Vertebral Body Stapling

Overview

Indication/Treatment Goals
We believe that vertebral body stapling (VBS) is a viable alternative to bracing treatment for mild to moderate scoliosis. The goal of both forms of treatment is to avoid progression of spinal curvature to a point where posterior spinal fusion is required. 

Bracing is widely accepted as the best treatment for mild-to-moderate scoliosis in a still growing child or adolescent. However, the results of brace treatment show that it is, at best, only moderately successful at preventing progression of spinal deformity. Wearing a brace also can be very difficult for a school-aged child. Parents often have difficulty enforcing their child’s brace wear.

With VBS, the staples act as a tether to delay growth on the convex (outer) side of a curve while the concave (inner) side catches up. The spine thus straightens itself out with growth. For more challenging curves, stapling plus a period of night- time bracing may be used together during a growth spurt to help the staples do their job.

Device Description
The staples are  metallic brackets that are inserted into adjacent  bones of the spine and are made of a metal called nitinol, which is 50 percent nickel and 50 percent titanium. Unlike the staples in the stapler on your desk, these staples have something called shape memory.  When the staple is inserted, the two prongs are parallel to each other. As the staple reaches body temperature, the prongs begin to close, pulling the bone with it.

Post-Op Course
Following surgery, the child will be admitted overnight to the pediatric intensive care unit (PICU) then transferred to the inpatient surgical unit to continue recovery. Post-operative care in the PICU is supervised by physicians who are board certified in pediatric critical care. Staff physicians, nurse practitioners, nurses and rehabilitative therapists work as a team when caring for your child in the post-op period.  Most children are out of bed and starting to eat by mouth within 24-36 hours after surgery. Pain is controlled initially by IV and then by oral pain medications. Generally, hospital discharge occurs within three to five days after surgery.

After leaving the hospital
The child will be given a prescription for pain medication but most do well with just over the counter ibuprofen (Motrin) after the first few days at home. A normal diet and walking are to be encouraged. Most children return to school approximately 2 weeks after surgery.

An office visit for a wound check is generally done two to three weeks post op. If you live far away, this wound check can often be done by your local doctor to make sure the incisions are healing well. The stitches are absorbable, so there are no stitches to be removed.

X-rays of the child’s back are done before leaving the hospital, then four to six weeks later and every six months thereafter until skeletal maturity (usually around 14 years old for girls and 16 years old for boys). If the patient lives more than a few hours from Philadelphia, we will make every effort to minimize travel back to Philadelphia for these routine checkups. A phone call and routine spine X-rays sent to us are often sufficient to make sure the child continues to do well at home. We are always happy to work with your local orthopedist, if desired.

Restrictions
No gym, sports or strenuous activity for one month after surgery. Then no restrictions thereafter.

If the lumbar curve is stapled, the child may need to wear a soft lumbosacral corset for one month to further limit the amount of bending and twisting while healing. Patients have returned to highly competitive activities such as gymnastics, figure skating, cheerleading, ballet and wrestling after stapling surgery.

Complications (in our series to date)
There have been relatively few minor complications. One patient had a temporary gastrointestinal problem which required nutritional supplementation for a few days. Another patient required a post operative bronchoscopy to remove mucous which had accumulated in the lung.  A hernia developed in another patient. A total of 4 staples (out of ~1800) were removed from 2 patients. In two patients, one of the staples began to fall out of the bone, In one other patient, the curvature fully corrected and began to curve in the opposite direction.
   
Outcomes (in our series to date)
Thoracic Curves: Growing patients with idiopathic thoracic curves measuring less than or equal to 35° at the time of stapling had a 79% success rate. If the thoracic curve measured less than 20° on the first erect radiograph after stapling, the success rate was even higher at 86%. In patients with thoracic curves greater than 35° at the time of stapling, 6 out of 8 of those patients curves continued to progress past  50°. Many of these curves over 35° are stiff (not flexible on bending x-ray) and may need additional options such as a posterior growing device or a brace until their curve stays below 20° for 6 months.

Lumbar Curves: Growing patients with stapled idiopathic lumbar curves have an overall 87% success rate. Only one patient with a 40° curve before stapling progressed to 50°

Children and young adolescents with very stiff or very large scoliosis curves, or are nearing skeletal maturity perhaps won’t benefit from VBS. A combination of options may be needed. Additional surgery may be needed if VBS is not successful in stopping the progression of the spinal curve. Long term results are not known.

Learn more about vertebral stapling
As a nationally and internationally respected leader in fusionless treatment options for scoliosis, we continue to share our expertise with others.  Our surgeons teach other surgeons the latest techniques.  We have a support network of parents and children who are willing to share their experiences with others.  www.vertebralstapling.com or www.ncbi.nlm.nih.gov/pubmed, search “vertebral body stapling”