Pediatric spine surgeons have always had to plan for decades, not years. Now, the rest of spine appears to be catching up.
Nicholas Fletcher, MD, medical director of the spine program at Children’s Healthcare of Atlanta’s Orthopedic and Sports Medicine Center, led a Harms Study Group study published Sept. 14 in Spine Deformity that put a number on one of the field’s hardest trade-offs. Among 97 adolescent idiopathic scoliosis patients followed for at least 10 years, those who had selective thoracic fusion kept more lumbar motion. Those who had longer, nonselective fusion ended up with smaller residual lumbar curves — 17 degrees versus 23 degrees — and more reached a meaningful self-image improvement, 83% vs. 60%. Complication and reoperation rates did not differ.
“I always sort of joke with families: We could get you perfectly aligned from your skull to your pelvis, but you would lose all your motion,” Dr. Fletcher said.
How families weigh it
The two questions Dr. Fletcher hears most: Is one option better, and what would he do for his own child? His answer leans on the 10-year data.
“Unless you’re really bothered by the cosmesis and the way the spine appears, the outcome scores were comparable between the two,” he said. “So you’re not necessarily, at least out to 10 years, going to make a bad decision.”
Teenagers often prioritize a symmetric waist and trunk. Parents, he said, tend to prioritize motion, because they feel the difference between 14 and middle age every morning. Most of his patients choose motion preservation when it’s possible. For those who say appearance matters most to them, the study lets him tell them they will likely function as well as patients with the shorter fusion.
The same weighing applies to newer motion-preserving options. Vertebral body tethering carries a revision rate of at least 20%, Dr. Fletcher said, compared with roughly 2% to 5% for spinal fusion in the first 10 years.
One question remains open: whether it is better to fuse longer up front, or stop shorter and accept a possible extension decades later. Dr. Fletcher’s own bias is toward a shorter fusion when the curve allows it, and toward operating in late adolescence or early adulthood rather than later in life, when surgery carries more physiologic burden.
A two-way street with adult spine
A decade ago, pediatric and adult deformity surgeons had little overlap, Dr. Fletcher said. That has changed. The theme of this year’s Scoliosis Research Society annual meeting in Sydney, where he helped build the educational program, was bridges and transitions — including the one between pediatric and adult care.
Pediatric surgeons have borrowed lateral and oblique approaches and minimally invasive techniques from the adult side. The biggest lesson, he said, is sagittal alignment. Alignment targets developed in adults now guide pediatric planning, though open questions remain, such as whether to set a 12-year-old’s alignment for their age now or for where they will be at 18.
The next step is pairing precise planning with precise execution: patient-specific rods, AI-based planning, navigation and robotics. “It really becomes precision medicine, and that I think at the end of the day, for all of us, is the ultimate goal,” he said.
“Kids don’t stop having spine issues when they’re 21, and adults don’t start having spine issues when they become 21,” he added. “There’s a lot of bleed-over across the two areas.”
Scale and the long view in Atlanta
Children’s Healthcare of Atlanta cares for the majority of children in Georgia and has the highest operative pediatric spine volume in the country, Dr. Fletcher said. About two years ago, the system merged the spine programs at two of its hospitals into one. Each had done 250 to 300 spine surgeries a year; the combined program now does about 550.
“We want to deliver the same level of quality at a high volume,” he said.
Volume and academic output also give the program access to the Harms Study Group, the largest international multicenter pediatric spinal deformity database. The group began enrolling patients prospectively about 20 years ago, and its first 20-year follow-up data is coming online. Prospective tracking matters in pediatrics, Dr. Fletcher said, because teenagers move away and are hard to follow for a decade on their own. Most legacy studies stop at two years, when outcomes typically look good.
“There are no other studies that I know of out there that have roughly 100 patients with 10-year follow-up in this sort of area,” he said.
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