What is the most appropriate surgical treatment for a skeletally immature adolescent with a 50-degree thoracolumbar curve due to adolescent idiopathic scoliosis, who has failed conservative management with bracing (Boston TLSO) and has a history of depression and social anxiety?

Surgical Management of Adolescent Idiopathic Scoliosis with 50-Degree Thoracolumbar Curve After Failed Bracing

For this skeletally immature adolescent with a 50-degree thoracolumbar curve who has failed 2 years of bracing, posterior spinal fusion with instrumentation remains the gold standard treatment, and vertebral body tethering should not be approved as it is investigational with high complication and revision rates that compromise both short-term morbidity and long-term quality of life.

Critical Pre-Operative Requirements

Before any surgical intervention, the following must be completed:

• Obtain complete spine MRI to rule out neural axis abnormalities, which occur in 2-4% of adolescent idiopathic scoliosis patients and include Chiari I malformation, cord syrinx, cord tethering, and intrinsic spinal cord tumors 1
• Document Risser stage to confirm skeletal immaturity and optimal surgical timing, as younger age and Risser stage IV are significant risk factors for curve progression 2
• Confirm curve magnitude exceeds surgical threshold, as this patient's 50-degree curve clearly exceeds the 45-50 degree threshold for surgical intervention in skeletally immature patients 2

Why Vertebral Body Tethering Should Be Denied

The evidence against VBT in this clinical scenario is compelling:

• High revision rate of 39-50% in recent studies, indicating poor durability of the procedure 3, 4
• Cable breakage occurs in 43% of patients, though not all require revision 3
• Only 50% clinical success rate at 2-year follow-up when defined as achieving skeletal maturity with ≤30° curves without conversion to fusion 3
• Significantly higher complication burden compared to established fusion techniques, with 39% requiring revision surgery versus 17% for posterior spinal fusion 4
• Investigational status with no long-term outcome data beyond 5 years, making it inappropriate for standard care 5, 6

Recommended Treatment: Posterior Spinal Fusion with Instrumentation

Posterior spinal fusion (PSF) with instrumentation should be approved as it provides:

• Superior deformity correction with mean curve reduction to 11±7 degrees (79% correction) compared to 19±10 degrees (63% correction) with VBT at 2-year follow-up 4
• Proven long-term durability as the gold standard treatment for adolescent idiopathic scoliosis 6
• Lower revision rate of 17% compared to 39% with VBT 4
• Predictable outcomes with established surgical techniques and complication profiles 6

Perioperative Advantages of PSF

While VBT advocates cite shorter operative times and less blood loss, the clinical significance is questionable:

• PSF has mean operative time of 331±83 minutes versus 419±95 minutes for VBT 4
• PSF has mean blood loss of 120±47 mL versus 498±290 mL for VBT 4
• Length of stay differs by only 1 day (4 days for VBT versus 5 days for PSF) 4
• Overall direct costs are equivalent ($47,655 for PSF versus $50,891 for VBT) 4

Addressing the Psychosocial Concerns

The patient's history of depression and social anxiety requiring homeschooling is concerning but does not change surgical recommendations:

• Both procedures require similar recovery periods and temporary activity restrictions 4
• The higher revision rate with VBT (39%) means greater likelihood of additional surgeries, potentially worsening psychological burden 3, 4
• PSF provides definitive correction in a single surgery for most patients, minimizing prolonged medical engagement 6

Surgical Planning for PSF

When proceeding with posterior spinal fusion:

• Extend instrumentation to include all structural curves in the thoracolumbar region 6
• Implement intraoperative neuromonitoring with EMG (100% sensitivity for detecting screw malposition) to minimize neurological complications 7
• Consider minimally invasive techniques if appropriate, as percutaneous instrumentation shows equivalent clinical outcomes to open techniques 1
• Verify Risser stage and growth potential to determine if anterior release is needed to prevent crankshaft phenomenon 5

Common Pitfalls to Avoid

• Do not delay surgery in patients with curves >50 degrees and remaining growth potential, as 39.2% will experience significant progression and 24.7% will exceed 50 degrees even at late skeletal maturity 2
• Do not approve VBT based on "motion preservation" claims when the revision rate approaches 50% and many patients ultimately require fusion anyway 3, 4
• Do not skip pre-operative MRI even with normal neurological examination, as neural axis abnormalities can affect surgical planning 1

Risk Stratification for Curve Progression

This patient has multiple high-risk features for continued progression:

• Curve magnitude of 50 degrees at presentation 2
• Skeletal immaturity with ongoing growth potential 2
• Failed conservative management with 2 years of bracing 2
• Younger age as a risk factor for progression 2