An “Old-Fashioned” Treatment Gains Modern Momentum: Serial Casting for Infantile Scoliosis

AP spine age  eight months

X-ray at eight months and 45 degree angle

Douglas Armstrong, M.D., Penn State Hershey Bone and Joint Institute, has taken a serious second look at serial casting for infantile scoliosis and found reason to pursue its use for his own patients. “Just ten years ago, the technique was largely rejected by U.S. physicians, who regarded it as ineffective. But patients with early onset scoliosis, meaning those who develop scoliosis before age five, face grim long-term outcomes if not treated.” Serial casting seemed to Armstrong a reasonable option.

“Many surgeons believe that infants with scoliosis onset don’t do well with brace treatment. Apart from casting, the only other option is surgical intervention,” explains Armstrong.

Inadequately corrected infantile scoliosis leads to chest wall deformities, poor lung development, and higher rate of early adulthood mortality; therefore, physicians have begun to use more aggressive treatment approaches. Typically, Armstrong and his Penn State Hershey colleagues may treat twelve or more cases of early onset scoliosis per year.

Age 14 months in second cast

Age fourteen months, 22 degree angle in second cast.

“For small curves, we may monitor to see whether the deformity resolves on its own. If the curve magnitude is larger or the rib-vertebral angle difference (RVAD) is greater than 20 degrees, we may need to intervene,” says Armstrong, who learned the casting technique from its modern-day proponent Min Mehta, M.D. Depending on the size and overall health of the child, Armstrong may consider serial casting beginning at nine to twelve months of age.

AP spine age 24-months

Age twenty-four months, out of cast for six months.

“With this technique, the casts are replaced every two to three months with the infant under anesthesia. Each cast progressively corrects the spinal curve; the goal is a curve less than 20 degrees,” explains Armstrong.

In Armstrong’s opinion, odds of success with casting are influenced by overall health and severity of the deformity. About half of children with the disorder present only with scoliosis and these cases tend to have the best outcomes; others have serious comorbid neuromuscular, spinal, or neurological disorders that impact treatment success.

“We regularly consult with pediatric neurosurgeons to help diagnose and treat common comorbid conditions like Chiari malformation. In these cases, we may do serial casting to help prevent scoliosis progression, in concert with neurosurgical intervention,” says Armstrong.

Usually, casting is applied for only eighteen months, but follow-up treatment is extensive, with braces applied for several years to maintain correction. Armstrong explains, “Now that serial casting is more widely accepted in the United States, the technique is evolving. While results may be highly variable, I believe it’s a useful tool that may help patients who might otherwise have a bleak outlook.”

Douglas Armstrong, M.D.Douglas G. Armstrong, M.D.

Edwards P. Schwentker Professor, Orthopaedics

Division chief, pediatric orthopaedics

Pediatric orthopaedic surgeon

Phone: 717-531-4826
Fellowship: Pediatric orthopaedics, Buffalo Children’s Hospital, Buffalo, New York
Fellowship: Spine surgery, University of Ottawa Civic Hospital, Ottawa, Ontario
Residency: Orthopaedic surgery, McGill University, Faculty of Medicine, Montreal, Quebec
Medical School: University of Ottawa Faculty of Medicine, Ottawa, Ontario


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