Rib-based Distraction Surgery Maintains Total Spine Growth

Background: For children undergoing treatment of early onset scoliosis (EOS) using spine-based distraction, recently published research would suggest that total spine length (T1-S1) achieved after the initial lengthening procedure decreases with each subsequent lengthening. Our purpose was to evaluate the effect of rib-based distraction on spine growth in children with EOS. Methods: This was a retrospective multi-center review of 35 patients treated with rib-based distraction (minimum 5 y follow-up). Radiographs were analyzed at initial implantation and just before each subsequent lengthening. The primary outcome was T1-S1 height, which was also analyzed as: Change in T1-S1 height per lengthening procedure, percent of expected age-based T1-S1 growth per lengthening time interval, percent increase in T1-S1 height as compared with postimplantation total spine height, and percent of expected T1-S1 growth based upon patient age at time of lengthening procedure. Results: Thirty-five patients with a mean age of 2.6 years at initial surgery were studied. Diagnoses included congenital (n = 18), syndromic (n = 7), idiopathic (n = 5), and neuromuscular (n = 5). Major Cobb angle was 63.5 degrees and kyphosis was 40.5 degree. Four postoperative time periods were compared: L1 (preoperative first lengthening surgery), L2-L5 (preoperative second lengthening to preoperative fifth lengthening), L6-L10 (preoperative sixth lengthening to preoperative 10th lengthening), L11-L15 (preoperative 11th lengthening to preoperative 15th lengthening). Cobb angle stayed relatively constant for each lengthening period while maximum kyphosis increased. Total spine height was 19.9 cm pre-implantation, 22.1 cm postimplantation, and 28.0 cm by the 15th lengthening (P < 0.05). Percent expected T1-S1 growth per lengthening was 62% for L2-L5, 95% for L6-L10, and 52% for L11-L15. As compared with postimplantation spine height, over the course of 15 lengthening procedures, a further 27% increase in spine height was observed. When lengthening procedures were performed when children were under age 5 years, 82% of expected growth was observed; between ages 6 and 10 years, 76% of expected growth was observed; and beyond age 10 years, 14% of expected growth was observed. Conclusions: Patients treated with rib-based distraction surgery had an increase in total spine height from 20 cm preimplantation to 28 cm by the 15th lengthening. They maintained greater than 75% of expected age-matched spine growth until age 10 years and lengthening procedures did not appear to follow a law of diminishing returns. Rib-based distraction is an effective means of maintaining spine growth which is likely beneficial for pulmonary development as compared with the natural history of EOS. Level of Evidence: Level IV-Therapeutic study, case series.