2025 Pediatric Surgery Update Course - Vertebral Body Tethering (VBT) for Scoliosis

I'm really excited about this session because I think this is what the update course is all about. I don't think I even knew what this was a year ago. And this primarily was in the orthopedic world, but if you haven't heard of this, you may hear this soon because I think it's becoming more common and pediatric surgeons are being asked to help. Presenting most of it is Lourina Flakari. She's one of the orthopedic surgeons at Akron Children's. They have an exceptional spine program and it's actually been pretty fun to participate in these. So I'll let her take it over. All right. Well, thank you so much for having me. So we're just going to briefly review indications, some techniques and early to midterm outcomes. So here's a clinical scenario. So nine-year-old female with juvenile idiopathic foliosus, otherwise healthy, active gymnast, initially presented with a moderate-sized foliosus curve. So at this point, we indicated bracing for her not to fix the curve, but to hopefully prevent progression. She was non-compliant. So return two years later with a 50 plus degree curve. Pretty flexible. She's skeletonly immature. So what would be the best treatment option for her? So as you can get from the title of this talk, I am wondering what is an advantage of VBT, Ritirobadi tethering over a standard spinal fusion. So should we even back it up a little and who in the audience has even heard of this? Like are we doing tethering at all of the hospitals? Maybe 50-50? Yeah, looks like it. Yeah, so at Akron Children's, we have not been a super early adopter. So some of you might have even more experience than we do. So we are here to discuss this. But we, I think that it is a technique that is here to stay because of some of these potential theoretic advantages. So should I move on? What's that? Oh, sorry about that. Yeah, so this procedure has a lot of inherent theoretic advantages over fusion. So it is definitely less invasive. It's more physiologic. We are hopeful that disc mobility will improve long-term outcomes in these kids. But it is early. And so I think it's great to be discussing it on that early end here. Yes. So as shown here, it is this tether that you put on the convex side of the spine. And so the intention is to partially correct the curve and then modulate growth. So this goes on the front of the spine, typically for our spinal fusions that's posterior approach. But we don't want the spine to fuse. So going anteriorly, you can place these tether devices without actually fusing the spine. So this is like a polyethylene really flexible band that we're putting on the convex side. And that's why it needs to be a skelty immature patient so that as they're growing, they're growing strater. So the timing, the right patient at the right time is really critical for these cases. If you do it in a mature patient, it's probably not going to work. So these are our current indications they've been evolving as more data has been coming out. So immature, moderately severe curves and flexible. We are also doing some hybrid techniques where if the thoracic curve doesn't meet criteria, the lumbar spine is where you need motion so you can do a hybrid. So positioning. So the tricky thing with a double tether is you have to do lateral de-cubitus with the convex side up and then flip the patient over to do the lumbar. So Justin, I don't know if you want to comment on anything. Yeah, so it's actually really helpful and kind of feels unfair that you guys can see everything just under floro. I would love that for the structures we operate on, but they kind of mark out the levels ahead of time and we mostly put the ports on the anterior axillary line and kind of space out three five millimeter ports. And then where they actually put their instrument through is a 15 millimeter port so it's pretty big and they have to be pretty much right on top of it. But you can usually get two to three levels. I would say through each skin incision and just move the port up the next intercoxel space to get them a straight angle. And then you can obviously use the 15 millimeter port as an extra hand too. And I think you have some pictures of yeah, and we meant to get better pictures the last case we did, but basically like our job is to expose the vertebral bodies and you use kind of the rib heads as your marker and you the hook works really nice. I think you have a new picture of that. Yeah, so the hook works really nice. Some of the larger segmentals you can use the wiggins. You're basically just exposing the vertebral bodies for them. And then you can usually get down to T12 L1 through the thoracic, the thoracoscopic approach and kind of just bluntly dissect the plane along the diaphragm to get to that level. And then L1 to L4 through an open incision. Yeah, just one comment we do typically ligate the segmentals here. I know in the fine world, it's a you certainly don't want to do that on both sides of the spine due to risk of a spinal infarct, but we do neuro monitor all of these patients, but I think if you're taking it on one side, it's pretty safe. So some centers are using 3D navigation to place screws. We have some great x-ray text and so we're able to do this under just fluoroscopy, which works better in our hands. So we do an opening all, we tap it, we probe it to confirm that we're not in the spinal canal, we place a staple, place a hydroxyapatite screw, and we're doing this under fluoroscopic guidance at each level and we're trying to go straight across the vertebrae. So it's dependent, the trajectory is really dependent on the curve, body habitus and such. The lumbar exposure can be really challenging, so we've appreciated our pediatric surgery colleagues with getting us great exposure here and just trying to be really careful around the lumbar sacripluses. We use EMG neuro monitoring. There's a couple of ways to do this. You can kind of bluntly retract the so-as off the vertebral body. You can dilate it up through tubes. Getting down to L4 can be challenging just because the Iliac crest can prevent the right trajectory. So some places have a table that will actually split to pull that downwards. We have used a second incision when needed. I don't know if you have any other pearls for the lumbar exposure at your center or if anybody else has found anything successful, but it can be challenging to get really far distal. Then we place this tether in. We place it, we thread it through each screw and then we use a tensioning gun to place tension mostly centered around the apex and that's what we're using to get our correction. Closure, there are some places are using chest tubes, others are just using drains. We are preferences at chest tube, but certainly there I'm going to show a study where there were similar outcomes, but that is one of the number one reasons for a return to surgery would be for some sort of like hemathorax, hemathorax, et cetera. Then postoperatively we mobilize them immediately. We return them to sports within six weeks, which typical return to sports for a fusion would be three to six months. So this is a big game changer for the athletes that are really eager to get back right away. Then we just monitor them over time especially since they're going to be growing and we're hoping to see curve correction moving forward. Anybody else in the audience? Has anyone done some of these? No one? Yeah, Todd. I was just with Steve Rothenberg last weekend and he's so excited about this and he says he's doing a tongue now. So my question is since we're not going to be doing appendectomy anymore, is this the new operation? Do you typically need a pediatric surgeon? That's question one. So really this is going to be pretty common for all of us. It sounds like this is pretty high. In the last couple of months I never heard of it. Now everyone's talking about it. And it only works in kids right because you have to grow. Otherwise it doesn't, you can't use this in adults. You have to grow. Is that not right? Yeah, so those are some great points and there are people out there doing this in adults and their outcomes are not very good. So I would say that everybody is moving towards only doing this in scarcely immature patients. So kids right around the time of peak growth velocity. We don't want to do it too soon and then they over-correct. If we do it too late, nothing's going to happen and eventually the tether will break and they'll revert back to the shape that they were in previously. So the sweet spot is when we can actually modulate growth and change the shape of the disk space and the shape of the vertebrae as they grow. And so absolutely this is gaining in popularity. It started to be done like mid-2000s at certain centers and I think a lot of places were very skeptical. And I think it has kind of exploded in recent years. I think that the data is showing that outcomes are improving over time. So I'm of the opinion that this is here to stay. But you just have to be really careful about doing it in the right patient at the right time. So this is one of the first prospective studies. It was just published this year. Prior to this, we were really limited to retrospective reviews that were really pretty flawed. So I think that we're starting to do a better job now that we have this FDA investigational device exemption that we can study this better prospectively. So this study was actually from Mayo. I trained there. So I was involved in some of these early cases. And they have found that there's been a big learning curve. And so their success rate is really only considered to be 75% at two years based on curve size and lack of revisions. Down to 63% at 3.8 years with a 20% revision rate. But they have commented that most of the issues occurred early on when they didn't know how to select the right patient. And so I think the more you do of these, the better you get. So I think that's why it is starting to become more popular because I think centers are really feeling like the data is encouraging that this will provide benefit in the right patient. So to answer your other question about collaboration, there are definitely some orthopedic surgeons doing this by themselves who may feel comfortable with a thoracoscopic approach. We're of the opinion that you guys are the experts in this. You've been trained in this. And so we love the collaboration. We love learning from each other, learning how to take care of patients using each other's expertise in different areas to work together. And a lot of the publications that are coming out are done jointly now by orthopedics and pedesturgery. So I think this is a really right barrier for some great collaboration. So these are just a little sampling. So there was the one study looking at drain options with no difference in complications between check tubes and bulb suction drains. Another study looking at postoperative trans-examic acid to reduce drainage and retention time, which is what we typically use intra-op. And then another study just really suggesting that this multidisciplinary collaborative approach can improve outcomes. So we definitely believe that and are excited by this collaboration. So I work with my orthopedic colleague. I think he's actually watching in. But I call this in a very loving way defense against ortho because the lung is there and then the orda is also like right through there if we go too far the screws. So you know it's I would agree with you. It's been a super fun collaboration. I got a question. It seems like the chest tube outputs, whatever, drain chest tube doesn't matter. But the outputs are super high. Have you guys noticed that? Like I feel like my my chest tubes are putting out like you know 300 CCs and you know when is the decision of pulling? I just pull them high. Have you thought about controlling bleeding? No I'm just kidding. It tends to be high for the first like six to eight hours. Yeah. It seems like it. I feel like it's a lot of serious like from opening that clura. Yeah it's a big surface area that you're facing. Yeah so I struggle with that that it feels like it's high chest tube output and then I have had one of these segmentals bleed and the patient came back like went home and came back a week later with the pseudo-aneurysm. And I do the hook also. Yeah the hook works really nice for the borah and then just the larger vessels I think like a ligature will work well. I think the other thing you know if you've done anterior exposure for the lumbar part before a lot of times there's a really severe scoliosis you can you know almost feel the spine. These are quite a bit deeper and they're younger kids. This is now the last space between the lower ribs and the iliacrass so sometimes removing one of this floating ribs we found is helpful. On the lumbar? Yeah. Yeah to give you a little bit more space. Hey you were there we used to begin to search? I don't actually know do you know? Yeah you can do it as like a co-surgeon case we've done that. Oh. And that's another another question so Mike Nance taught me how to do it. He comes in does the exposure and leaves I stay for the whole case. Yeah we stay for the whole time. I think it's helpful especially when they're doing the instrumentation to retract the lung and especially when they use their instrument you lose all the insiplation because it just that 15 port just opens up unless you're using like a higher flow of system or something. Do you use double-invent tubes? Yeah we use double-invent tubes. Yeah but just providing that retraction and for the lumbar part reflecting the so-as giving them space like it's kind of a team effort to get that exposure. All right thank you.