| Objective Early onset scoliosis and severe scoliosis are tough challenges to spine surgeons for a long period. Growth valve technique was reported to treat early onset scoliosis and distraction by multiple points and rods technique was also reported to treat severe scoliosis cases. The study is to evaluate the effectiveness and safety of posterior small incision technique in the treatment of early onset scoliosis and severe scoliosis by stages.Methods For the first part, retrospective control investigation of the clinical data and images of57early onset scoliosis patients who treated in our spinal center was held. The patients were divided into two groups by two different growing techniques. One is growth valve technique group and the other is small-incision technique group. For the growth valve group,18cases (range,5-11years; mean,8.2years; render,6males and12females) were included. The average preoperative major curve angle was92.0±16.4°(68～142°). The average preoperative kyphosis was40.8±5.2°(22～69°).All of them were treated with posterior growth valve technique using China Great Wall spinal instrumentation system after the spine was exposed in the concave side. The spine growing surgery was performed6～12months later. Final fusion surgery and thoracoplasty surgery was performed when the patient was12～14years old and skeletally Initial mature. For the small-incision group,39cases (range,6-12years; mean,8.1years; render,12males and27females) were included. The average preoperative major curve angle was92.0±15.4°(78～135°). The average preoperative kyphosis angle was38.8±14.7°(17～65°). All of them underwent small incision minimally invasive surgery by multiple stages. The first stage posterior surgery was performed by2small incisions and minimally invasive technique. The second stage surgery was performed6～12months later. Final fusion surgery and thoracoplasty surgery was performed when the patient was12～14years old and skeletally Initial mature. For the second study,32patients (range,13-26years; mean,16.8years; gender,9males23 females) with severe scoliosis were treated with posterior operation by two stages. The mean preoperative Cobb angle was129.4°(95°～175°). The posterior surgical procedures were performed by two stages. First stage surgery was performed with posterior small incision and less invasive technique. For the second stage, posterior correction with osteotomy, facet joints release, shave abnormality excision and fusion were performed surgery3～6months later. Pretreatment radiographs and radiographs taken after first surgery (internal distraction by two small incisions), before second surgery (posterior correction, instrumentation and fusion), one week after second surgery and final follow-up were measured. Subjects were analyzed by age, gender, major coronal curve magnitude, flexibility of major curve, major sagittal curve magnitude before first surgery, after first surgery, before second surgery, after second surgery and at final follow-up. Complications related to two-stage surgeries were noted in each case.Results For the first study, the mean follow time of the growth valve group was5years and2months.10patients finished the final fusion surgery,3cases spontaneous fusion.1case finished5times of growth surgery,3cases finished4times of growth surgery,7cases finished3times of growth surgery, and2cases finished2times of growth surgery.13cases broken rods,8cases screw loose,3cases skin infection. There were none server complications occurred. The curve correction was41.1°and26°were achieved after the first growing surgery. The mean correction was18°after that. The major curve was40.2±22.1°(31～64°) after the final fusion surgery and the mean overall correction rate was59.6%.For the small-incision group, the mean follow up time was2years and8months.12cases finished the final fusion surgery,11cases underwent2times of growth,16cases underwent growth surgery once. During the follow up, rod broken1case, internal fixation loose1case, spontaneous fusion1cases, skin infection1case and no severe complications was found. The major curve after the final fusion surgery was31.8±6.6°(27～48°) and the mean overall correction rate was65.4%. There are significant statistic differences between two groups. For the second study, The average major curve magnitude was129.4°(range,95°to175°), reduced58.9°or45.4%after first stage surgery and reduced30.6°or24.6%after second stage surgery. The lost of correction during the interval between two surgeries was7.1%. The total major coronal curve correction was81.4°or62.9%. Loss of correction averaged3.9°for major coronal curve and the final correction rate was averaged59.7%. The average major sagittal curve magnitude was80.3°(range,30°to170°), and the total major sagittal curve correction was48.2°. Loss of correction averaged4.0°or major sagittal curve and the final correction averaged42.2°.Conclusions small incision and minimally invasive surgery by stages in the treatment of early onset scoliosis was safe and the correction rate was improved compared with growth valve technique. This technique delayed the final fusion surgery and reduced the impact of early fusion of the spine and decreased surgery related complications in the skeletally immature EOS patients. Two-stage surgery for the treatment of severe scoliosis was a safe and effective surgical strategy in this difficult population. By using two-small-incision technique, the first stage surgery was less invasive and the final correction rate was high. No permanent neurologic deficit was noted in this series.
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