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Thread: 10-year old: growth rods or fusion?

  1. #1
    Join Date
    Aug 2004
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    Wisconsin
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    Question 10-year old: growth rods or fusion?

    (I posted this in the adolescent section under surgery and probably should have posted it here instead, so here it is...My daughter actually has infantile scoliosis, but she's turning 10 very soon.)

    Hi,

    I have been a member here for a long time but haven't posted in a few years. My daughter, Bronwen, will be 10 in less than two weeks. She's had scoliosis since she was 18 months old. She wore a brace full time for a long time, then there was a period where her curves reduced down below 20 and she didn't wear a brace, then they started creeping back up and we did vertebral body stapling. That we had to do twice, once in May 2007 (age 8) and again in March 2008 (age almost 9) (both at the Philadelphia Shriners Hospital). In March last year, the curves were both about 35. She has a lumbar curve, and a compensatory thoracic curve. Initially the correction was under 20 for each curve.

    We saw her doctor (Dr. Sturm at Shriners Chicago) last week, and her curves have been creeping up again. Right now the lumbar is at 43 and the thoracic is at 40. So now we have moved on to discussing some type of fusion, because we expect the curves to keep increasing. He said we can pick between a regular fusion and growth rods. He also said that at age 10, 90% of spinal growth is done. I don't want to put her through many more surgeries (she has had 9 surgeries already; she has had other problems besides scoliosis: hip dysplasia and an umbilical hernia) but I don't want to stunt her growth any more than we have to.

    I am wondering if her spine might possibly be stabilizing in the low 40s. Well, I suppose I am hoping. ;-) Last November, her curves measured 35 L and 20 T, but now they are closer together at 43 and 40.

    Anyway, does anyone have experience with a fusion or growth rods in a 10-year old? What should we ask the doctor about? Any other options out there? We go back mid-June.

    In case there is confusion about the hospitals above: we live not far from Chicago and have been going to the Shriners there since Bronwen was 3. When we wanted the stapling done, Dr. Sturm didn't do it yet. So, we traveled to Philadelphia for it. She had the first one with Dr. D'Andrea and the second one with Dr. Asghar, both under the oversight of Dr. Betz. Dr. Sturm was going to assist on the first surgery but at the last minute could not, but did assist on the second and is now trained to do the surgery. He also replaced a staple that came dislodged, in May 2008. That we did in Chicago.

    The reason the stapling had to be done twice is that Dr. D'Andrea only stapled the lumbar curve, because she thought there was too much kyphosis on the thoracic curve (kyphosis is a contraindication for stapling). The next year it was clear it was not working and so we hoped that by also stapling the upper curve, it would work better. There was no kyphosis at that time, according to Dr. Asghar.

    Thanks,

    Nola

  2. #2
    Join Date
    Nov 2007
    Location
    Houston, TX
    Posts
    1,757
    Nola,

    I recall seeing you post over on the VBS site, and I hate to hear Brownwen may still be at risk after everything she's already been through .

    Is she a candidate for either the hybrid or VEPTR? If not, why?

    As you know, fusion is ... well ... fusion. Which doctor said a 10 year old spine is 90% mature? I've never heard anything like that, and it would seem if that were valid, you wouldn't see crankshafting in kids with early fusions.

    Growth rods, VEPTR and Betz's hybrid all need fairly substantial growth to have any efficacy: It seems contradictory they're saying on one hand a 10 year old only has 10% of their growing left to do, but they're talking about a choice between traditional fusion and growth rods. Either she has (or will have in 6 months) significant growth left or not. It appears a bit preemptive to have you examine those options and make a choice *now*, you know?

    The only real way to make that claim *with your child* is by her Risser, Tanner, or some kind of skeletal maturity indicator. What's her Risser now, and is she pre-menarchal?

    Growing rods come with their own set of issues, and a rod that causes spontaneous fusion doesn't seem like it has much advantage over plain old fusion in my mind.

    Out of curiousity, with any type of rod (except the hybrid) would they remove her existing staples prior to instrumentation and/or fusion?

    Regards,
    Pam
    Fusion is NOT the end of the world.
    AIDS Walk Houston 2008 5K @ 33 days post op!


    41, dx'd JIS & Boston braced @ 10
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  3. #3
    Join Date
    Aug 2004
    Location
    Wisconsin
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    Thanks, Pam

    I do not know whether the staples would come out or not.

    We're to go back in 3 months, mid-June, and decide what we're going to do at that time, if anything (I suppose if the measurements are the same we'll wait). He was saying with the growth rod option, we'd want to do it soon, like in 3 months, but with the fusion option, we could probably wait until at least 6 months.

    He mentioned VEPTR, but then told me why it wasn't the best choice for her, but now I have forgotten what he said.

    I don't know how far off that 10% would be. She's 56" right now, plus probably 2.5" for how much shorter she is because of the scoliosis, according to the doctor. If you take 10% of that left to grow, that puts her at 64", which is 5'4". I am 5'3". She's always been a bit tall for her age. So at a max, I would think she'd only grow 10-20% more, so it doesn't seem that far off to me. 20% would put her at an adult height of 70", or 5'10". However, I do not know her scores on those maturity scales you mentioned, but will make sure we find out before we make any surgical decision. She is pre-menarchal, probably by 1.5-2 years. I just read about the Tanner Stage, and I am thinking she is stage II.

    I'm not sure about the hybrid rod surgery. If the staples aren't doing diddly right now, would adding this rod help? I guess I don't know enough about the surgery, but it seems to me like the idea is for them to work in conjunction with one another, and if one part is not working....though perhaps it's not working because it's not getting the help it needs. Just totally guessing here.

    I am feeling like I do not yet know enough about the growing rods to make a decision about those.

    We have been patients of Dr. Betz's in the past; he is going to review her files from the Chicago Shriners. I'm eager to hear what he has to say.

    Dr. Sturm was saying that age 10 is kind of a "gray area." On the one hand, there is obviously more growth, but on the other, it's not a huge amount overall.

    Thanks for your thoughtful reply!

    Nola

  4. #4
    Join Date
    Apr 2007
    Location
    Seattle, WA
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    I just wanted to add here that when we were told Alexander needed surgery, any of the surgeons I asked (we had four opinions) all said the same thing about the 10% of spinal growth left at age 10. I was relieved because Alexander was going to have just turned 12 a few months before his surgery. Then I read somewhere that since boys often mature and grow at later ages than girls, their comparable age for 10% of spinal growth left was approx. age 12. Since his surgery 1.5 years ago, he has hardly grown taller at all. So far, he is a very short boy: 5'1/4". I really hope he grows a few more inches...

    Nola, it sounds like your daughter has been through more than her "fair" share of surgeries. Good luck with your decision-making process for what could possibly be her last surgery. It sounds like she will be a decent height no matter what option you and the surgeon choose. The instrumentation these days is pretty good at preventing crankshafting from what I've been told.

    I wish you and Bronwen all the best.
    Laurie

    Mother of Alexander & Zachary:
    Alex is 16 years old and in the 11th grade. He has congenital scoliosis due to a hemivertebrae at T10. Wore a TLSO brace for 3 1/2 years. Pre-op curves were T45 & L65; curves post-op are approx. T31 & L34. Had a posterior spinal fusion from T8 to L3 on 7/12/07 at age 12. Doing great now in so many ways, but still working on improving posture.
    Zach is 13 years old and very energetic.

  5. #5
    Join Date
    Jan 2008
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    NC
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    I don't think there is anything amiss with saying a 10 y.o. has achieved 90% of the total spinal growth. That seems to ring a bell.

    That last 10% apparently is enough to cause crankshafting. Ten percent is actually a lot when you think about the actual lengths involved.

    Nola, do they know why stapling failed in your daughter's case?

    Did she have curves that they now know are too large to staple?

    Or are there some other contraindications for stapling?

    Are the failures in the highly rotated cases for instance even if the curve is within range?

    Is it only meant for IS and doesn't tend to work well in connective tissue disorders like bracing doesn't work with Marfan's for example?

    Anyone know?

    Nola, I wish you good luck gong into the future. Better techniques are always coming down the pike.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

  6. #6
    Join Date
    Nov 2005
    Posts
    402
    Crankshafting can be avoided if the spine is fused anteriorly as well as posteriorly. This certainly worked for me; I was fused at 10 (T1-T12) and didn't have any problems with crankshafting. The downside to this is that the extra anterior surgery is needed, though a lot of kids require a two stage surgery anyway.

    As I mentioned on another of your threads, I can well believe that 90% of spina growth is done by the age of ten because I never ended up looking significantly shorter than I should have been (and that's with a residual post-op curve of 45/35 degrees as well!). I was always told that after this time, most of a child's growth is in its limbs rather than its spine. I'm 5'3 tall and just look like I have long legs rather than a short torso, which is cool with me

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