From
Dr. Nelson G. Rosen
Vertebral body tethering for pediatric scoliosis: patient selection and surgical technique
hosted by Dr. Jill Knepprath
Chapter 1 of 7
Clinical scenario
Introduction and Clinical Scenario
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
VBT is definitely less invasive and more physiologic than standard spinal fusion.
VBT uses a polyethylene flexible band placed on the convex side of the spine.
VBT requires a skeletally immature patient so that as they're growing, they're growing straighter.
If VBT is done in a mature patient, it's probably not going to work.
VBT cannot be used in adults; outcomes in adults are not very good.
Everybody is moving towards only doing VBT in skeletally immature kids right around the time of peak growth velocity.
The sweet spot for VBT is when we can actually modulate growth and change the shape of the disk space and the shape of the vertebrae as they grow.
Current indications for VBT are immature, moderately severe curves, and flexible.
Hybrid techniques can be used where if the thoracic curve doesn't meet criteria, the lumbar spine is where you need motion.
You can usually get down to T12, L1 through the thoracoscopic approach and bluntly dissect the plane along the diaphragm to get to that level.
L1 to L4 is accessed through an open incision.
Segmental vessels are typically ligated, but you certainly don't want to do that on both sides of the spine due to risk of a spinal infarct.
Be really careful around the lumbosacral plexus; EMG neuromonitoring is used.
You can bluntly retract the psoas off the vertebral body and dilate it up through tubes.
The tether is threaded through each screw and a tensioning gun is used to place tension.
VBT patients are mobilized immediately postoperatively.
VBT patients return to sports within 6 weeks, while typical return to sports for a fusion would be 3 to 6 months.
A Mayo study showed VBT success rate is only considered to be 75% at 2 years based on curve size and lack of revisions.
The Mayo study showed VBT success declined to 63% at 3.8 years with a 20% revision rate.
VBT started to be done mid 2000s at certain centers, and it has exploded in recent years.
You have to be really careful about doing VBT in the right patient at the right time.
Vertebral body tethering is an FDA approved minimally invasive non-fusion surgical treatment for growing patients with idiopathic scoliosis.
The goal is to operate during peak growth velocity; if done too early, you overcorrect.
Peak growth velocity occurs when kids are going through a period of significant skeletal growth around ages 8 to 15.
If VBT is done too late, the tethering will eventually break and the spine will revert back to its initial shape.
L1 can be accessed more easily thoracoscopically than by open surgery.
L2 through L4 is better accessed by open approaches and removing one of the floating ribs.
Lumbar exposure can be challenging, especially distally because of the iliac crest.
The key is to bluntly retract the psoas off of the vertebral bodies during the open approach and make sure you are around the entire psoas muscle.
The issues early on with VBT were due to poor patient selection.
With more experience and better selection criteria, the data is now showing improved outcomes for VBT.