The state of the art spinal deformity surgery program at Johns Hopkins All Children's Hospital is led by Jeffrey B. Neustadt, M.D. and Gregory V. Hahn, M.D. who have performed over 1,200 scoliosis surgical procedures to date over the past 21 years. Over 100 children and adolescents have been treated surgically each year in recent years. Utilizing the most advanced treatment options, such as intraoperative computerized image guidance, their cases are completed in a new operating room equipped with a navigation suite. While technology is helpful, the team of nurses, scrub techs, neuromonitoring personnel, blood salvage perfusionists, and experienced pediatric anesthesiologists is even more critical. The team that has been assembled at Johns Hopkins All Children’s is second to none, and excellent patient outcomes are proof of that.
Drs. Neustadt and Hahn evaluate and treat all types of scoliosis and kyphosis. Of every one thousand children, three to five will develop spinal curves that are considered significant enough to need treatment. There are four different types of scoliosis: congenital, idiopathic, syndromic, and neuromuscular. The cause for scoliosis is unknown. It does however, tend to be genetic and may be hereditary. The cause of idiopathic scoliosis is unknown but is multifactorial and includes a strong genetic predisposition. Idiopathic scoliosis may occur at any age but is most commonly seen in adolescence. If it progresses, it usually does so most rapidly during puberty. Neuromuscular scoliosis occurs secondary to muscle weakness or paralysis such as occurs with cerebral palsy, muscular dystrophy, spina bifida, and spinal muscular atrophy.
There are four different types of kyphosis: congenital, developmental, postural and Scheuremann’s.Kyphosis may also be caused by vertebral compression fractures (due to tumors or weak bone) or degenerative bone conditions, such as arthritis.The cause for Scheuermann’s kyphosis is unknown. It may be caused by abnormal growth of the vertebra in which the front part stops growing before the back part does. This growth abnormality causes wedge-shaped vertebral bodies, which create an abnormally rounded thoracic spine. It typically progresses during puberty. Congenital scoliosis and kyphosis occurs during the formation of the vertebrae in the embryonic stage of development. It is often associated with congenital fusion of the ribs, and may also be seen in conjunction with a number of other non-orthopaedic anomalies affecting the heart, kidneys, upper extremities and gastrointestinal tract: the so-called VACTERL syndrome.
Idiopathic scoliosis is the pediatric spinal condition seen most commonly by family physicians and pediatricians. This condition affects approximately 7 million people in the United States. While scoliosis is more common, Scheuermann’s kyphosis also occurs and severe cases require treatment as well. Scoliosis is usually painless, while severe kyphosis is commonly associated with pain.
After the child has been diagnosed with scoliosis, several courses of action are possible. Mild curves that remain at 20 degrees or less are observed and monitored every 4 to 6 months. Curves greater than 25 degrees may be amenable to orthotic treatment in an effort to prevent further progression. Investigation continues to determine the effectiveness of braces in preventing progression of scoliosis. Unfortunately, no brace has been shown to actually improve scoliosis. That desired outcome is only available via surgical treatment. Electrical muscle stimulation, exercise programs and manipulation have not been found to be effective treatments for scoliosis. Attempts to treat kyphosis orthotically (with a brace) have been largely unsuccessful but may be tried.
The surgical treatment of idiopathic scoliosis is usually reserved for curves that have progressed beyond 40 to 45 degrees. If left untreated, continued progression of these curves may lead to pulmonary dysfunction from restrictive lung disease; chronic, severe pain; and psychosocial disability from deformity with decreased quality of life as measured with validated quality of life outcomes instruments. Likewise, kyphosis of greater than 65 or 70 degrees is often indicated for surgery due to pain and disability.
When surgery is indicated, Drs. Neustadt and Hahn, who are fellowship-trained, pediatric orthopaedic spine surgeons, utilize the most advanced techniques in reconstructive spinal surgery. Advances in surgical technology have led to highly effective and safe surgical procedures resulting in excellent results as measured by patient satisfaction surveys as well as by standard radiographic measurements.
Modern spinal instrumentation has led to significant improvement in the 3-D correction of spinal deformity but the placement of pedicle screws as anchors is significantly more challenging in the three-dimensionally deformed spine which is not only curved in the frontal and sagittal planes, but rotated along the axis of the spine as well. Use of CT-based, intra-operative image guidance has facilitated placement of these screws. Drs. Neustadt and Hahn are nationally and internationally renowned in use of this technology, having committed to it over ten years ago. Surgeons from Europe and throughout the United States have visited them in the operating room at Johns Hopkins All Children’s to learn these techniques.
CT-based, intra-operative image guidance allows a surgeon to navigate the spine with "smart tools" by merging the data from a preoperatively acquired CT scan of
the spine with in vivo anatomical reference points that have been preoperatively selected from the 3D, axial and sagittal CT images.This has facilitated rapid and accurate placement of pedicle screws for which there is virtually no tolerance for inaccurate placement due to the aorta, spinal cord and lung being immediately adjacent to the vertebral pedicles. This technology also enables more precise sizing of the screws within the pedicles and the vertebral body, lessening the chances of loosening. Where 50 percent correction of frontal plane deformity was seen with the use of hook and rod constructs utilized from the late 1980s until early in the new millennium, pedicle screw and rod fixation has resulted in scoliosis correction of 75 to 95 percent, normalization of sagittal plane profile, and better derotation of the spine. The combination of advanced computer technology, precisely engineered metallic implants, and cutting-edge biologics utilized in bone grafting has led to the current state of the art in scoliosis and spinal deformity surgery. With continued basic science research and clinical investigation, even more exciting advances will be seen in the future with Drs. Neustadt and Hahn and Johns Hopkins All Children’s leading the way.