (|RSH|) of 45 PSF patients were compared to 46 VBT patients. Mean values were compared and then collapsed into discrete groups (|RSH| GROUP) and compared. Patients were propensity score matched. Regression models based on pretest–posttest designs were used to compare procedure type on post-operative outcomes. Results Pre-operatively there were no differences in |RSH| between PSF and VBT, however, at latest post-operative follow-up PSF maintained a larger |RSH| imbalance compared to VBT (0.91 cm vs 0.63 cm, p = 0.021). In an ANCOVA regression, PSF was associated with a larger |RSH| imbalance compared to VBT, F(1, 88) = 5.76, p = 0.019. An ordinal logistic regression found that the odds ratio of being in a worse |RSH| GROUP for PSF vs VBT is 2.788 (95% CI = 1.099 to 7.075), a statistically significant effect χ²(1) = 4.658, p = 0.031. Results were similar in subgroup analyses of Lenke 1 and Lenke 2 patients, though to less statistical significance. Conclusion While PSF was found to be associated with worse |RSH| outcomes, the actual numbers (2–3 mm) are unlikely to be clinically meaningful. Thus, in this analysis, VBT can be said to show comparable shoulder balance outcomes to PSF.