Scoliosis Surgery in Children: When Is It Necessary? Risks & Recovery

Scoliosis is a condition where the spine curves sideways instead of remaining straight. Medically, scoliosis is diagnosed when the spine has a curvature greater than 10 degrees.

Scoliosis can be broadly classified into three main types: 

• Idiopathic scoliosis: This is the most common form of scoliosis and is most often seen in adolescents. However, different treatments may be required for children under 3 years old, between 3-10 years old, and over 10 years old. Idiopathic scoliosis often develops during the growth phase, where the spine is initially straight but gradually begins to curve as the child grows.
• Congenital scoliosis: This condition may arise due to incomplete development during pregnancy or abnormalities that occur while the fetus is developing.
• Scoliosis from other causes, such as neuromuscular scoliosis: This type of scoliosis can occur in patients with neurological and muscular disorders, such as muscle weakness, cerebral palsy or clubfoot. It can also result from other medical conditions like herniated discs that compress nerves, or leg length discrepancies, among others.

The symptoms of scoliosis worsen with the degree of curvature. In cases of mild curvature, the patient may only experience slight back pain and an unattractive posture. However, when the curvature is more severe, it can affect other systems of the body, such as:

• Lung and heart issues: Individuals with scoliosis that affects the upper spine, near the lungs and heart, may experience shifting bones and muscles that press against these organs. This can impair the function of the lungs and heart, potentially leading to other related health problems.
• Chronic back pain: The misalignment of the spine caused by scoliosis disrupts the body's balance, leading to chronic back pain, and can also cause the intervertebral discs to degenerate more quickly than normal.
• Psychological issues: Scoliosis directly impacts posture and physical appearance. The more pronounced the curvature, the more noticeable it becomes, which may cause patients to feel embarrassed or lack self-confidence.

The treatment of scoliosis has three main objectives:

1. To improve the skeletal structure and prevent further curvature, ensuring that it does not negatively affect the functioning of the heart and lungs.
2. To improve aesthetic appearance.
3. To reduce pain caused by the imbalance in muscle function.

If the degree of spinal curvature is relatively mild, surgery may not be necessary. Instead, the patient should be regularly monitored, and the use of a back brace, combined with physical therapy, may help reduce the risk of further curvature. However, if the curvature increases to the point where it interferes with daily life or affects overall health, surgery may be considered as a treatment option.

Scoliosis surgery is a method of correcting spinal curvature by using metal rods to stabilize the spine and keep it in the correct position, reducing the likelihood of further curvature and minimizing the risk of other complications related to scoliosis. There are two types of scoliosis surgery, as follows:

• Spinal correction surgery with bone fusion
  This surgical approach uses metal rods to straighten the curved spine, combined with screws or hooks to secure the spine. The bones of the spine are fused together in the correct position. In this type of surgery, the spine becomes fused in a much straighter position, but it loses flexibility, so it is typically used for patients whose spine has stopped growing. The metal used in the surgery is biocompatible and can remain in the body for a lifetime, so there is usually no need to remove the metal. However, in some cases, the metal may need to be removed, for example, if the screws that secure the metal rods move and press on nerves, causing pain, or if the patient requests the removal of the rods.
  In the case of children whose spine is still growing, this method may cause uneven growth. The spine part that is not fused, such as the front portion of the vertebrae, will continue to grow, which may lead to worsening curvature. Alternatively, if the spine becomes straighter, but both the front and back portions of the vertebrae are fused, the fused vertebrae will stop growing while the rest of the body continues to grow, leading to an imbalance or a shortened stature.

• Scoliosis surgery without bone fusion using growing rod technology
  Advances in medical technology mean that scoliosis surgery in children can now be performed more safely using growing rods. These rods are designed to stabilize the spine while allowing it to grow. There are different methods for adjusting the rod, such as surgical insertion, self-expanding rods, or magnetic expansion control rods (MAGEC Rod). After the surgery, these rods are adjusted every three months using magnetic technology, which helps the spine gradually lengthen without the need for further surgery. This procedure is painless and only takes a few minutes, and the growing rods allow the child’s spine to continue growing, which also has a beneficial impact on their height.

  

In most cases, doctors consider scoliosis surgery for children in whom the curvature exceeds 40 degrees, as this level of curvature begins to affect health and is likely to increase with further growth.

Additionally, doctors take the patient's age into account when deciding on surgery. If the child is under 10 years old and has a curvature of 30-40 degrees, doctors may recommend surgery to correct the scoliosis without fusing the bones. However, if the patient is an older child whose spine has stopped growing, and the curvature is less than 30-40 degrees with no other complications, surgery may not be necessary. 

     5.1 What are the risks of scoliosis surgery that should be considered before making a decision?

Before deciding on scoliosis surgery to correct the spinal curvature, careful consideration is necessary, as spinal surgery is a major procedure with high risk. The child will be under general anesthesia for 4-6 hours, and the surgical incision is often quite large, with the potential for significant blood loss and infection. Additionally, there are risks of nerve damage, paralysis, and, in extreme cases, life-threatening complications.

When a doctor determines that the child should undergo scoliosis surgery, they will explain the potential risks. However, with advances in medical technology, tools like navigation systems or robotic systems are now used to make surgeries safer and, as a result, these risks have been significantly reduced.

Before scoliosis surgery, the doctor will schedule a health assessment to determine if the child is ready for surgery, including the following:

• Psychological and emotional preparation, which involves talking with the child to reduce anxiety and explain the surgical procedure
• X-rays, MRIs, or CT scans
• Blood tests
• Cardiopulmonary evaluation

The information gathered from these health assessments will help plan the scoliosis surgery and ensure the child is properly prepared.

After the child has been physically and emotionally prepared for the surgery, the anesthesiologist will administer general anesthesia before the surgeon begins the procedure. The length of the surgery depends on the complexity and difficulty of the patient’s spinal condition, but typically, it takes around 4-6 hours.

Once the surgery is complete, the child will be taken to the Pediatric Intensive Care Unit (PICU) for initial monitoring before being moved to a regular patient room. After scoliosis surgery, the child will typically stay in the hospital for about 7-10 days.

Spinal surgery is a major operation, and to ensure close post-operative care, Samitivej Children's Hospital provides a dedicated PICU for critical pediatric care. 

The child will be looked after by a team of pediatric specialists collaborating with medical professionals with various subspecialties, such as pediatric infectious diseases, cardiology, respiratory, gastrointestinal, neurology, nephrology, and hematology. The team will monitor the patient 24/7 to ensure the highest level of safety, prepare for any complications, and help the child return to normal daily activities.

After spinal surgery, the child will need to remain in the hospital for about 7-10 days. During the first 1-2 days, the child may experience significant pain from the surgical wound and the doctor will administer pain relief medication periodically to alleviate the discomfort. Additionally, a drain will be placed to remove excess blood, and a urinary catheter will be used. If the child lost a significant amount of blood, a blood transfusion may also be provided.

By the 3rd or 4th day after the surgery, if the child is able to sit up, the doctor will encourage the child to start walking and will remove the urinary catheter to allow the child to manage their personal needs independently.

Once the doctor approves discharge, the child may be required to wear a soft back brace for 3-6 months to aid in stability. Follow-up appointments will be scheduled in the first 1-2 weeks to monitor the surgical site. Over time, the frequency of follow-ups will decrease, such as every month, every three months, every six months, and then annually, depending on the doctor’s recommendations.

After recovery from scoliosis surgery, the child will be able to return to their daily activities but should avoid sports that involve intense impact, such as extreme sports, to prevent serious injuries to the spine, which could be more severe than in individuals who have not undergone spinal surgery.

     9.1 Is scoliosis surgery dangerous?
All types of surgery carry risks and potential dangers, but with the advancements in treatment techniques and technology today, such as navigation systems, intraoperative neurophysiological monitoring systems (IONM), and others, combined with the experience of skilled surgeons with over 25 years of experience in scoliosis surgery, the safety of the procedure has significantly improved. Additionally, recovery time has shortened due to professional, multidisciplinary teams providing post-operative care.

     9.2 Will the metal rods need to be removed after scoliosis surgery?
The metal used in spinal surgery is biocompatible, meaning it can remain in the human body for a lifetime. Therefore, there is no need to remove the metal unless the patient specifically requests its removal.

     9.3 What are the disadvantages of scoliosis surgery?
In addition to the potential risks during scoliosis surgery, the fusion of metal to the spine reduces the flexibility of the spine. As a result, the patient may experience increased limitations in movement, such as difficulty bending or stretching, as the spine becomes stiffer.

Scoliosis is a condition where the spine is abnormally curved, which can lead to the spine pressing against other organs and causing complications. Additionally, scoliosis causes an imbalance in the body’s structure and can affect the mental well-being of the individual due to the physical deformity. If the curvature is severe, doctors often recommend surgery to correct the scoliosis, reduce the risk of future complications and improve the child's quality of life.

Choosing to undergo scoliosis surgery at Samitivej Children's Hospital ensures access to advanced surgical technologies, state-of-the-art operating rooms with high safety standards, and a complete team of pediatric specialists in various fields. The hospital also has orthopedic surgeons with more than 25 years of experience in scoliosis surgery, as well as a Pediatric Intensive Care Unit (PICU) for the close monitoring and care of pediatric patients 24/7.