According to data from various researchers, the prevalence of scoliosis remains relatively stable, affecting approximately 1.5–3 % of the general population. Within the overall disease structure, idiopathic scoliosis (IS) predominates, accounting for 75–85 % of all cases [33]; [34]; [6]; [35].
Clinically significant progressive scoliotic deformities that progress to the surgical stage are observed in only 0.1–0.38 % of all scoliosis cases [40]; [41]; [42]; [43]; [44].
Surgical treatment plays a central role in the management of scoliosis and is primarily aimed at correcting and stabilizing spinal deformities. Although modern instrumented surgical technologies demonstrate high effectiveness in deformity correction, they significantly restrict spinal mobility and remain complex, invasive, and costly procedures associated with a high risk of complications. These factors have led some researchers to question the overall appropriateness and justification of their widespread use [45]; [46]; [47].
Considering these limitations, there is a growing need to develop and implement new surgical strategies for scoliosis treatment that are cost-effective, efficient, and technologically advanced. Multimodal approaches—such as active surgical treatment programs or “Fast Track” surgery protocols—originally introduced during the expansion of minimally invasive and endoscopic surgery, may currently offer substantial benefits for scoliosis surgery and clinical practice.
Assessment of the mobility or correctability of a scoliotic deformity is a mandatory functional diagnostic component in surgical planning. Traditionally, the flexibility of the main scoliotic curve is evaluated radiographically using non-standardized external corrective forces. These include lateral bending of the trunk, application of manual pressure to the apex of the curve, or various combinations of these maneuvers. Radiographs may be obtained with the patient in the supine, prone, or lateral decubitus position, with manual pressure applied to the curve apex, as well as in standing or lateral decubitus positions using a bolster placed beneath the apex of the deformity (fulcrum bending radiographs) [48]; [49]; [50].
In addition, axial traction techniques are used, performed manually or mechanically in the supine position in conscious patients [49], under general anesthesia [51], or by suspension from the axillae [48], sometimes combined with additional manual pressure applied to the curve apex [52].
Despite the variety of available methods, no standardized approach currently exists for determining the individual mobility or correctability of scoliotic deformities. This is primarily due to substantial variability in the magnitude and point of application of corrective forces, not only among different investigators but even within the same study [53]; [52]; [48].
This lack of standardization complicates informed surgical decision-making, increases the risk of planning errors, and introduces uncertainty in outcome prediction [53]; [48]. Moreover, inconsistent and non-uniform concepts of spinal mobility may limit the effectiveness of surgical correction and increase the risk of complications, while also preventing meaningful comparison and systematization of clinical outcomes. As a result, reporting accuracy is compromised and scientific discussion becomes more complex [48]. To date, the effects of systematic traction on the organism of patients with scoliotic deformities have not been sufficiently investigated.
In most studies addressing preoperative corrective interventions for scoliosis, the nonlinear and viscoelastic properties of the muscle–tendon system— which determine the extensibility of spinal and thoracic deformities—have not been adequately considered or investigated. These biomechanical properties indicate that elongation of spinal and thoracic deformities may depend not only on the magnitude of the applied corrective force but also on the duration of its application. Moreover, the nature and adaptive capacity of time-dependent changes occurring during growth and development in the spine and other skeletal structures, as well as in the cardiovascular, respiratory, and nervous systems, remain insufficiently understood. Such changes are likely associated with the effects of systematically repeated and prolonged corrective interventions on the developing organism.
According to DeWald (1970), halo traction—including permanent halo-pelvic or halo-gravity traction systems—has been used as part of preoperative preparation for the surgical treatment of severe and rigid scoliosis. This method aims to reduce intraoperative complications, assess and increase deformity mobility, and improve the effectiveness of surgical correction [54]; [55]; [56]; [57].
However, the use of such traction techniques remains limited, as they represent independent surgical interventions associated with a high complication rate (up to 50 % or more), strict patient selection criteria, and a labor-intensive, invasive, and prolonged treatment course [57]. To date, no universally accepted, resource-efficient, and minimally traumatic clinical alternatives have been proposed.
In the surgical treatment of scoliosis, modern double-rod, frame-based, hook-based, hybrid, and pedicle screw transpedicular fixation (TPF) systems, including Cotrel–Dubousset instrumentation (CDI) and its analogues, enable highly effective correction of scoliotic deformities, achieving correction rates of 70 % or more [58]; [59]; [60].
At the same time, numerous studies have emphasized that the transition to TPF systems—particularly strategies involving high-density pedicle screw placement—has increased the invasiveness, technical complexity, operative difficulty, and duration of surgical procedures. The number of implanted construct components has risen substantially, along with the demand for specialized instruments, equipment, and pharmacological support. These factors have contributed to increased intraoperative blood loss, higher rates of complications and reoperations, and a marked escalation in hospital costs, ultimately reducing the accessibility of surgical treatment [61]; [58]; [62]; [63]; [64]; [59].
Attempts by the Texas Scottish Rite Hospital (TSRH) to revert to single-rod hook constructs placed on the concave side of the primary scoliotic curve—aimed at reducing complication rates, hospital costs, surgical burden, and invasiveness—failed to achieve the anticipated benefits. On the contrary, this approach was associated with serious complications and a need for additional revision surgeries, ultimately rendering the strategy unreliable.
From the perspective of correction mechanics, the use of a single-rod segmental hook construct positioned on the concave side of the primary scoliotic curve should theoretically be no less effective in correcting scoliosis deformities than modern double-rod frame-based systems, including TPF strategies. From both structural and technological standpoints, this positional strategy has the potential to address many of the limitations inherent in widely used contemporary techniques.
However, the clinical indications and the technique itself have not yet been fully developed, and its potential effectiveness, surgical burden, and associated risks remain insufficiently studied. To date, no publications in the scientific literature have specifically investigated the outcomes of scoliosis deformity correction using single-rod hook constructs applied according to this positional strategy.
Despite advances in modern orthopedics, surgical management of severe and rigid scoliosis deformities remains far from ideal. There are no standardized methods or universal criteria to stratify the severity of the pathology, which results in a lack of differentiated surgical correction strategies and limited understanding of the prevalence of severe deformities. Treatment of severe scoliosis carries a significant risk of complications, remains technically and technologically demanding, and often yields outcomes that are unsatisfactory for both patients and surgeons, occasionally raising questions about its medical and social justification [65]; [66]; [67]; [68]; [55]; [69].
Complex reconstructive-corrective methods aimed at mobilizing deformities are employed in the treatment of severe scoliosis. These include staged anterior correction [55]; [70] and/or halo-traction [65]; [66]; [56]; [57]; [71], as well as multi-segment anterior and/or posterior column reconstructions [55]; [72]; [73]; [69]. Some surgeons consider preoperative deformity mobilization unnecessary and rely solely on posterior approaches combined with instrumented correction [74], while others emphasize the effectiveness of vertebrotomy and spinal reconstruction [75]; [76].
Due to their structural characteristics, implantable systems do not always provide an adequate corrective effect tailored to the primary scoliotic curve [68]; [77], resulting in correction rates often not exceeding 30–40 % [55]. The incidence of complications—including pseudoarthrosis, infection, loss of achieved correction, postural imbalance, and pain—ranges from 20 % to 59 % [78]; [79]; [69], and may reach or exceed 100 % depending on deformity severity and surgical techniques employed [80], while the rate of severe neurological complications ranges from 0.68 % to 7.7 % [81].
Complications, insufficient correction, loss of functional capacity, cosmetic defects, and anatomical disproportions limit professional opportunities, reduce employment prospects, marriage, and childbearing potential, and constitute a major cause of impaired medical-social adaptation and decreased quality of life in the younger population [82]; [83]; [69].
The lack of less invasive, standardized multimodal approaches, preoperative treatment and preventive interventions, individualized prediction, and functional mobility assessment, along with the limited practical applicability of existing surgical strategies and implantable correction systems, remains a pressing problem.
Preoperative mobilization and preventive development of mobility in the scoliotic spine and thoracic cage, together with a personalized functional diagnostic and prognostic approach using systematic traction-based “suspension” techniques, constitute a standardized, effective, and safe treatment-diagnostic complex.
For children and adolescents with scoliosis of varying etiology and severity, a comprehensive strategy—including preoperative diagnostic preparation, planning and prognosis, and correction using less burdensome, resource-saving, minimally invasive, and highly effective single-rod systems—can reliably improve quality of life in both the short and long term. This approach forms the basis for considering it as an active surgical strategy or “Fast Track” surgery in scoliosis management.
References:
1. Садовая Т. Н. Скрининг, мониторинг и организация специализированной ортопедической помощи детям с деформациями позвоночника. Дисс. Док. мед. наук. — С-Пб., 2010. — 322 с.
2. Умарходжаев Ф. Р. Реконструктивно-корригирующие методы лечения прогрессирующего сколиоза. Дисс. Док. мед. наук. — Ташкент., 2021. — 235 с.
3. Умарходжаев Ф. Р., Умаров Д. Т. Идиопатический сколиоз (обзор литературы). O'zbekiston tibbiyot jurnali, 2024. Ташкент. Стр. 196–199.
4. Умарходжаев Ф. Р. Bemorlarni skoliotik deformatsiyalarni to'g'irlash yuzasidan operatsiyaga tayyorlash usuli. № FAP 2521. Ташкент. 2024.
5. Boachie-Adjei O., Cunningham M. E. Revision Spine Surgery in the Growing Child. Management of Spinal Disorders in Young Children / The Growing Spine // Editors: Akbarnia; Yazici; Thompson. — 2011.- P. 487–497.
6. Campbell R. M., Spine Deformities in Rare Congenital Syndromes. Clinical Issues // Spine. — 2009. — V. 34. — pp. 1815–1827.
7. Chan G., Dormans, J. P. Update on Congenital Spinal Deformities Preoperative Evaluation // Spine. — 2009. — V. 34. — pp. 1766–1774.
8. Cheung W. Y., Lenke L. G., Luk K. D. Prediction of scoliosis correction with thoracic segmental pedicle screw constructs using fulcrum bending radiographs // Spine. — 2010. — 35:557–561.
9. Crostelli M., Mazza O., Mariani M., Mascello D. Treatment of severe scoliosis with posterior-only approach arthrodesis and all-pedicle screw instrumentation // Eur. Spine J. — 2013. — V. 22(6). — P. 808–814.
10. Davis B. J., et al. Traction radiography performed under general anesthetic: a new technique for assessing idiopathic scoliosis curves // Spine. — 2004. — 29: P. 2466–2470.
11. Demura S., Bastrom T. P., Schlechter J., Yaszay B., Newton P. O. Should postoperative pulmonary function be a criterion that affects upper instrumented vertebra selection in adolescent idiopathic scoliosis surgery? // Spine. — 2013. — V. 38(22). — P. 1920–1926.
12. Diard G. H. Idiopathic scoliosis: epidemiology and natural history // Spine. — 2002.
13. Hamilton D. K., Smith J. S., Sansur C. A., et al. Rates of new neurological deficit associated with spine surgery based on 108,419 procedures: a report of the scoliosis research society morbidity and mortality committee // Spine. — 2011. — Vol. 36(15). — P. 1218–1228.
14. Hari T., et al Surgical treatment of adolescent idiopathic scoliosis in the United States from 1997 to 2012: an analysis of 20,346 patients // J Neurosurg Pediatr. — 2015. — 16:322–328.
15. Hyun S. J., Lee B. H., Park J. H., et al Proximal junctional kyphosis and proximal junctional failure following adult spinal deformity surgery // Korean J Spine. — 2017. — 14: 126–132.
16. Jasiewicz B., Potaczek T., Szcześniak A., Retrospective study of two-stage surgery in the treatment of scoliosis exceeding 100 degrees-assessment including spinal balance evaluation // Ortop Traumatol Rehabil. — 2009. — 11:495–500.
17. Klepps S. J., Lenke L. G., Bridwell K. H., et.al. Prospective comparison of flexibility radiographs in adolescent idiopathic scoliosis // Spine. — 2001. — 26:E74–E79.
18. Kulkarni A. G., Shah S. P. Intraoperative skull-femoral (skeletal) traction in surgical correction of severe scoliosis (>80°) in adult neglected scoliosis // Spine–2013 -Apr 15; 38(8): 659–64.
19. Kwan KYH, Alanay A, Yazici M, et al. Unplanned reoperations in magnetically controlled growing rod surgery for early onset scoliosis with a minimum of two-year follow-up. Spine (Phila Pa 1976) 2017;42(24):E1410-E1414.
20. Lamarre M. E., et al Assessment of spinal flexibility in adolescent idiopathic scoliosis: suspension versus side-bending radiography // Spine. — 2009. — 34(6): 591–597.
21. Lenke L. G., Newton P. O., Sucato D. J., et al. Complications after 147 consecutive vertebral column resections for severe pediatric spinal deformity: a multicenter analysis // Spine. — 2013. — Jan 15; 38(2): P. 119–32.
22. Lonner B. S., Ren Y., Yaszay B., et al. Evolution of Surgery for Adolescent Idiopathic Scoliosisover 20 Years: Have Outcomes Improved? // Spine. — 2017. — Jul 18.
23. Luhmann S. J., Lenke L. G., Bridwell K. H., et al. Revision surgery after primary spine fusion for idiopathic scoliosis // Spine. — 2009. — V. 34(20). — P. 2191–2197.
24. Luo M., Li N., Shen M., Xia L. Pedicle screw versus hybrid instrumentation in adolescent idiopathic scoliosis: A systematic review and meta-analysis with emphasis on complications and reoperations // Medicine (Baltimore). — 2017. — 96(27): e7337.
25. Mehlman C. T., Al-Sayyad M. J., Crawford A. H. Effectiveness of spinal release and halo-femoral traction in the management of severe spinal deformity // J Pediatr Orthop. — 2004. — 24: 667–73.
26. Modi H. N., Suh S. W., Hong J. Y. Posterior multilevel vertebral osteotomy for severe and rigid idiopathic and nonidiopathic kyphoscoliosis: a further experience with minimum two-year follow-up // Spine (Phila Pa 1976). — 2011. — 36(14): 1146–53.
27. Mueller F. J., Gluch H. Cotrel–Dubousset instrumentation for the correction of adolescent idiopathic scoliosis. Long-term results with an unexpected high revision rate // Scoliosis. — 2012. — 7(1): P. 13.
28. o’Brien M., Newton P., Betz R. Complications in the Surgical Treatment of Adolescent Idiopathic Scoliosis (AIS): A Ten Year Review of a Prospective Database with 1292 Patients // Spine. — 2013. — 38(19)pgs.i-i, 1613–1713, E1179-E1234.
29. Park D. K., Braaksma B., Hammerberg K. W., Sturm P. The efficacy of preoperative halo-gravity traction in pediatric spinal deformity the effect of traction duration // J Spinal Disord. — 2013. — 26(3): 146–154.
30. Qian B. P., Qiu Y., Wang B. Brachial plexus palsy associated with halo traction before posterior correction in severe scoliosis // Stud Health Technol Inform. — 2006. — 123: 538–42.
31. Rafi S., Munshi N., Abbas A., et al. Comparative analysis of pedicle screw versus hybrid instrumentation in adolescent idiopathic scoliosis surgery // J Neurosci Rural Pract. — 2016. — 7(4): 550–553.
32. Ramos D. G. R., Nakhla J., Nasser R. Effect of body mass index on surgical outcomes after posterior spinal fusion for adolescent idiopathic scoliosis // Neurosurg Focus. — 2017. — 43(4):E5.
33. Rushton PRP, Siddique I, Crawford R, Birch N, Gibson MJ, Hutton MJ. Magnetically controlled growing rods in the treatment of early-onset scoliosis: a note of caution. Bone Joint J 2017;99-B(6):708–713.
34. Smyrnis Alexopoylos A., Sekouris N., et al. Screening for preadolescent and adolescent Idiopathic Scoliosis of the spine in a Greek ROM population // Scoliosis.-2009.-Vol. 4. — Suppl 1. — 04.
35. Soultanis K., Pyrovolou N., Karaliotas G., et al. A radiographic evaluation of elasticity ın idiopathic scoliotic curves: are lateral bending films reliable enough to estimate curve elasticity? // Scoliosis. — 2009, — 4 (Suppl 1): O12 The electronic version of this abstract is the complete one and can be found online at: http://www.scoliosisjournal.com/content/4/S1/O12.
36. Suh S. W., Modi H. N., Yang J., e.a. Posterior multilevel vertebral osteotomy for correction of severe and rigid neuromuscular scoliosis: a preliminary study // Spine.- 2009. — V34. — P. 1315–1320.
37. Suk S. I., Kim W. J., Lee S. M., Kim J. H., Chung E. R. Thoracic pedicle screw fixation in spinal deformities // Spine. — 2001. — V. 26. — P. 2049–2057.
38. Suk S. I., Kim J. H., Kim W. J., et al. Posterior vertebral column resection for severe spinal deformities // Spine. — 2002. — V. 27. — P. 2374–2382.
39. Tan R., Ma H., Zou D., Wu J. et al. Surgical treatment of severe scoliosis and kyphoscoliosis by stages Chinese Medical Journal. — 2012. — 125(1): P. 81–86.
40. Theologis A. A., Sing D. C., Chekeni F. et al. National Trends in the Surgical Management of Adolescent Idiopathic Scoliosis: Analysis of a National Estimate of 60,108 Children From the National Inpatient Sample Over a 13-Year Time Period in the United States // Spine Deform. — 2017. — 5(1): 56–65.
41. Watanabe K., Lenke L. G., Bridwell K. H., et al. Efficacy of perioperative halo-gravity traction for treatment of severe scoliosis (≥100°) // J Orthop Sci. — 2010. — Nov. — 15(6): 720–30.
