Who should treat spine deformity in children?

MODERATOR Dennis R. Wenger, MD Orthopedic surgeon at Childrens Specialists in San Diego Ronald DeWald, MD Professor of orthopedic surgery and director of the Spine Deformity Service at Rush St. Luke’s Medical Center in Chicago Lawrence G. Lenke, MD Professor of orthopedic surgery and a member of the Spine Deformity Service at Washington University in St. Louis Tony Herring, MD Chief of staff at the Texas Scottish Rite Hospital in Dallas Vernon Tolo, MD Chief of the orthopedic service at Los Angeles Children’s Hospital.

Progressive trunk deformity due to idiopathic scoliosis is a complex orthopedic condition. Until the early 1960s, treatment was difficult, depending on in-situ fusion performed through a window in a corrective body cast that had to be worn for up to a year. In the early 1960s, Paul Harrington, MD, of Houston introduced the Harrington rod system, which greatly improved the results of corrective surgery in idiopathic scoliosis. Since that time, progressively more sophisticated forms of internal fixation have been developed that allow both anterior and posterior approaches for correction of deformity.

In addition to scoliosis, both children and adults have other types of spine deformity, including severe spondylolisthesis, Scheurmann’s kyphosis, post-tumor kyphosis, congenital kyphosis, congenital scoliosis and deformity due to fracture. As the complexity of spine deformity diagnosis and treatment has evolved, a group of orthopedic surgeons has focused their clinical care and research to the point that they have become specialists in the treatment of spinal deformity.

Certificate of special qualification

Parallel to this evolution, the Scoliosis Research Society (SRS), an international organization that focuses on treatment and research issues related to the correction of spinal deformity, was formed in the mid-1960’s. Recently, the SRS has led an effort to develop a certificate of special qualification (CSQ) for spine deformity surgery (similar to the establishment of a CSQ in hand surgery some years ago and the very recently approved CSQ in orthopedic sports medicine).

Correction of spinal deformity was much simpler in the late 1960s. This patient was treated with a single Harrington distraction rod. Courtesy of Dennis R. Wenger

Proponents of those seeking a CSQ contend that spine deformity surgery embodies a very specific knowledge set that can be taught and tested. They believe that such certification will improve the overall treatment of spine deformity in North America by allowing patients with a severe spine deformity to be aware that they are seeing a trained and certified expert.

Specialization by age or disease

Another issue is specialization according to disease vs. specialization according to patient age and the relationship to training centers. In much of medicine, particularly in developed countries, adults and children are treated by different specialists. In these countries most educated parents take their child to a pediatrician for primary care. If they have special medical problems they might see a pediatric subspecialist (pediatric endocrinologist, dermatologist, etc.). If they have a visceral disorder (appendicitis, etc.), they would consult a pediatric surgeon. Similarly, in developed countries, complex pediatric orthopedic conditions are usually treated by a children’s orthopedic specialist rather than by a general orthopedic surgeon.

Perhaps the greatest growth of pediatric orthopedics as a subspecialty has been in North America, with the Pediatric Orthopedic Society of North America having more than 600 members. Due to the evolution of pediatric orthopedic training in the United States, many North American pediatric surgeons are trained to perform scoliosis and spinal deformity surgery. Some refer to this as the “John Hall Model,” established by John Hall, MD, at the Hospital for Sick Children in Toronto in the 1960s and continued at Boston’s Children’s Hospital in the ‘70s through the ‘90s after he became chief of orthopedic surgery at that institution.

Pediatric orthopedic surgeons trained by Hall and those in other centers who follow this model learned both advanced pediatric orthopedic methods and advanced surgical methods to treat spine deformity. This concept spread throughout North America and was further developed by surgeons such as Dean MacEwan at the DuPont Institute. The tradition continues at many large North American general children’s hospitals as well as in the Shriner’s Hospital system. Thus in North America the majority of spine deformity surgery in patients under age 18 are performed by pediatric orthopedic surgeons who have had training for scoliosis surgery in their fellowship program.

Interestingly, the picture is somewhat different elsewhere in the world. Throughout Europe and Asia, spine deformity surgery has developed as a disease-related specialty, with surgeons trained to treat spinal conditions in patients of all ages. In these centers, a spine deformity would be treated by the spine service rather than by the pediatric orthopedic service.

Pros, cons of international model

As spine deformity surgery becomes more complex, with an intense knowledge base and advanced instrumentation and intervention methods, some North American spine surgeons have suggested that the international model of disease-related rather than age-related spine deformity specialization be developed in North America. They contend that the quality and outcome would be better if procedures were performed by a surgeon who does only spine surgery.

On the other hand, surgeons trained in children’s hospitals contend that they can better treat children’s conditions because they understand children better, particularly the associated anomalies and syndromes that children with complex spine deformities often have. Furthermore, they are familiar with working in children’s hospitals along with the many subspecialists who consult on these complex cases.

This thoracoscopic setup is in preparation for anterior disc excision and fusion plus instrumentation via a thoracoscopic approach. Courtesy of Dennis R. Wenger

CSQ for spine deformity

These two concepts have been brought into focus recently because of the formal proposal by the SRS to be presented to the American Board of Orthopedic Surgery (and subsequently the ACGME) for consideration of a CSQ for spine deformity surgery. The proposed criteria for education include an intensive, year-long curriculum covering basic science, diagnostic methods, and sophisticated intervention for treatments of every type of spine deformity from birth to old age.

A CSQ would be issued by examination. Understandably, spine deformity surgeons who are academic leaders in children’s hospitals are concerned that surgeons who train in pediatric orthopedics and spine deformity surgery will want to take the examination. The international model proponents visualize that those who take a spine fellowship would sit for the examination.

Dennis R. Wenger, MD: We have asked several widely recognized North American experts to express their views on this interesting topic. I am sure that you will find their viewpoints enlightening.

Dr. Herring, who should treat spinal deformities in children and adolescents: pediatric orthopedists or spine surgeons?

Tony Herring, MD: Pediatric orthopedists with appropriate training are the ideal individuals to perform surgery for spinal deformity. In many cases they are better able to oversee the total management of such patients than are spine surgeons who primarily deal with adult deformity. Many children with spine deformity have other medical and orthopedic problems that are routinely managed by pediatric orthopedists. Such problems are cerebral palsy, spinal muscular atrophy, Duchenne dystrophy, Marfan syndrome, osteogenesis imperfecta, myelomeningocele, spondyloepiphyseal dysplasia, and myriad other problems that are part of the experience, training and daily practice of pediatric orthopedists. The treatment of these children can be challenging and complex, requiring not only a knowledgeable surgeon but also a well-coordinated management team.

The pediatric orthopedist with spine deformity training has had extensive training dealing with the challenges of adolescents with idiopathic scoliosis. As such, he or she is experienced in managing teenagers and their families, has current knowledge of classification systems, and is often a leader in instrumentation techniques. Many of the innovations in spinal fusion techniques and instrumentation have been pioneered by pediatric orthopedic spine surgeons. One may argue that all pediatric orthopedists are not so trained and certainly those without training should not perform surgery for spinal deformity. By the same token, the adult-trained spine surgeon who spent a fellowship dealing with lumbar spine, cervical spine, or other non-deformity cases may not be qualified to manage spine deformity.

The thoracoscopic view shows the placement of instrumentation. Courtesy of Dennis R. Wenger

It has been argued that European spine deformity is managed by spine surgeons and that, therefore, Americans should also follow this approach. This, to me, is equivalent to comparing the European traumatologist who does burr holes, thoracotomies, laparotomies and femoral nailings to the American traumatologists who never do such procedures.

Wenger: What about training?

Herring: The crux of the matter is really the training. If the training and experience are appropriate for the diseases and challenges encountered, the basic background is only an additive. The pediatric-trained deformity specialist may be the best person to manage the complex child with ostegenesis imperfecta, and the adult-trained surgeon is perhaps better at treating the adolescent with disc degeneration. Both should be able to competently manage idiopathic scoliosis.

Wenger: Should training be reflected in certification?

Herring: Any certification must recognize the training, competence and scope of practice of the individual and not rely on an arbitrary formula.

Wenger: Dr. DeWald, what do you think should happen with certification in spinal deformity surgery?

Ronald DeWald, MD: This debate should be called Spine Deformity Surgery in Children and Adolescents: Should it be performed by a children’s orthopedist trained in spine surgery or a spinal deformity surgery specialist? I have added the word deformity, which changes the whole nature of the debate.

Clearly, this will be a moot point in the future.

Currently there is no further recognition or certification for any type of orthopedic spinal surgery. Also, there is no recognition or certification for pediatric orthopedic surgery. Routine spine surgery and pediatric surgery are adequately covered in the accredited orthopedic residency programs. Spinal deformity surgery is not adequately covered.

Above: This patient has a severe right thoracic curve. Below: This is a clinical photograph and radiograph of a 12-year old girl with cerebral palsy and severe scoliosis. Courtesy of Dennis R. Wenger

There are 24 primary boards in medicine recognized by the American Board of Medical Specialists (ABMS). Many boards have several subspecialty boards. Orthopedic surgery is a primary board and has one subspecialty, the Hand Surgery Board.

Those surgeons who want to only do orthopedic pediatric spinal deformity surgery do so without any recognized certification. And, unfortunately, those surgeons who do pediatric and adult spinal deformity surgery do so without any recognized certification.

It is my understanding that there are hundreds of boards not under the umbrella of the ABMS, and hence have no standing.

Wenger: What position does the SRS take on certification?

DeWald: The SRS, the first spine society, was founded in 1966, and now it has an international presence. The SRS mission statement is to foster optimal care of the patient with any disorder that may affect the shape, alignment or function of the spine throughout life.

The SRS is taking the initiative to apply to the American Board of Orthopedic Surgery for subspecialty certification in spinal deformity surgery. The spinal deformity surgeon must have an extensive pediatric experience. It is necessary that the spinal deformity surgeon have knowledge and experience of adult patients. Of course one cannot be a spinal deformity surgeon without knowledge and experience of spinal deformity throughout life.

The business of the SRS is knowledge. The society is concerned with new knowledge, education of its members and communication of that knowledge to others. Knowledge brings responsibility and raising the bar of knowledge by certification will bring higher standards of ethical practice and professional service to the public.

In the future a certified spinal deformity surgeon may elect to treat only children, only adults, or both. This is why I think the debate is moot.

Wenger: Dr. Lenke, how has treatment of patients with spinal deformities changed in recent years and who is best prepared to treat them?

This postop A/P radiograph shows the complex instrumentation required to provide correction for the 12-year-old patient with cerebral palsy from the previous image. Advocates for children’s hospital centered training would suggest that the complexity of this patient’s diagnosis and associated medical condition require treatment in a children’s center. Courtesy of Dennis R. Wenger

Lawrence G. Lenke, MD: The patient with a spinal deformity, whether pediatric or adult, presents a significant challenge to the surgical practitioner, whether a pediatric orthopedist trained in spine surgery or a spinal surgery specialist. The surgical treatment has changed dramatically over the last four decades. Much of this progress has emanated from subspecialization of pediatric orthopedic surgeons who specialize in pediatric spine surgery, as well as the spinal surgeon specializing only in spinal deformity surgery. Many spinal deformity surgeons will cover both pediatric and adult patients in their clinical practice. There is no debate that only the spinal surgeon will be best prepared to treat adult patients with various spinal deformities.

Wenger: Who is the best practitioner to perform spinal deformity surgery in children and adolescents — a pediatric orthopedist trained in spine surgery or a spinal deformity specialist?

Lenke: Certainly there are some advantages that a pediatric orthopedist has when evaluating a child with a significant spinal deformity. A more comprehensive evaluation of the entire musculoskeletal system in this young age group, as well as superior knowledge of various syndromes and related malformations will help provide more complete care of young children by these specialists. The ability to plan and perform spinal surgical procedures on very young skeletons also may be a bit of an advantage since pediatric orthopedists are used to working on smaller, more skeletally immature structures.

The advantage may be somewhat tempered, though, if the pediatric orthopedist spends a great deal of time treating nonspine conditions such as problems related to the extremities. The familiarity with normal and pathologic spinal anatomy certainly is optimized with repetition, whether the repetition occurs in smaller vertebrae (ie, younger children) or adult-sized vertebrae.

Also, the distinction between children and young adults certainly falls in a gray zone with the adolescent patient. The majority of patients with adolescent idiopathic scoliosis already have fairly mature spinal columns and can be considered an adult by the skeletal maturity of their spinal column. Since the majority of pediatric spinal surgery done by most practitioners will fall in the adolescent age range, the pediatric orthopedist really spends most of his or her time treating adult-type skeletons.

Wenger: What are the advantages for patients if the surgeon treats a variety of conditions across several age groups?

Lenke: Spinal surgery specialists who treat a variety of pediatric and adult conditions offer several advantages. First and foremost, all aspects of their professional career deal only with pathologies of the spine. Thus all office evaluations, surgical procedures, graduate medical education, and research endeavors are focused solely on the spinal column and its various afflictions. Certainly, we are creatures of habit and repetition, and this should provide for optimally trained and experienced surgeons to deal with the myriad spinal surgical pathologies encountered.

Additionally, with regard to surgical procedures, there certainly is a fair amount of synergy that occurs in treating both pediatric and adult patients. Specifically, surgeons treating adult pathologies — such as spinal stenosis, spinal tumors and fractures with neurologic compromise — must be familiar and comfortable doing neural decompressive procedures. Handling of the dura including any potential sequelae (dural closure following incidental durotomy) is a skill that must be mastered for adult spinal surgeons.

Pictured is the final clinical result for the patient pictured on the top of page 62. The patient has a well-balanced trunk and has only three small stab incisions on the lateral trunk. Advanced training is required to perform this type of surgery. The procedure can be done in both children and young adults. Courtesy of Dennis R. Wenger

Mastery obtained through adult surgery

Furthermore, the ability to gain experience to perform various complex techniques including spinal instrumentation is often mastered in the adult spine before utilizing these techniques in the pediatric spine. As an example, the rapid explosion in the use of thoracic and lumbar pedicle screws for the correction and stabilization of various spinal deformities have been a product of spinal surgeons gaining experience in their adult practice and then transferring that to the pediatric sector, rather than vice versa. Similarly, the use of complex biplanar or triplanar osteotomies to correct pediatric complex deformities can be transferred from techniques gained in the adult spine where osteotomies are routinely performed from the treatment of coronal or sagittal imbalance syndromes.

Lastly, the ability to follow spinal development and the results of surgical treatment from the pediatric into the adult years is a benefit of the spinal deformity specialist who takes care of all age ranges. Certainly, the goal of the spinal deformity specialist is to optimally manage spinal deformity. Ideally, this means when surgery is performed on a child or adolescent, it will produce a stable spinal deformity that will last a lifetime. However, realistically this is usually not the case and follow-up into adult life is necessary to observe changes or problems that may arise from inevitable degenerative processes.

It would seem that a surgeon taking care of spinal deformity in all age groups would have a much better understanding and appreciation for the ultimate outcome of spinal deformity care delivered at any age previously. The outcome of spinal deformity care does not end at age 18 or 21; in reality, it is just the beginning.

Wenger: What is the role for pediatric orthopedists who specialize in spinal surgery?

Lenke: They have shown in the past an ability to provide excellent pediatric spinal deformity care. One example is the promotion of thoracoscopic techniques for the treatment of the deformed pediatric spine. However, they must be willing to devote most if not all of their practice to pediatric spinal deformity, as the occasional pediatric orthopedist who does spinal deformity along with a number of other operative techniques may find it more difficult now and in the future to stay current and state-of-the-art.

The same could be said for a spinal surgeon who does mainly adult degenerative spinal surgery and an occasional deformity. The skill sets are different and the stakes are high. Patients with spinal deformity deserve the best care possible and best short- and long-term outcomes. I believe the future of spinal deformity care rests in the hands of spinal deformity experts who devote their careers to these challenging yet rewarding patients.

Wenger: Dr. Tolo, there has been a lot of controversy about subspecialty certification. Why is that?

Vernon Tolo, MD: It has been difficult to show that the establishment of a certificate of added qualification (CAQ) in hand surgery has had much of an effect on who does hand surgery in the United States and on who is preferred by the insurers.

Despite the position of the American Academy of Orthopaedic Surgeons in opposition to further certificates of added or CSQ, a recent CSQ in orthopedic sports medicine has been established. Now there is renewed interest in establishing a similar subspecialty certification for spinal deformity surgery. The question has arisen as to who would be eligible to take this subspecialty examination. Suggestions have been made that pediatric orthopedic fellowships offer inadequate training for a surgeon who does a considerable amount of deformity surgery.

The concept that knowing the ins and outs of adult spinal surgery qualifies the surgeon as an expert in pediatric spinal deformity ignores the realities of the training that most spinal surgeons have. Most adult spinal deformity involves degenerative conditions. Pediatric spinal deformity treatment today manages not only young patients with idiopathic scoliosis, but also a large number of children with neuromuscular diseases, congenital scoliosis and kyphosis, and genetic disorders. While a teenager with adolescent idiopathic scoliosis will be treated with the same surgical approach and postoperative management as a 30-year-old, the surgical and perioperative management of childhood spinal deformity with other underlying causes differs dramatically from that encountered in the adult spinal patient.

Wenger: What other orthopedic problems and conditions are pediatric surgeons likely to treat?

Tolo: Orthopedic problems that arise in neuromuscular conditions are not seen today by adult spinal surgeons, and I detect little to no interest in adult surgeons to see this relatively large group of patients, which includes those with cerebral palsy, spina bifida, muscular dystrophy, spinal muscular atrophy, and others.

Spinal deformity is not the only orthopedic condition needing treatment in these kids, and until the adult spinal surgeon becomes interested and facile in management of the extremity problems of these children, then the spinal deformity management is best done by a pediatric orthopedic surgeon. Cognition and recognition of the other medical problems these children have is essential to providing the best care, and this knowledge is deficient in nearly all orthopedists concentrating in adult spinal surgery. The special needs these children have in the perioperative period, as well, benefit from the availability of pediatric anesthesiologists, intensivists, and other pediatric specialists.

Wenger: What type of training is needed?

Tolo: For the optimal results and for patient safety, appropriate training in pediatric spinal deformity surgery and in the perioperative management of pediatric-age patients is what is required, period. This is not taught in most adult spinal fellowships today. I do not think it is necessary to have a CSQ for spinal deformity.

Wenger: Is subspecialty certification needed?

Tolo: While I do not oppose subspecialty certification in spinal deformity surgery, exclusion of those with pediatric orthopedic fellowships from being eligible for this certification is an ill-conceived idea and reflects an ignorance of the spinal deformity patients many pediatric orthopedic fellows obtain. If the pediatric orthopedic fellowship includes the management of a large number of spinal deformity surgical experience, the pediatric orthopedist is qualified to treat all types of spinal deformity in children and adolescents, as well as young and middle-aged adults with idiopathic scoliosis.

The knowledge to treat the nonorthopedic problems that arise with pediatric spinal deformity is often the key to the safe and successful surgical management of these young patients and may be more important than the technical feat of implant placement.