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Would instrumenation without fusion be a better alternative than fusion when growth potential is remaining

Dr. Charles E. Johnston, II

Texas Scottish Rite Hospital Orthopedic Group

This is a very complex subject. There is no "cookbook" answer, and such surgery must be carefully decided on an individual basis. One thing to remember is that instrumentation without fusion will automatically mean you will need more than one operation, whereas if fusion is done, there is the strong possibility that that will be the only operation required.

Dr. Scott J. Luhmann

St. Louis, MO

Ideally the answer is yes. Currently, several U.S. medical centers specializing in pediatric spinal deformity are researching various types of fusionless scoliosis surgery. Preliminary reports from these centers are encouraging, but these are still in the developmental phase and indicated only for very specific conditions.

Dr. John T. Smith

University of Utah Department of Orthopaedic Surgery

There are instances in younger children where the spine is instrumented without fusion. Unfortunately, this continues to carry a high complication rate. In my practice, we are looking closely at techniques of scoliosis correction that do not involve fusion, but involve growth manipulation of the spine. These techniques are being developed here at the University of Utah and elsewhere. If the spine is not fused at the time of instrumentation, the complication rate is quite high. As a result, second surgeries with fusion are generally always required at a later date.

Dr. Frank J. Schwab

New York, NY

This question has been discussed for many years without a good answer. In general, if there is only limited growth remaining in the spine it is considered best to correct the deformity (balance the spine) and perform a fusion. If there is still a lot of growth remaining, then bracing and casting may 'buy some time' until a fusion is performed. Instrumentation without fusion is used in very rare circumstances. Such an approach requires multiple surgeries and may not lead to significant overall gains in height for many patients.

Dr. Patrick Bosch

Albuquerque, NM

This is an appealing concept, but at this point these techniques are applicable only to very few situations and are largely unproven.

Dr. Dennis G. Crandall

Mesa, AZ

We consider this controversial concept an option in treating very young children with progressive curves. Parents should understand that several “instrumentation lengthening” procedures are required as the child grows and there is a high complication rate.

Dr. Baron S. Lonner

New York, NY

Non-fusion surgery is recommended for patients with large remaining growth. Fusion in a child under age eight results in significant restriction of spinal growth in the thoracic region, thus also limiting vertical growth of the thoracic cavity and may impact development of lung tissue. This may result in significant restrictive lung disease. Therefore, depending on remaining growth and the skeletal and biological maturity of the patient "a growing rod" may be appropriate. A growing rod procedure entails the placement of rods for correction without performing a simultaneous fusion. This procedure is not without its limitations as it does require multiple operative procedures in order to lengthen the rod over time, and instrumentation problems and kyphosis can occur.

Dr. Thomas G. Lowe

Woodridge Orthopaedics & Spine Center, P.C.

Following surgery, we use an electronic patient controlled button delivery system, which delivers just the appropriate amount of pain medication into the vein. It takes care of the pain immediately but will not allow too much pain medicine to be given. This is only necessary for 1-2 days after surgery. A mild narcotic pain pill will almost always take care of the pain for the next 3-4 days. Following that, on discharge, a Non-Narcotic pain pill will be used for as long as necessary, which is usually an additional two weeks.

Dr. David W. Polly, Jr.

Minneapolis, MN

This is a very unusual situation. Maybe only 0.1% of the time is this appropriate. Usually it is in very, very young children (1-5 years old) with very bad curves.

Dr. Michael F. O'Brien

Denver Orthopaedics

In the very young individuals, occasionally, this technique is used. This consists of a rod which is connected to the spine which is at intervals lengthened during an outpatient surgical procedure. This technique is typically only necessary for the very young when significant growth potential remains. However, in most adolescent patients with scoliosis, surgery is postponed until growth is nearly complete and the amount of spinal length which is lost is minimal.

Dr. John P. Lubicky

Chicago, IL
Shriner's Hospital for Children

The answer is yes and no because it depends on how much growth is remaining. Typically in very young children who have either infantile or juvenile scoliosis which cannot be controlled in a brace, what is called a "growing rod" is implanted, which may be combined with a short anterior fusion at the apex of the curve. The "growing rod" is then periodically lengthened to account for growth and to maintain the correction of the curve. However, this is not a permanent solution. Implanted rods left permanently that are not associated with fusion will eventually break or tear out from the vertebrae because of the continued motion of the spine across that area. However, the use of the growing rod temporarily is a reasonable option to preserve some of the growth of the spine while still controlling the curve.

Dr. Jean-Pierre C. Farcy

New York, NY
M.M.C. Spine Center

No, fusion with or without instrumentation is the same and even with some preserved elasticity it will not change anything. On the contrary very rigid instrumentation may limit "crank shaft phenomenon" development.

Dr. W. Christopher Urban

Glen Burnie, MD

Spinal instrumentation without fusion may be used in rare circumstances involving a severe and progressive curve in a patient younger than six years of age. The rods are inserted beneath the skin and act as an internal splint that braces the curve but does not fuse it. These distraction rods require periodic lengthening as the patient grows. Eventually, a formal instrumentation and fusion are performed. The major complications include infection, spontaneous fusion, and implant dislodgement.

Dr. James Mooney, III

Detroit, MI

Instrumentation without fusion has been attempted and in rare instances still is performed. It generally has a poor track record and is not recommended.

Dr. Christopher L. Hamill

Buffalo General HospitalBuffalo General Hospital

No. The fusion is what ultimately prevents progression of the curve. Instrumentation without fusion would lead to instrument failure.

The commentary above recounts the experiences of these physicians. Medtronic invited them to share their stories candidly. Keep in mind that results vary; not every patient's response is the same. Talk with your doctor to learn more about any products that are mentioned above.

It is important that you discuss the potential risks, complications and benefits of spinal surgery with your doctor prior to receiving treatment, and that you rely on your doctor's judgment. Only your doctor can determine whether you are a suitable candidate for this treatment.

  • Published: June 20, 2002
  • Updated: April 19, 2010