Adult and Pediatric Spine and Scoliosis Surgeon, Jason E Lowenstein, MD, of Morristown Medical Center, discusses an innovative technique to treating scoliosis. Vertebral Body Tethering (VBT) offers a flexible alternative to traditional spinal fusion.
Learn more about Vertebral Body Tethering for Scoliosis Patients
So V BT or vertebra body tethering is a flexible approach to treatment of scoliosis. And the concept is is that you're trying to put implants into the spine to allow for the surgeon to get correction of the patient's scoliosis. But still providing the opportunity for the spine to move. The gold standard has been for years to do something called a spinal fusion. And what a spinal fusion is, is that the surgeons putting screws or hooks or implants into the spine to get points of fixation, it's a flexible cord so that it does move, placing bone graft between the bones to try to get them to stop moving in a tether. You're hoping that they continue to move. And with the idea that a they can recover much faster because you're not trying to limit their motion post op but also two throughout their life, they hopefully retain motion across those segments which allows them to be more active and more flexible. We trained on it early and we were the first group in New Jersey to both get FDA approval authorization through an IRB at our institution, which is Morristown Medical Center. And we're able to do our first cases in 2021 1 of the risks of tether is a breakage of the cord or a tether breakage. 20% risk. So about one in five. But if there's no change in the curve and the curve remains stable, there's really nothing you have to do surgically. In some cases, if the curve gets worse after the tether breaks, then there's an opportunity to fix it. That's called a revision tether where you go back in and you basically take out the old broken tether and you put in a new tether, uh and then retention it to try to correct the scoliosis or correct the curvature. Um And that can be done. Uh We have done that. It's incredibly challenging and complicated, but it's absolutely doable. And then again, it offers the opportunity to preserve motion to keep going through that process. The hope is is that once kids become skeletally mature, the risk of tether breakage goes down significantly. So if you can keep them stable long enough until they're done growing, then typically the core cord won't break as they're an adult. So there's no reason to take it out once it's implanted. Unless there's a problem, you have your thoracic spine, which is your middle spine and your lumbar spine, which is your lower spine. And the thoracic spine is inherently more stiff and it's more stiff because you have the ribs which come off the thoracic spine, wrap around and insert on your sternum and it's just a stiffer part of your spine. So, studies have shown that when you do a tether in the thoracic spine versus a fusion in the thoracic spine, sometimes it's hard to see a noticeable change in post operative range of motion. That might also be because thoracic curves oftentimes are stiffer. So if you have a very stiff thoracic curve and you try to do a VB T construct to straighten it, you don't always correct or increase the range of motion. It was stiff to start and it remains stiff. The lumbar spine is different. The lumbar spine is supposed to be flexible. It's where you get the majority of the motion in your spine. And the studies have shown that there's a big difference in terms of doing a fusion into the lumbar spine versus a VB T or a tether in the lumbar spine. So hybrid constructs have started becoming more interesting and more acceptable in the sense that you can do a selective thoracic fusion where you're trying to fuse the thoracic spine. And potentially you can get a better correction, a better de rotation of the rib asymmetry in scoliosis, there's oftentimes rotation of the spine and the rib cage around the spine and you can de rotate that sometimes better with the fusion. So sometimes we'll do a selective thoracic fusion coupled with a lumbar tether. So you're kind of getting the best of both worlds, you're fusing a thoracic spine, but you're preserving motion in the lumbar spine through a tether, thereby getting a better correction of the thoracic spine, but still preserving the motion and flexibility of the lumbar spine. I think the other big question about BT is how old is too old to do it. And right now, the indications are really for skeletally immature patients. So Children that still have growth ahead of them and it's really considered to be a growth modulation procedure. So patients that are still have growth ahead of them, those are ideal, you have to temper how much correction you do based on the age of the patient. If they're very young, then you may not want to try to get as much of a correction because there is a risk of something called over correction where the curve can actually flip the opposite way. If you get too much correction at the time of surgery in an older patient who's closer to being done growing, you really want to try to get more correction because it's less likely that they're gonna grow into their curve. Um So that's really where the art of this uh comes into play. You wanna tailor each surgical procedure based on the age and relative skeletal maturity of the individual patient, vertebral body tethering is really a wonderful advancement in the treatment of scoliosis for Children and young adults and the opportunity to try to preserve motion, but still correct, scoliosis is really beneficial. Uh, both, I think short term in terms of their faster recovery, but also long term, hopefully, that will prevent these patients from needing more surgery as adults. Hopefully it'll prevent their discs from wearing out from having degenerative disease below the construct of where the scoliosis surgery ends. And it really is a wonderful advancement. And I've personally been so impressed with my patients and how well they've done. And I think it's a huge opportunity for scoliosis patients. And I think this is the future. And uh you know, I think the indications for how we apply V BT to our scoliosis patients will expand and change and improve over time. But it's also an amazing opportunity now to help take care of patients with scoliosis through V BT. And we did our first V BT procedure in 2021 and we were actually the first team in New Jersey to do V BT with the FDA approved tether device in 2021. Um Since then, we've been doing them routinely uh this past year in 2023 we were the first team to actually do a revision tether for a tether breakage uh in the state of New Jersey as well.
