Orthopaedic Advances

“Growth Friendly” Spine Surgery:

Management Options for the
Young Child With Scoliosis

Abstract
Jaime A. Gomez, MD The natural history of early onset scoliosis is dismal and
Joseph K. Lee, MD associated with poor pulmonary function and increased mortality.
Although limited in situ fusion may be appropriate for certain types
Paul D. Kim, MD
of congenital scoliosis deformities, spinal deformity that affects
David P. Roye, MD young children often requires a “growth friendly” surgical approach
Michael G. Vitale, MD that allows for curve control while maintaining growth of the spine
and thorax. Growth-friendly surgical management of early onset
scoliosis can follow a distraction-based (ie, growth rods, vertical
expandable prosthetic titanium rib [Synthes, West Chester, PA]),
guided-growth (ie, Luque trolley technique, Shilla technique), or
compression-based (ie, tethers, staples) strategy.

B ecause of both the dismal natu-

From the Department of Orthopedic
Surgery, Columbia University
Medical Center, New York, NY.
Dr. Roye or an immediate family
member has received research or
institutional support from Synthes.
Dr. Vitale or an immediate family
member has received royalties from
Biomet; serves as a paid consultant
to Biomet and Stryker; has received
research or institutional support from
Synthes; and serves as a board
member, owner, officer, or
committee member of the Chest
Wall and Spinal Deformity Study
Group, Scoliosis Research Society,
and Pediatric Orthopaedic Society of
North America. None of the following
authors or any immediate family
member has received anything of
value from or owns stock in a
commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Gomez,
Dr. Lee, and Dr. Kim.
J Am Acad Orthop Surg 2011;19:
722-727
Copyright 2011 by the American
Academy of Orthopaedic Surgeons.
ral history of early onset scolio-
sis and the unfavorable effects of
early fusion, clinicians who treat
young children with scoliosis use a
variety of surgical techniques in an
attempt to avoid, delay, or limit spi-
nal fusion. These “growth friendly”
techniques and implants allow curve
control and limit early spinal fusion.
The growth rate of the spinal col-
umn varies bimodally with age, with
the most rapid growth taking place
from birth to age 2 years, and fur-
ther rapid growth occurring again at
adolescence. The volumetric growth
of the thorax as a three-dimensional
structure is of major importance; un-
derstanding has improved regarding
the complex relationships between
the structure and function of the
spine, thorax, and lungs. Although
the spine has a major effect on lung
and thoracic cavity development,
cross-sectional volume also depends
on the growth of the ribs, both in
length and the degree of rib obliq-
uity. Thoracic volume increases to
30% of the adult size by 5 years of
age and to only 50% of the adult
size by 10 years of age.1,2 Thoracic
volume can be limited by curve pro-
gression or by early fusion.3,4
Pehrsson et al5 noted a statistically
significant increased risk of mortality
related to respiratory failure in chil-
dren with infantile or juvenile scolio-
sis compared with children with ado-
lescent scoliosis. Vitale et al6 and
others7 have demonstrated untoward
effects of early fusion on pulmonary
function. Avoidance of this iatro-
genic thoracic insufficiency is a guid-
ing principle of treatment in the
young patient with scoliosis.8
Early Onset and
Congenital Scoliosis
Early onset scoliosis is a heteroge-
neous condition. Prognosis and natu-
ral history vary widely depending on
whether the etiology is congenital,
idiopathic, syndromic, or neuromus-
cular.9 The natural history of congen-

722 Journal of the American Academy of Orthopaedic Surgeons


ital scoliosis is unpredictable, and
patients require close follow-up.
Those at highest risk of progression
include young patients with a failure
of segmentation, especially when ac-
companied by a contralateral unseg-
mented hemivertebra.10
Resection and/or early limited fusion
may be the best option in cases of iso-
lated anomalies that affect short spinal
segments before progression and
the development of compensatory
curves.11 However, young patients with
more complex, multisegment deformi-
ties may benefit from a growth-friendly
approach.6,12,13 Although indications
for surgical intervention vary,14 most
surgeons prefer to intervene with a
growth-friendly construct before ro-
tation results in a windswept thorax,
intrusion into the hemithorax, and
subsequent restriction of pulmonary
function.15
Management
Successful management of early on-
set scoliosis intends to improve or
prevent progression of spinal defor-
mity and chest wall constriction,
avoid or limit early spinal fusion,
and minimize surgical complications
and negative effects of treatment on
quality of life.
Casting techniques were commonly
used for the treatment of scoliosis
before the introduction of spinal in-
strumentation.16,17 Mehta18 reported
extensive experience with serial cast-
ing in patients with infantile idio-
pathic scoliosis, which resulted in a
resurgence of interest in this method.
Curves with a rib vertebral angle dif-
ference >20° were considered to have
a high propensity for progression
and were serially casted every 8 to
16 weeks. In one study, 94 of 136
patients (69%) had full curve correc-
tion, with greater success in children
treated before age 2 years.16 Princi-
ples of Mehta casting include the use
December 2011, Vol 19, No 12
of a specialized casting table, moder-
ate traction, and emphasis on derota-
tion of the thorax and spine.19 Skin
complications have been reported,
and attention to meticulous tech-
nique is essential.
Growth-friendly implants are used
to control thoracic spinal deformity
and minimize the adverse impact on
growth and development of the spine
and thorax. Skaggs et al20 have pro-
posed a classification of growth-
friendly implants that describes im-
plants as distraction-based (ie,
growth rods, vertical expandable
prosthetic titanium rib [VEPTR; Syn-
thes, West Chester, PA]), guided-
growth (ie, Luque trolley, Shilla),
and compression-based techniques
(ie, tethers, staples).
In large curves, preoperative halo
traction is sometimes used before in-
strumentation in an effort to de-
crease neurologic risk, obtain better
correction, and improve pulmonary
function before surgery.21 Recent
publications have described the use
of traction in early onset scoliosis for
curves >80° and when associated
with kyphosis before growth-friendly
instrumentation.19
Distraction-based
Implants
Distraction-based implants correct
and maintain spinal deformity via
spinal distraction, not unlike the
manner in which the original Har-
rington rods functioned. These
distraction-based implants can be at-
tached to the spine, ribs, or pelvis de-
pending on patient age, characteris-
tics of the curve, and available bone
stock. In our experience, proximal
rib fixation is generally more appro-
priate in younger children in whom
we are trying to avoid or delay spinal
fusion and in whom spinal fixation is
limited by an immature spine, in
which implants may lead to compli-
Jaime A. Gomez, MD, et al
cations. Traditional growth rods and
the VEPTR provide similar options
for the management of young chil-
dren with scoliosis.
Although Bess et al22 and Akbarnia
et al23 demonstrated increased curve
correction and overall T1-S1 growth
with frequent lengthening, more re-
cent studies have demonstrated an
increased risk of complications with
each procedure as well as less length
gained with each subsequent length-
ening. Controversy exists regarding
the optimum timing for implantation
of a growth rod as well as optimum
lengthening intervals.
Growing Rods
Originally described by Harrington
and modified by Moe, the growing
rod technique has undergone several
modifications that allow for control
of the deformity while minimizing
complications. Although no absolute
indications exist for the use of grow-
ing rods, generally accepted indica-
tions include significant remaining
axial growth, progressive deformity
>50°, and flexible spinal defor-
mity.9,24-27 Typical results include
those reported by Akbarnia et al,9
who reported on 23 children with
progressive early onset scoliosis who
underwent dual growing rod treat-
ment. The Cobb angle improved
from 82° preoperatively to 36° at
time of fusion. T1-S1 length in-
creased from an average of 23 cm
preoperatively to 32.6 cm at the time
of fusion. Complications occurred in
11 of 23 patients (48%). Innovations
such as low profile designs, growing
connectors, dual rod application,
and the use of rib fixation and/or
pedicle screws have enabled surgeons
to control deformity. Allowing con-
tinued spinal column growth though
these systems could benefit from fur-
ther technological improvements;
however, this is a challenge given the
“orphan nature” of this small patient
723
“Growth Friendly” Spine Surgery: Management Options for the Young Child With Scoliosis

Figure 1 which generally need to be placed at

the thoracolumbar junction.
Several studies demonstrate the ef-
ficacy of the VEPTR in controlling
curve magnitude and promoting
spine growth (Figure 2). Campbell
and Hell-Vocke29 reviewed 27 chil-
dren with congenital scoliosis and
fused ribs who underwent expansion
thoracostomy and VEPTR insertion.
At a mean follow-up of 5.7 years,
scoliosis had decreased from a mean
of 74° preoperatively to 49°. Mean
thoracic spine growth per year was
0.80 cm. The presence of an unseg-
mented bar seemingly did not pre-
vent spine growth; expansion thora-
coplasty led to an average of 7.3%
increase in length of the bar at a 4.2-
In an 8-year-old girl with tetralogy of Fallot with progressive thoracic
scoliosis, the curve continued to progress despite the use of year follow-up.29
thoracolumbosacral orthosis bracing. A, Preoperative PA radiograph Complications are similar to those
demonstrating a 65° thoracic curve. B, The patient underwent implantation of of traditional growing rods, includ-
a growing rod distraction system. Immediate postoperative PA radiograph
demonstrating a Cobb angle of 29°. C, PA radiograph made after 3-year ing wound problems, rib fracture,
follow-up demonstrating that curve correction is maintained after multiple and creeping fusion. Iliac S-hook mi-
lengthenings. The white arrow demonstrates axial lengthening along the gration has also been reported, and
growing rod. debate continues regarding the ap-
propriate means of anchoring to the
population (Figure 1). screws. At a follow-up of 40 months, pelvis in growing constructs.30 Tradi-
Pedicle screws should be used with iliac screws achieved statistically sig- tional growing rods are currently
caution in the upper thoracic spine of nificantly better Cobb and pelvic employed in a “physician directed”
the very young child; other types of obliquity correction than did sacral use, whereas the VEPTR has been
proximal instrumentation (ie, hooks, fixation (47% versus 29% and 66% FDA approved for the management
rib cradles) should be considered in- versus 40%, respectively). However, of progressive scoliosis with “tho-
stead. In our experience, when screws there were five broken iliac screws, racic insufficiency” under a humani-
are used in the proximal thoracic spine whereas the other fixation tech- tarian device exemption.31
of the young child, it is advisable to niques had no breakage. Limited data exist regarding the ef-
have at least four screws sharing load. fect of distraction instrumentation
Also, to avoid convergence, the start- on lung function, in part because of
Vertical Expandable
ing point should be positioned on the the difficulty in measuring pulmo-
Prosthetic Titanium Rib
medial edge of the pedicle aiming di- nary function in young children. Mo-
rectly down the pedicle. This technique VEPTR placement was originally in- toyama et al32 measured forced vital
may prevent devastating neurologic dicated for patients with rib fusions, capacity in 10 children with thoracic
complications if proximal control of but currently the VEPTR functions insufficiency syndrome and scoliosis.
the deformity is lost or if screws pull very much like the traditional grow- At a mean follow-up of 33 months,
out posteriorly. ing rod. Compared with the growing forced vital capacity increased signif-
Pelvic fixation for growing rods in- rod, the VEPTR features circumfer- icantly, averaging 26.8% per year.
cludes sacral screws, iliac screws, or ential rib anchors, telescopic length- Using hemoglobin as a surrogate
iliac hook fixation. Sponseller et al28 ening allowing twice more lengthen- marker for pulmonary function,
compared four different types of pel- ing, and a lengthening mechanism Caubet et al33 reviewed hemoglobin
vic fixation in 36 children with pro- that allows expansion in the ky- levels in 138 children with early on-
gressive scoliosis, including iliac photic segment of the thoracic spine, set scoliosis preoperatively and at 6
screws, iliac rods, S-rods, and sacral as opposed to axial connectors, to 24 months postoperatively follow-

724 Journal of the American Academy of Orthopaedic Surgeons

 Jaime A. Gomez, MD, et al

Figure 2

Vertical expandable prosthetic titanium rib (VEPTR [Synthes]) instrumentation in a 5-year-old girl with early onset
scoliosis as well as congenital diaphragmatic hernia and rapid curve progression. Radiographs made following surgery
to insert a bilateral rib-to-pelvis VEPTR, with a lengthening every 6 months, demonstrate adequate curve correction
and spine growth. Clinically, the patient’s lung function significantly improved, as well, at 2-year follow-up.
A, Preoperative AP scoliosis radiograph. Lateral (B) and AP (C) scoliosis radiographs made 2 months postoperatively.
D, AP scoliosis radiograph made 6 months postoperatively. E, AP scoliosis radiograph made 2 years postoperatively.

ing VEPTR (n = 85) or growing rod the instrumented region.

(n = 58) insertion. These authors
noted that 23% of children with
early onset scoliosis had evidence of
chronic hypoxia as measured by se-
rum hemoglobin levels, with signifi-
cant improvements noted after spinal
distraction using the VEPTR.
Guided-growth Implants
The Luque trolley was a technique in
which rods were attached to the
spine using sublaminar wiring. Now
largely of historical interest, this
technique required extensive subperi-
osteal dissection, which increased the
risk of inadvertent fusion and, thus,
limited spine growth. Mardjetko
et al34 retrospectively reviewed nine
children treated with the Luque trol-
ley system; all required revision sur-
gery and had spontaneous fusion of
The Shilla technique allows for
apical curve control while allowing
spine growth, without the need for
frequent, planned subsequent surger-
ies.35 Apical pedicle screws are
placed, effecting a limited fusion,
while proximal and distal screws are
placed under fluoroscopic guidance
with the intention of avoiding fusion.
The rods are fixed to the screws at
the apex and can slide inside the
screw head at the proximal and dis-
tal end. McCarthy et al35 demon-
strated continued spine growth and
no implant failure with the Shilla
system in a goat model; however, sig-
nificant facet arthrosis was also
found. Although these implants are
currently not available for clinical
use, they will likely soon be available
under a humanitarian device exemp-
tion.
Compression-based
Implants
Vertebral body stapling is a new
technique used for adolescent and ju-
venile idiopathic scoliosis. As pre-
dicted by the Hueter-Volkmann prin-
ciple, increased pressure across a
growth plate in the vertebral body
slows growth. Although this phe-
nomenon has been observed in ex-
perimental animal spine models,36
experience in the 1950s using sta-
pling with large congenital curves
was disappointing.37
More recently, flexible tethers at-
tached to vertebral anchors have been
used to modulate spinal growth. Use of
tethers in animal models by Newton et
al38 have demonstrated vertebral
wedging, which could potentially
correct scoliosis. Using a goat scolio-
sis model, Braun et al39 showed that

December 2011, Vol 19, No 12 725

“Growth Friendly” Spine Surgery: Management Options for the Young Child With Scoliosis
flexible bone anchor/tethers can
moderately correct deformity in the
coronal plane but that this effect was
lost over time. They concluded that
rigid shape-memory alloy staples
have better final deformity correc-
tion compared with the flexible liga-
ment tethers.
Modern vertebral body staples
consist of shape-memory alloy (ie,
nitinol) that allows the staple to
clamp down into a C shape when it
is warmed to body temperature. Lit-
erature reviewing the effect of sta-
pling in scoliosis is limited. Betz
et al40 retrospectively reviewed 21
children with adolescent idiopathic
scoliosis treated with vertebral body
stapling. Of the 10 children with >1-
year follow-up, 60% had stable or
smaller curves; 40% progressed. One
patient’s curve progressed to >50°,
requiring subsequent fusion. In an-
other study, Betz et al41 followed 28
children with adolescent idiopathic
scoliosis treated with vertebral body
stapling for 2 years. A procedure was
considered successful when curves
corrected >10° or corrected to within
10° of the preoperative measure-
ment. Eighty-six percent of lumbar
curves and 80% of thoracic curves
<35° were successfully corrected us-
ing the stapling technique. There
were no major neurovascular injuries
or staple migration. Curves >35° did
not do well with stapling, and the
authors recommended alternative
treatments.41
Crawford and Lenke42 recently
presented a case report in which they
used anterior thoracic screws with
polypropylene tethers in an 8-year-
old boy with juvenile idiopathic sco-
liosis and a 40° right thoracic curve.
At 4-year follow-up, the curve had
corrected to 6°.
Compression-based implants re-
quire continued innovation, and
their use requires close follow-up to
assess optimal indications and poten-
tial complications as well as a com-
726
mitment to foster these novel im-
plants through the regulatory
process. Still, early work has docu-
mented “proof of concept.”
Complications
Nonfusion techniques carry with
them the risk of numerous complica-
tions, with minor complication rates
reported to be from 58% to
200%.22,43 Wound-healing problems,
device migration, and rib fracture are
common concerns. A study by Ak-
barnia et al9 reported a complication
rate of 48% after dual growing rod
implementation, with 17% of pa-
tients undergoing unplanned proce-
dures. Meticulous surgical technique
in exposing the lengthening mechan-
ism and in closing these repeat
wounds is essential. Limited subperi-
osteal stripping may avoid uninten-
tional fusion, and strong foundations
are key to avoid device migration
and possible neurologic injury.22 Sub-
muscular (rather than subcutaneous)
instrumentation and dual rod tech-
niques may play a role in minimizing
complications. Although neurologic
injuries are rare, Sankar et al44 per-
formed a retrospective review of neu-
romonitoring changes in growing
rod surgeries and recommended rou-
tine neuromonitoring for the inser-
tion and exchange of growing rod
constructs.
Conclusion and Future
Directions
Early onset scoliosis remains a chal-
lenging problem. Growth-friendly
implants such as growing rods and
the VEPTR provide the surgeon with
treatment options that allow control
of the curve while permitting contin-
ued spine growth and pulmonary de-
velopment. Although technologies to
modulate growth of the spine and
control scoliosis in young people ap-
Journal of the American Academy of Orthopaedic Surgeons
pear to be viable, notable regulatory
hurdles will delay widespread dis-
semination of such techniques. Sig-
nificant research efforts are under
way that seek to address many of the
gaps in our understanding of how
best to optimize management of pa-
tients with early onset scoliosis.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references 6,
21, 22, 30, and 38 are level II stud-
ies. References 3, 5, 7-9, 14, 16, 23,
and 27 are level III studies. The re-
mainder are level IV or V case series,
expert opinion, or animal studies.
References printed in bold type are
those published within the past 5
years.
1. Davies G, Reid L: Effect of scoliosis on
growth of alveoli and pulmonary arteries
and on right ventricle. Arch Dis Child
1971;46(249):623-632.
2. Reid LM: Lung growth in health and
disease. Br J Dis Chest 1984;78(2):113-
134.
3. Jones RS, Kennedy JD, Hasham F, Owen
R, Taylor JF: Mechanical inefficiency of
the thoracic cage in scoliosis. Thorax
1981;36(6):456-461.
4. Campbell RM Jr, Smith MD: Thoracic
insufficiency syndrome and exotic
scoliosis. J Bone Joint Surg Am 2007;
89(suppl 1):108-122.
5. Pehrsson K, Larsson S, Oden A,
Nachemson A: Long-term follow-up of
patients with untreated scoliosis: A study
of mortality, causes of death, and
symptoms. Spine (Phila Pa 1976) 1992;
17(9):1091-1096.
6. Vitale MG, Matsumoto H, Bye MR,
et al: A retrospective cohort study of
pulmonary function, radiographic
measures, and quality of life in children
with congenital scoliosis: An evaluation
of patient outcomes after early spinal
fusion. Spine (Phila Pa 1976) 2008;
33(11):1242-1249.
7. Karol LA, Johnston C, Mladenov K,
Schochet P, Walters P, Browne RH:
Pulmonary function following early
thoracic fusion in non-neuromuscular
scoliosis. J Bone Joint Surg Am 2008;
90(6):1272-1281.

8. Karol LA: Early definitive spinal fusion
in young children: What we have
learned. Clin Orthop Relat Res 2011;
469(5):1323-1329.
9. Akbarnia BA, Marks DS, Boachie-Adjei
O, Thompson AG, Asher MA: Dual
growing rod technique for the treatment
of progressive early-onset scoliosis: A
multicenter study. Spine (Phila Pa 1976)
2005;30(17 suppl):S46-S57.
10. McMaster MJ, Ohtsuka K: The natural
history of congenital scoliosis: A study of
two hundred and fifty-one patients.
J Bone Joint Surg Am 1982;64(8):1128-
1147.
11. Hedequist DJ: Surgical treatment of
congenital scoliosis. Orthop Clin North
Am 2007;38(4):497-509, vi.
12. Canavese F, Dimeglio A, Volpatti D,
et al: Dorsal arthrodesis of thoracic spine
and effects on thorax growth in
prepubertal New Zealand white rabbits.
Spine (Phila Pa 1976) 2007;32(16):
E443-E450.
13. Hedequist D, Emans J: Congenital
scoliosis: A review and update. J Pediatr
Orthop 2007;27(1):106-116.
14. Vitale MG, Gomez JA, Matsumoto H,
Roye DP Jr, Chest Wall and Spine Defor-
mity Study Group: Variability of expert
opinion in treatment of early-onset
scoliosis. Clin Orthop Relat Res 2011;
469(5):1317-1322.
15. Campbell RM Jr, Smith MD, Mayes TC,
et al: The characteristics of thoracic
insufficiency syndrome associated with
fused ribs and congenital scoliosis.
J Bone Joint Surg Am 2003;85(3):399-
408.
16. Mehta MH: Growth as a corrective force
in the early treatment of progressive
infantile scoliosis. J Bone Joint Surg Br
2005;87(9):1237-1247.
17. Sanders JO, D’Astous J, Fitzgerald M,
Khoury JG, Kishan S, Sturm PF:
Derotational casting for progressive
infantile scoliosis. J Pediatr Orthop
2009;29(6):581-587.
18. Mehta MH: The rib-vertebra angle in the
early diagnosis between resolving and
progressive infantile scoliosis. J Bone
Joint Surg Br 1972;54(2):230-243.
19. D’Astous JL, Sanders JO: Casting and
traction treatment methods for scoliosis.
Orthop Clin North Am 2007;38(4):477-
484, v.
20. Skaggs DL, Akbarnia B, Flynn J, Myung
K, Sponseller P, Vitale M: Classification
of treatment of early-onset scoliosis.
Presented at the Second International
Congress of Early Onset Scoliosis and
Growing Spine, Montreal, Quebec,
Canada, November 7-8, 2008.
21. Sink EL, Karol LA, Sanders J, Birch JG,
December 2011, Vol 19, No 12
Johnston CE, Herring JA: Efficacy of
perioperative halo-gravity traction in the
treatment of severe scoliosis in children.
J Pediatr Orthop 2001;21(4):519-524.
22. Bess S, Akbarnia BA, Thompson GH,
et al: Complications of growing-rod
treatment for early-onset scoliosis:
Analysis of one hundred and forty
patients. J Bone Joint Surg Am 2010;
92(15):2533-2543.
23. Akbarnia BA, Breakwell LM, Marks DS,
et al; Growing Spine Study Group: Dual
growing rod technique followed for three
to eleven years until final fusion: The
effect of frequency of lengthening. Spine
(Phila Pa 1976) 2008;33(9):984-990.
24. Masso PD, Meeropol E, Lennon E:
Juvenile-onset scoliosis followed up to
adulthood: Orthopaedic and functional
outcomes. J Pediatr Orthop 2002;22(3):
279-284.
25. Yang JS, McElroy MJ, Akbarnia BA,
et al: Growing rods for spinal deformity:
Characterizing consensus and variation
in current use. J Pediatr Orthop 2010;
30(3):264-270.
26. Tello CA: Harrington instrumentation
without arthrodesis and consecutive
distraction program for young children
with severe spinal deformities:
Experience and technical details. Orthop
Clin North Am 1994;25(2):333-351.
27. Klemme WR, Denis F, Winter RB,
Lonstein JW, Koop SE: Spinal
instrumentation without fusion for
progressive scoliosis in young children.
J Pediatr Orthop 1997;17(6):734-742.
28. Sponseller PD, Yang JS, Thompson GH,
et al: Pelvic fixation of growing rods:
Comparison of constructs. Spine (Phila
Pa 1976) 2009;34(16):1706-1710.
29. Campbell RM Jr, Hell-Vocke AK:
Growth of the thoracic spine in
congenital scoliosis after expansion
thoracoplasty. J Bone Joint Surg Am
2003;85(3):409-420.
30. Sankar WN, Acevedo DC, Skaggs DL:
Comparison of complications among
growing spinal implants. Spine (Phila Pa
1976) 2010;35(23):2091-2096.
31. Federal Drug Administration: Summary
of safety and probable benefit data:
Vertical Expandable Prosthetic Titanium
Rib (VEPTR). Available at: http://
www.accessdata.fda.gov/cdrh_docs/pdf3/
H030009b.pdf. Accessed September 26,
2011.
32. Motoyama EK, Deeney VF, Fine GF,
et al: Effects on lung function of multiple
expansion thoracoplasty in children with
thoracic insufficiency syndrome: A
longitudinal study. Spine (Phila Pa 1976)
2006;31(3):284-290.
33. Caubet JF, Emans JB, Smith JT, et al:
Increased hemoglobin levels in patients
Jaime A. Gomez, MD, et al
with early onset scoliosis: Prevalence and
effect of a treatment with Vertical
Expandable Prosthetic Titanium Rib
(VEPTR). Spine (Phila Pa 1976) 2009;
34(23):2534-2536.
34. Mardjetko SM, Hammerberg KW,
Lubicky JP, Fister JS: The Luque trolley
revisited: Review of nine cases requiring
revision. Spine (Phila Pa 1976) 1992;
17(5):582-589.
35. McCarthy RE, Sucato D, Turner JL,
Zhang H, Henson MA, McCarthy K:
Shilla growing rods in a caprine animal
model: A pilot study. Clin Orthop Relat
Res 2010;468(3):705-710.
36. Wall EJ, Bylski-Austrow DI, Kolata RJ,
Crawford AH: Endoscopic mechanical
spinal hemiepiphysiodesis modifies spine
growth. Spine (Phila Pa 1976) 2005;
30(10):1148-1153.
37. Smith AD, Von Lackum WH, Wylie R:
An operation for stapling vertebral
bodies in congenital scoliosis. J Bone
Joint Surg Am 1954;36(2):342-348.
38. Newton PO, Farnsworth CL, Faro FD,
et al: Spinal growth modulation with an
anterolateral flexible tether in an
immature bovine model: Disc health and
motion preservation. Spine (Phila Pa
1976) 2008;33(7):724-733.
39. Braun JT, Akyuz E, Udall H, Ogilvie JW,
Brodke DS, Bachus KN: Three-
dimensional analysis of 2 fusionless
scoliosis treatments: A flexible ligament
tether versus a rigid-shape memory alloy
staple. Spine (Phila Pa 1976) 2006;31(3):
262-268.
40. Betz RR, Kim J, D’Andrea LP, Mulcahey
MJ, Balsara RK, Clements DH: An
innovative technique of vertebral body
stapling for the treatment of patients
with adolescent idiopathic scoliosis: A
feasibility, safety, and utility study. Spine
(Phila Pa 1976) 2003;28(20):S255-S265.
41. Betz RR, Ranade A, Samdani AF, et al:
Vertebral body stapling: A fusionless
treatment option for a growing child
with moderate idiopathic scoliosis. Spine
(Phila Pa 1976) 2010;35(2):169-176.
42. Crawford CH III, Lenke LG: Growth
modulation by means of anterior
tethering resulting in progressive
correction of juvenile idiopathic
scoliosis: A case report. J Bone Joint
Surg Am 2010;92(1):202-209.
43. Sankar WN, Skaggs DL, Yazici M, et al:
Lengthening of dual growing rods and
the law of diminishing returns. Spine
(Phila Pa 1976) 2011;36(10):806-809.
44. Sankar WN, Skaggs DL, Emans JB, et al:
Neurologic risk in growing rod spine
surgery in early onset scoliosis: Is
neuromonitoring necessary for all cases?
Spine (Phila Pa 1976) 2009;34(18):
1952-1955.
727