CHAPTER
Oswald
77
Stapling Techniques
THE PROBLEM
The natural history of adolescent idiopathic scoliosis (AIS) is
dependent on the patients skeletal maturity, curve severity,
curve pattern, and possibly yet to be determined genetic fac-
tors. The current standard of care is bracing of immature
patients with AIS curves of 20 to 40 with the hopes of prevent-
ing progression. Continued curve progression despite bracing,
however, is reported in 18% to 50% of cases.15,21,24,26 These
results, along with poor compliance with brace wear1,2,12,14,17,19,23
and the long treatment period required for bracing, have
driven a search for more effective treatment options.
One such treatment modality is vertebral body stapling.
Because of the success of hemiepiphysiodesis in treating angu-
lar deformities in the extremities of children, a similar approach
has been applied to the spine. Through minimally invasive
anterior approaches, vertebral body stapling offers the poten-
tial for deformity stabilization, curve correction, and segmental
motion preservation for the growing child and adolescent
(Table 77.1).
ADVANTAGES AND DISADVANTAGES
OF BRACING
Bracing is a noninvasive treatment that does not possess the
risks inherent with surgery. In addition, it preserves motion,
growth, and segmental spine motion. Although bracing has
been shown to produce better results than the observed natural
history of curve progression in scoliosis,18,21,23 it offers no
chance of deformity correction. Bracing has its own set of dis-
advantages, including the need to wear the brace between 14 to
23 hours a day until skeletal maturity, a period of time that can
be significant. In addition, brace wear can be associated with
poor self-image during the teenage years, leading to poor brace
wear compliance.1,2,12,14,17,19,23 Lastly, 18% to 50% of curves will
progress despite bracing.15,21,23,24,26
HISTORY OF SPINE STAPLING
The inspiration for stapling the spine for scoliosis grew out of
the success obtained in lower extremity deformity conditions in
children. Stapling the physis in the appendicular skeleton has
been used extensively to correct length and angular deformi-
ties. It is minimally invasive, avoids the need for fusion, and is
766
LWBK836_Ch77_p766-777.indd 766
Timothy S.
Patrick J. Cahill
Amer F. Samdani
Randal R. Betz
potentially reversible, and the correction starts immediately
upon insertion.6
Hemiepiphyseal stapling for scoliosis was initially evaluated
in the 1950s in both animal models and humans.22,28 Nachlas
and Borden used staples placed across the physeal plates and
discs in a canine model to create and subsequently correct spi-
nal deformity. Some staples failed due to the technique of sta-
pling more than one interspace (up to three in some cases),
and due to the design of the staple.22 Smith et al presented the
earliest results of stapling for congenital scoliosis in humans,
but the results were disappointing.28 He was only able to obtain
a limited amount of correction due to the use in severe curves
with rotational components and in patients with little growth
remaining. In his series, a number of staples became loose or
broke, possibly due to vertebral body motion.
The HueterVolkmann law is believed to drive the progres-
sion of vertebral wedging in the apical region of the curve. The
law states that compressive loads retard growth at the physis
while distractive forces accelerate growth. A significant amount
of work has been done in animal models looking at the devel-
oping spine and the effect of the HueterVolkmann law.
Rat tail models have confirmed the ability to modulate verte-
bral growth plates. Stokes model demonstrated that the
HueterVolkmann law could predict vertebral body growth
through mechanical modulation in a rat model. Using external
fixation, compression reduced growth to 68% of normal while
distraction increased growth to 114%.29,30 Mente et al demon-
strated that asymmetrical loading of rat trail vertebrae resulted
in differential growth on the compression and tension sides
that allowed for production and subsequent correction of
deformities.20
Braun et al reported the role of the HueterVolkmann law
in the spine of a goat model. They demonstrated that with a
mechanical tether, a progressive, structural, lordoscoliotic
curve of significant magnitude could be created with an
increase in apical spinal wedging of 11.3. In addition, Braun
et al were able to obtain significant correction of the deformity
in a goat spine that was stapled versus untreated controls with
deformity. Therefore, Braun et al demonstrated spine defor-
mity creation and subsequent control of its progression in a
large animal model with staples.811
Braun et al demonstrated that relative and absolute growth
was modulated by vertebral stapling at the apical spinal seg-
ment in a progressive goat scoliosis model. Previous studies uti-
lized Cobb angles to measure relative changes in growth. Braun
et al measured both the concave and convex vertebral body
8/17/11 11:16:53 AM

Potential Benefits of
TABLE 77.1 Bracing, Vertebral Body
Stapling, and Fusion
Independent
Curve Curve Motion of Patient
Stabilization Correction Preservation Compliance
Bracing 0 0 bovine biomechanical model.25 They determined that staples
Stapling were able to significantly restrict motion while not achieving
Fusion 0 the motion reductions associated with fusion. Axial rotation
heights to establish absolute vertebral body growth. Anterior
vertebral stapling, although able to control progressive wedg-
ing and scoliosis at the apical segment, was not able to fully
reverse the HueterVolkmann effect. During the tethering
period, all goats had a relative and absolute decrease in con-
cave growth (78%) and an increase in convex growth (33%) at
the apical segment compared with controls. During the treat-
ment period, the relative modulation of growth with stapling
demonstrated modest correction of wedging at the apical seg-
ment (2.2) versus untreated goats, which showed progres-
sion (3.5). However, absolute modulation of growth was not
able to fully reverse the HueterVolkmann effect; at the apical
spinal segment, growth was decreased on both the concavity
(10%) and convexity (18%).7
Wall et al induced spine curvature in the coronal plane (0.8
to 22.4) in a normal porcine model utilizing spinal hemiepi-
physiodesis with a staple. Histological evaluation of the porcine
growth plate demonstrated chondrocyte hypertrophy on the
stapled side indicating structural changes in the growth plate.32
Since the early use of staples for the spine by Nachlas and
Borden22 and Smith et al,28 the design and metal composition
have continued to evolve. The early stainless steel staples were
originally designed for use in long bones and were ill suited for
the motion seen in the spine; the rigid implant was prone to
dislodge. In response to these limitations, Medtronic Sofamor
Danek (Memphis, TN) designed staples specifically for the
spine constructed of Nitinol, a shape memory alloy. The Food
and Drug Administration has given 510(k) approval for Nitinol
shape memory staples for fixation of a bone screw in the ante-
rior spine as well as for hand and foot osteotomies. The staples
are not approved for use across the disc space and are used off
label. The prongs of the staple are straight when cooled but
bend into a C shape when introduced into the body, provid-
ing more secure fixation than possible with parallel stainless
steel staples. The temperature at which the staples undergo
transformation can be controlled by the manufacturing pro-
cess.27 With shape memory staples that crimp when warmed,
Braun et al, in their goat scoliosis model, demonstrated slight
back-out of 27% of 56 staples but with no complete dislodge-
ments.10 Back-out was not an issue in a recent human trial.3
Nitinol is a biocompatible metal alloy of 50% titanium and
50% nickel with extensive clinical experience in cardiovascular
stents,13,16 and no injury has been seen to surrounding tissues
in animal or human experiences.31 In addition, Nitinol has
been utilized in orthodontic appliances due to its low corrosion
rate.27 Implant studies in animals demonstrate minimal eleva-
tions of nickel in tissues in contact with Nitinol. While nickel
sensitivity occurs in people very rarely, it is not expected to
LWBK836_Ch77_p766-777.indd 767
Chapter 77 Stapling Techniques 767
occur with the use of the Nitinol staple. This is due to the nickel
crystal structure in Nitinol, which is different than the structure
of nickel in stainless steel where nickel can occasionally leach
out and cause sensitivity issues. Titanium is considered a bio-
logically safe implant material.33 No method of sterilization has
been shown to affect Nitinols properties.27
Puttlitz et al evaluated differences in thoracic spine range of
motion due to placement of Nitinol staples in an immature
and lateral bending were significantly limited with lateral sta-
ples without clear superiority between two- and four-prong
staples. Puttlitz et al demonstrated that by adding an anterior
staple, overall flexionextension was significantly decreased.25
Betz et al demonstrated the feasibility, safety, and utility of
vertebral body stapling for the treatment of AIS in a group of
21 patients4 (Figs. 77.1 and 77.2). In this study, there were no
major and three minor complications, which included a seg-
mental vein injury, a chylothorax, and a mild case of pancreati-
tis. No staple dislodgement or movements were noted.
INDICATIONS FOR STAPLING
Stapling is indicated in girls younger than 13 years and boys
younger than 15 who are Risser 0 or 1 or have at least 1 year of
growth remaining by wrist X-ray. The thoracic and lumbar cor-
onal curves should measure less than 45, with minimal rota-
tion, and flexibility to less than 20. The sagittal thoracic curve
should measure less than 40, due to the theoretic potential of
the staples to induce kyphosis. If the thoracic curve measures
35 to 45 and does not bend below 20, then the senior author
will consider adding a posterior rib to spine hybrid construct at
the same time, doing the posterior first (Figs. 77.3 and 77.4).
For a patient in whom the curves do not measure less than 20
on first erect film, a corrective brace will be worn until the
curves measures below 20.
CONTRAINDICATIONS TO STAPLING
Early failures in the Betz et al studies occurred in patients with
preoperative curves greater than 50 and in those with second-
ary curves greater than 25, which were not stapled. Additional
contraindications included greater than 40 kyphoscoliosis, any
medical contraindication to general anesthesia, reduced pul-
monary function, or a known hypersensitivity to nickel.3,4
SURGICAL TECHNIQUES
Preoperatively, posteroanterior (PA) and lateral standing films
are evaluated and the levels of the major scoliotic curve identi-
fied. In general, staples are placed on the convexity of each level
within the measured curve. General anesthesia is induced with a
double lumen endotracheal tube. The double lumen tube pro-
vides for both single lung ventilation and deflation of the non-
ventilated (convex) lung for superior visualization. The patient
is placed in the lateral decubitus position with the convex side of
the curve facing up with all bony prominences well padded. Two
pads are placed under the pelvis and two pillows are positioned
8/17/11 11:16:54 AM
 768 Section VII Idiopathic Scoliosis

A B C

D E F

Figure 77.1. Posteroanterior (A) and lateral (B) erect radiographs of a 12-year-old girl demonstrate a 31
right thoracic curve and 15 thoracic kyphosis. Preoperative bending films (C and D) demonstrate the flex-
ibility of the curve. The patient underwent a thoracoscopic vertebral body stapling from T5-T12. Her first
erect X-rays (E and F) demonstrate curve correction to 19. Latest follow-up at 4.1 years postoperatively
(continued)

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 Chapter 77 Stapling Techniques 769

Figure 77.1. (Continued)(G and H) demon-

strates maintenance of curve correction at 22
G H
and a thoracic kyphosis of 28.

A B C

Figure 77.2. (A) Posteroanterior (PA) and (B) lateral erect radiographs of a 7-year-old boy demonstrate a
30 right thoracic curve and 8 of thoracic kyphosis. (C and D) Bending films demonstrate a flexible thoracic
curve, which is completely correctible. (continued)

LWBK836_Ch77_p766-777.indd 769 8/17/11 11:16:56 AM

 770 Section VII Idiopathic Scoliosis
D E
G H
between the arms with the endotracheal tube situated in
between the pillows. Fluoroscopic images are then obtained in
order to confirm the appropriate spine level (Figs. 77.5 and
77.6). Each of the levels within the major curve (as measured
on preoperative standing radiographs) is selected for stapling.
Neuromonitoring is used even though the risk of neurological
complications is extremely low. If a segmental vessel should
require ligation, then neuromonitoring is an important adjunct
to the procedure. Once adequately positioned with good
LWBK836_Ch77_p766-777.indd 770
F
Figure 77.2. (Continued) (E) First erect posteroan-
terior view after stapling demonstrates a 30 curve.
(F) First erect lateral radiograph after stapling dem-
onstrating placement of staples. (G) PA view at 2-year
follow-up demonstrates curve correction to 16.
(H) Lateral view at 2-year follow-up demonstrates
improvement in thoracic kyphosis to 26.
fluoroscopic visualization and baseline neuromonitoring, the
patient is prepped as if for a thoracotomy. This is done in case
the procedure needs to be converted to a thoracotomy, should
complications arise. Staples are allowed to cool for at least
45 minutes. Once adequately cooled, the staples are placed
onto their inserters, where they remain on ice until insertion.
For thoracic curves, a thoracoscopic-assisted approach is
preferred. The initial portal is made in the fifth to seventh
intercostal interspace along the anterolateral chest line for
8/17/11 11:16:58 AM
 Chapter 77 Stapling Techniques 771

A B C

Figure 77.3. (A) This is a 9-year-old girl with a 55 right thoracic curve. On right bending film, the curve
reduces to 15. Her trunk height is still relatively short compared with that of her parents, and they are desir-
ous of an alternative to bracing and eventual fusion. (B and C) These are the postoperative radiographs of a
fusionless strategy. First, a posterior hybrid rod is placed from T6-7-8 to the L1 lamina. This rod is inserted
with two small incisions, one over the proximal sites and one over the lumbar spine. The rod is passed subcu-
taneously. After the spine is distracted into its corrected position, the patient is rolled to a lateral decubitus
position, and vertebral body stapling is performed from T7 to T12. It is anticipated that the patient will
undergo an initial lengthening in 6 months and then approximately yearly after that, which is the reason the
rod is left long at both ends of the construct. The plan will be to remove the rod at skeletal maturity, and it is
anticipated that the curve would be maintained at less than 30.

visualization with the scope. Staples are inserted through addi-
tional working portals in the posterior axillary line created
under thoracoscopic visualization (Fig. 77.7). Another access
option is two minithoracotomy incisions with one centered at
T4-5 and the other at T9-10. If one encounters problems with
one lung ventilation, then two minithoracotomies are just as
effective for access. Upon access, appropriate levels are con-
firmed with fluoroscopy. A radiopaque trial instrument is uti-
lized to determine the proper size of the staple (3 to 10 mm)
and to create pilot holes. The smallest staple that is able to span
the growth plates and disc is utilized. In most cases, the parietal
pleura is not excised and the segmental vessels are preserved.
Occasionally, a small incision in the parietal pleura is required
to gently move the vessels away from the staple. The trial instru-
ment is lined up on the vertebral body, and AP and lateral
images confirm the location and proper placement. The trial is
tapped into vertebral body in preparation for the staple
(Fig. 77.8). Staples are sized based on the distance between the
prongs once clamped down in vitro. Staples come in two-prong
(Fig. 77.9A) and four-prong (Fig. 77.9B) varieties. Once the
trial is fully seated, repeat images are taken, the trial is removed,
and the staple is introduced and malleted into place
(Fig. 77.10). Throughout introduction, the staples position is
confirmed on both AP and lateral fluoroscopic views. If a staple
is found to be incorrectly positioned, it can be removed with a
gentle pull of the clamp. After staple insertion, a chest tube is
placed to prevent a pneumothorax and to allow for drainage of
any postoperative effusions.
If hypokyphosis (kyphosis 10) exists, correction can be
attempted by placing the staples more anteriorly or by applying
a third staple (Fig. 77.11A). Generally, all staples are placed
directly lateral on the vertebral body just anterior to the rib
head. If hypokyphosis is present, then at the apical one or two
discs an additional two-prong staple is placed just anterior to
the first staple(s). Occasionally, the T4 and T5 vertebrae are
too small to accommodate a four-prong staple, and a two-prong
staple is utilized. If possible, four-prong staples are used because
they decrease surgical time at each level (Fig. 77.11B). If the
diaphragm requires partial reflection at the thoracolumbar
junction for staple placement, it should be repaired.
In the lumbar spine, vertebrae may be approached through
two different techniques. One option is a miniopen retroperito-
neal approach. This involves anterior-to-posterior retraction of
the psoas to provide visualization of the posterior one third of the
disc space. Alternatively, a second option is the minimally invasive
transpsoas approach using a tube system in a manner popular-
ized by the lateral lumbar interbody fusion (XLIF) procedure
(Figs. 77.12A and B). With this technique, the psoas is bluntly dis-
sected in line with its longitudinal fibers over the posterior half of
the disc. During psoas dissection, direct electromyography

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 772 Section VII Idiopathic Scoliosis

A B C

Figure 77.4. (A and B) These are the preoperative anteroposterior and lateral radio-
graphs of a 10-year-old girl with a 48 lumbar curve. She has open triradiate epiphyses, is
Risser 0, and is premenarchal. The patient and family are adamant that they do not wish
to have a fusion if at all possible. (C and D) These are the immediate postoperative films.
The patient had first a percutaneous placement of pedicle screws from T12 to L2. A per-
cutaneous rod was inserted, and the spine was derotated and locked in place. The rod is
specifically left long to allow for future lengthenings. The patient was then rolled to a left
lateral decubitus position and the stapling was performed between T11 and L3. The
patient was then rolled to a right lateral decubitus position and underwent stapling from
T6 to T11. It is anticipated that the lumbar distraction rod may be lengthened once,
possibly twice, but then removed when it is felt that the spine is substantially corrected
D
and stable.

LWBK836_Ch77_p766-777.indd 772 9/2/11 6:25:35 PM


Figure 77.5. The patient is placed in a lateral decubitus position.
Using fluoroscopic imaging, the levels of the spine to be stapled are
confirmed (Courtesy of Medtronic Sofamor Danek, Memphis, TN).
monitoring is useful to prevent inadvertent damage to the lum-
bar plexus. Using either of these techniques, it is technically fea-
sible to staple to the L3-L4 disc, although this is rarely needed.3,4
Initial correction on the first erect film is highly predictive
of success, as will be described later in this chapter. If the curve
reduces to below 20 on the first erect X-ray, there is an 86%
success rate of stabilizing or correcting the curve. Therefore,
Figure 77.6. A lateral/medial image is used to again confirm the
vertebral levels to be stapled and also to center the portals in the
posterolateral line (Courtesy of Medtronic Sofamor Danek, Memphis,
TN).
LWBK836_Ch77_p766-777.indd 773
Chapter 77 Stapling Techniques 773
Figure 77.7. Generally two but up to four portals in the postero-
lateral line are used, with the thoracoscope being inserted in the ante-
rior axillary line at the apex of the curve (Courtesy of Medtronic
Sofamor Danek, Memphis, TN).
the senior author is being more aggressive with correction on
the operating room table. The spine from T10 distal generally
sags well while in the lateral decubitus position (postural cor-
rection from positioning on the operating room table), allow-
ing excellent correction at each disc level. However, above T10,
we have found it helpful to use additional mechanical correc-
tive force by using the four-prong inserter as a corrective device
at the apical vertebra. The trial is inserted across the T9-10 disc,
and the assistant applies downward pressure (reducing the
deformity) while the more proximal levels are stapled. After
placing the T8-9 staple, instead of removing the driver holding
the staple, it is left where it is and downward pressure applied
so the T9-10 inserter can be removed and a staple placed.
POSTOPERATIVE MANAGEMENT
Postoperatively, the chest tube is removed once output is less
than 100 cc per 24 hours. In Betzs initial series, chest tubes were
left in for an average of 3.8 days, and patients were discharged
after an average hospital stay of 6.6 days.3 The current regimen
is to remove the chest tube at 1 day and discharge in 3 days.
Early in the Betz cohort, the postoperative regimen was a
noncorrective thoracolumbosacral orthosis (TLSO) full time for
4 weeks, with no restrictions of activity thereafter. Currently, a
brace is not utilized for thoracic curves and activities are restricted
for only 1 month. For lumbar curves, we use a corset for 6 weeks
to remind the patient to limit motion. After 6 weeks there are
8/17/11 11:17:03 AM
 774 Section VII Idiopathic Scoliosis

Figure 77.8. Four-prong trial.

(A) The staple trial is passed through
one of the posterolateral portals and
centered over the intervening disc
space for staple sizing. The surgeon
should place the prongs as close to the
end plates as possible. (B) Once the
position is confirmed through an
anteroposterior image, starting holes
are created. Generally, the posterior
holes are created first, just anterior to
the rib heads (Courtesy of Medtronic
A B
Sofamor Danek, Memphis, TN).

Figure 77.9. (A) Two-prong staple.

(B) Four-prong staple (Courtesy of
Medtronic Sofamor Danek, Memphis,
TN). A B

Figure 77.10. (A) The staple is

inserted into the pilot holes and the
position confirmed with a fluoroscopic
image. (B) The staple is impacted into
the pilot holes (Courtesy of Medtronic
A B
Sofamor Danek, Memphis, TN).

LWBK836_Ch77_p766-777.indd 774 8/17/11 11:17:06 AM


A B
Figure 77.11. (A) Generally, two staples are utilized at each verte-
bral segment. This can be in the form of two single staples, which pro-
vides the flexibility of adding a third anterior staple if desired.
(B) However, to decrease operative time, a double staple is used when
appropriate (Courtesy of Medtronic Sofamor Danek, Memphis, TN).
absolutely no restrictions of activity. Patients are seen at 1 and 2
months for wound checks and then every 6 months until skeletal
maturity with standing PA and lateral radiographs to evaluate the
curve.3 If the curves on the first erect film do not measure less
than 20, then the patient wears a corrective brace (usually a
nighttime Providence brace or a standard Boston brace [8 to 12
hours per day]) until the curve measures less than 20 out of the
brace.
EXPECTED OUTCOMES AND RESULTS
Betz et al5 retrospectively reviewed 28 out of 29 patients (96%)
with idiopathic scoliosis treated with vertebral body stapling
followed for a minimum of 2 years using the aforementioned
TABLE 77.2 Results for Thoracic Curves
Success
Improved
Preoperative curve 3 (16.7%)
35
Preoperative 1 (12.5%)
curve 35
*
p-Value: Fishers exact test comparing preoperative 35 versus 35.
LWBK836_Ch77_p766-777.indd 775
Chapter 77 Stapling Techniques 775
criteria. There were 26 thoracic and 15 lumbar curves, with an
average follow-up of 3.2 years. The procedure was considered a
success if curves stayed within 10 of preoperative measurement
or improved more than 10. The procedure was considered a
failure if the curve progressed more than 10. Thoracic curves
measuring less than 35 had a success rate of 77.7% (Table 77.2).
Curves, which reached less than or equal to 20 on first erect
radiograph had a success rate of 85.7% (Table 77.3). This is why
we now use a night brace also if the curves are not below 20 on
the first standing radiograph, and we now aggressively try to get
the best correction mechanically at the time of surgery. Four of
the 26 thoracic curves (15%) showed correction greater than
10. Eighty-three percent of patients had normal thoracic kypho-
sis of 10 to 40 at most recent follow-up (Table 77.4). Thoracic
curves 36 to 45 had a 75% failure with greater than 10 of pro-
gression, which led the authors to pursue a posterior hybrid (rib
to spine) distraction rod in addition to the stapling. Lumbar
curves demonstrated a success rate of 86.7%. Four of the 15 lum-
bar curves (27%) showed correction greater than 10.
In summary, this series of patients with idiopathic scoliosis
with high-risk progression treated with vertebral body stapling
shows a success rate of 87% in all lumbar curves and in 79% of
thoracic curves less than 35 at minimum 2-year follow-up.
Thoracic curves greater than 35 continued to progress despite
stapling in most cases and thus required alternative treatments.
COMPLICATIONS
Betz and colleagues have utilized 1900 staples on more than
150 patients. In two patients, a staple became completely dis-
lodged from the spine and was free within the chest. A thoraco-
scopic assisted retrieval was performed in both cases. No
damage to the great vessels, heart, or lungs was noted, and no
further complications occurred. There have been two cases in
which a staple (one staple in each case) backed out by only 2
mm. Four four-prong staples of an early design were found to
have fractured at the waist, although they did not back out. The
design was then changed.
In the series of 29 patients described above in the Expected
Outcome and Results section, there were two minor complica-
tions, including superior mesenteric artery syndrome and
atelectasis due to a mucous plug. There were no instances of
staple dislodgement or neurovascular injury.
Additional complications reported in prior articles published
by the senior author3,4 included one major and five minor com-
plications. The major complication occurred in a 4-year-old
patient with infantile idiopathic scoliosis who had an uncompli-
cated thoracoscopic stapling from T5 to T12 with a rupture of a
Failure
No Change Progression 10 p-Value
11 (61.1%) 4 (22.2%) .0029*
1 (12.5%) 6 (75%)
8/17/11 11:17:12 AM
 776 Section VII Idiopathic Scoliosis

Figure 77.12. (A and B) Diagrams of the lateral lumbar interbody

fusion (XLIF) procedure as described by Dr. Louis Pimento with instru-
mentation designed by NuVasive, Inc. This is a retroperitoneal
approach with a retractor system that allows a transpsoas approach to
the disc space. While A shows an interbody graft, this is not performed
in this particular procedure; just two staples or a four-prong staple
across the disc space, as shown in B. (Courtesy of NuVasive, Inc., San
A Diego, CA.)

pre-existing unrecognized diaphragmatic hernia that required
emergency repair. Minor complications included puncture of a
segmental spinal vein with a staple prong requiring conversion
to a mini-incision thoracotomy to ligate the vein (this was the
first case, without all the trials and staple sizes now available); a
chylothorax from a staple prong puncture of the thoracic duct at
T12 not noticed at surgery but successfully treated conservatively
with a chest tube and total parenteral nutrition; mild pancreati-
tis, which resolved with a low-fat diet; and clinically significant
atelectasis treated conservatively in two patients.
One patient had lumbar pain with a bone scan demonstrat-
ing increased uptake at the staplebone interface. Three weeks
after removal of the two distal staples, the patients pain was
relieved.3,4
CONCLUSION
The authors are very enthusiastic about stapling for idiopathic
scoliosis. The indications continue to evolve. Where previously we
considered this procedure to be an alternative to bracing, we now
better understand growth modulation and look for cases where
correction of undesired cosmetic trunk shapes may be realized.
We are still cautious in recommending the stapling procedure to

Changes in the Sagittal

Effect of First Erect TABLE 77.4 Profile Following Vertebral
TABLE 77.3 Radiograph on Results of Body Stapling
Thoracic Curves
Thoracic kyphosis 10 1040 40
First Erect
Radiograph Success Failure p-Value Preoperative (no. of 7 (26.9%) 19 (73%) 0
patients)
20 6 (85.7%) 1 (14.3%) .095 Recent (no. of 3 (12.5%) 20 (83.3%) 1 (4.2%)
20 10 (52.6%) 9 (47.4%) patients)

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approximately 10% to 20% of those who may be candidates. We
try to choose children who have a very high risk of progression,
have progressed despite bracing, or who are troubled by the self-
image implications of bracing. However, we are beginning to
offer stapling when we think that correction may be possible, as
we are gaining more confidence in the procedures ability to
obtain correction. Hopefully, genetic tests such as the ScoliScore
will help us better define the best candidates in the future.
ACKNOWLEDGMENTS
The authors acknowledge Robert Decker, MD, and Carolyn
Hendrix for their contributions to this chapter.
REFERENCES
1. Andersen MO, Andersen GR, Thomsen K, et al. Early weaning might reduce the psycho-
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