A case series in vertebral body tethering results in improvement in coronal Cobb angle but deterioration in axial rotation: a 3-dimensional analysis
Case Series

A case series in vertebral body tethering results in improvement in coronal Cobb angle but deterioration in axial rotation: a 3-dimensional analysis

Teenie Kwan Tung Wong1 ORCID logo, Kenny Yat Hong Kwan1 ORCID logo, Jason Pui Yin Cheung1 ORCID logo, Kenneth Man Chee Cheung1,2 ORCID logo

1Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, China; 2Department of Orthopaedics and Traumatology, The University of Hong Kong Shenzhen Hospital, Shenzhen, China

Contributions: (I) Conception and design: All authors; (II) Administrative support: KMC Cheung; (III) Provision of study materials or patients: KMC Cheung; (IV) Collection and assembly of data: TKT Wong; (V) Data analysis and interpretation: TKT Wong; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Professor Kenneth Man Chee Cheung, MBBS, MD. Department of Orthopaedics and Traumatology, The University of Hong Kong Shenzhen Hospital, No. 1, Haiyuan First Road, Futian District, Shenzhen 518053, China; Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, China. Email: cheungmc@hku.hk.

Background: Vertebral body tethering (VBT) has shown improvements in coronal and sagittal plane correction in adolescent idiopathic scoliosis (AIS) patients, but axial correction over time remains unexplored. Three-dimensional (3D) spine reconstruction was used to analyse correctional changes in all spinal planes post VBT surgery.

Case Description: AIS subjects who underwent thoracic VBT surgery with a minimum 2-year follow-up were assessed. Biplanar radiographs were used for 3D spinal reconstructions, 3D coronal, sagittal thoracic kyphosis (TK), lumbar lordosis (LL), and axial rotation measurements were compared at pre-operative (pre-op), immediate post-operative (post-op), 1-year, and 2-year follow-up. Eight patients (7 females, 1 male) with a mean age of 11.8±1.3 years with right thoracic curves (mean 50.4°±8.1°) were followed for 26.8±4.1 months. Mean coronal Cobb angle showed significant improvement: 28.4°, 19.2°, and 27.1° at post-op, 1-year, and 2-year follow-up (P<0.001). Minimal changes were seen in sagittal plane: TK—35.2°, 39.0°, 31.3°, 37.0°; LL—46.1°, 42.8°, 36.5°, 42.8° (pre-op, post-op, 1-year, 2-year) respectively. Apical axial rotation improved from −5.5°±5.0° to −1.4°±4.8° post-op, then deteriorated to −3.2°±4.9° at 1 year and −7.0°±5.9° at 2 years, with no significant changes.

Conclusions: This is the first case series to use 3D radiographic digital measurements to reveal apical axial rotation progression in thoracic curves despite improved coronal curvature. While larger scales studies with longer follow-up are needed to verify our findings, surgeons and patients should be aware of such findings in their decision to select VBT as their procedure of choice.

Keywords: Adolescent idiopathic scoliosis (AIS); vertebral body tethering (VBT); three-dimensional (3D); growth modulation; case series

Submitted May 09, 2024. Accepted for publication Sep 25, 2024. Published online Nov 13, 2024.

doi: 10.21037/jss-24-59

Highlight box

Key findings

• This is the first case series to reveal apical axial rotation progression despite coronal Cobb angle improvements post-vertebral body tethering (VBT) surgery.

• VBT does not control changes in axial rotation and coupling effect may not hold true.

What is known and what is new?

• VBT has shown improvements in coronal and sagittal plane correction in patients with adolescent idiopathic scoliosis, however axial rotation correction overtime remains unexplored.

• We observed that apical axial rotation deteriorates compared to pre-operatively at 2 years follow up, while coronal Cobb angle shows improvement overtime at 2 years follow up.

What is the implication, and what should change now?

• Surgeons and patients should be aware of such findings in their decision to select VBT as their procedure of choice.

Introduction

Adolescent idiopathic scoliosis (AIS) is a complex three-dimensional (3D) deformity of the spine (1-4) which are commonly detected by radiographs, characterized by the rotation of the apical vertebrae away from the midline (3D) pattern (5,6). Notably, imaging studies have revealed that the apical vertebrae in AIS curves exhibit the greatest degree of axial rotation (7,8).

Traditionally, posterior spinal fusion (PSF) surgery had been the treatment of choice for severe scoliosis. Vertebral body tethering (VBT) has a raising popularity as a non-fusion method of treatment (9). VBT utilizes the Hueter-Volkman phenomenon (10), limiting the growth of spine on one side, and allowing the curvature to progressively correct with growth. Previous studies have demonstrated that VBT can lead to significant improvements in the coronal Cobb angle, with correction rates ranging from 28.5% to 100.0% at the 2-year follow-up compared to pre-operative angles (11-25).

Furthermore, VBT has been shown to maintain thoracic kyphosis (TK) values within a stable range of 5.0° (15-17,19,21,24-27), and even normalised to 20°–40° (28) at the 2-year follow-up. Additionally, lumbar lordosis (LL) was found to be stable within 7° at 2 years follow-up (13,17,24,25,27). On the other hand, axial correction of the deformity has not been well studied. Some studies utilising scoliometers have suggested improvements at 2-year follow-up (13,27,29).

It is generally recognized that if spinal deformity is corrected in one plane, the other planes will also spontaneously correct (30). However, it is currently unclear whether coupling effects and 3D spinal corrections occur in VBT patients. The objective of this study was to evaluate 3D corrections following VBT surgery and investigate whether axial correction is coupled with the correction of coronal deformity. We present this case series in accordance with the AME Case Series reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-24-59/rc).

Case presentation

This is a retrospective analysis of prospectively collected data of eight AIS subjects with right sided thoracic scoliosis treated by VBT at the Department of Orthopaedics and Traumatology, the University of Hong Kong, between February 2019 and December 2020, reported as a case series. Inclusion criteria were initial curve magnitude larger than 40°, a Risser sign of ≤2 at VBT surgery and with a minimum 2 years of follow-up. Ten continuous subjects were retrieved and assessed for eligibility. Of them, 2 were excluded since they did not have complete set of biplanar images or had only lumbar scoliosis. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (approval number: 19-002) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients and their parents for the publication of this case series and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Measurements

For each subject, pre-operative standing anteroposterior (AP) and lateral (LAT) biplanar spine radiographs were taken using EOS® system (EOS® imaging, Paris, France) preoperatively (pre-op). Subsequent images were then taken at immediate post-operative (post-op) with first erect X-ray, at 1- and 2-year follow-up. Subject-specific 3D spinal reconstruction models were then created by blinded evaluator at each timepoint using sterEOS® software (EOS® Imaging, Paris, France). Coronal, sagittal, and axial rotation measurements including major curve Cobb angle, TK (vertebral levels T1–12), LL (vertebral levels L1–5) and axial rotation of curve apex were made from 3D reconstruction models. Data were then compared at each timepoints.

3D reconstruction

The 3D reconstruction model data were compared with measurements made on original 2D biplanar radiographs for each subject at every timepoint, and difference between 2D and 3D measurement outcomes was compared to published thresholds (31).

Tether breakage

Tether cord integrity were closely assessed at each follow-up and tether breakages were confirmed with computed tomography (CT) scan (32,33).

Statistical analysis

All statistical data analyses were performed using SPSS software (SPSS Inc., Chicago, Illinois, USA). A paired t-test were used to evaluate whether the corrections in coronal, sagittal and axial planes were significant compared to pre-operative angles (P value of 0.05). A Pearson’s correlation coefficient was conducted to analyse the relationship of each parameter at each timepoint (P value of 0.05).

Demographics

There were 7 females and 1 male subjects included in our series with a mean follow-up of 26.8±4.1 months (range, 24–36 months). The average age at VBT surgery performed was 11.8±1.3 years (range, 10.0–13.9 years). Four subjects had Risser 0, one Risser 1 and three Risser 3 at the time of surgery. Six subjects had Lenke type 1 with thoracic VBT and two subjects had Lenke type 3 with thoracic and lumbar VBT. Subjects underwent tethering of an average of 7.1±0.6 (range, 6–8) levels, with the most proximal being T5 and most distal L1 (Table 1).

Table 1

Summary of all subjects’ preoperative fulcrum bending angle, VBT tethered levels, preoperative Cobb angle, 2-year follow-up correction rate and tether breakage record

Subject Pre-op Cobb angle (°) Fulcrum bend (°) 2YFU correction rate (%) VBT tethered levels Tether breakage
1 44.0 16.5 86.1 T6–L1 Y
2 45.4 4.1 77.8 T7–L1 Y
3 49.8 17.9 1.0 T6–T12 N
4 41.3 16.8 26.4 T5–T12 Y
5 65.7 35.8 39.0 T6–T12 N
6 51.8 3.6 38.4 T5–T11 Y (15M)
7 46.9 14.1 63.3 T6–T12 Y
8 58.1 10.3 45.4 T6–T11 Y

Subject 3 and 5 did not have tether breakage. Subject 6 had tether breakage at 15 months while others were after 2 years. VBT, vertebral body tethering; Pre-op, preoperative; 2YFU, 2-year follow-up; Y, yes; N, no; 15M, 15 months.

Coronal and sagittal correction

Coronal and sagittal correction results are summarised in Table 2. There is an improvement in mean coronal angle correction from 50.4°±8.1° to 27.1°±14.9° in 2 years. TK and LL had remained stable at 2 years follow-up.

Table 2

Preoperative, immediate postoperative, 1 and 2 years follow-up comparison of spinal coronal, sagittal and axial parameters

VBT subjects Coronal Cobb angle Apical axial rotation TK LL
Pre-op 50.4° (8.1°) −5.5° (5.0°) 35.2° (10.1°) 46.1° (8.7°)
Immediate post-op 28.4° (10.0°) −1.4° (4.8°) 39.0° (8.5°) 42.8° (11.0°)
   Correction rate 43.7% 74.7% −10.7% 7.3%
   P 0.001* 0.071 0.037 0.062
1-year follow-up 19.2° (14.0°) −3.2° (4.9°) 31.3° (15.4°) 36.5° (15.3°)
   Correction rate 62% 42.4% 11.3% 20.9%
   P <0.001* 0.207 0.492 0.015
2-year follow-up 27.1° (14.9°) −7.0° (5.9°) 37.0° (14.5°) 42.8° (10.5°)
   Correction rate 46.2% −27.2% −4.9% 7.3%
   P 0.001* 0.275 0.325 0.18

The results are expressed as mean and standard deviation. Correction rate is relative to pre-operative angles. *, significant differences (P<0.05). VBT, vertebral body tethering; Pre-op, preoperative; Post-op, postoperative; TK, thoracic kyphosis; LL, lumbar lordosis.

Apical axial rotation

Axial rotation of the curve apex showed a mean deterioration from −5.5°±5.0° to −7.0°±5.9° over 2 years with results summarised in Table 2. Subject-specific axial rotation changes are shown in Figure 1. Subject 1, 2, and 5 showed improvements at 2 years follow-up, while subject 3, 4, 6, 7, and 8 showed deterioration at 2-year follow-up when compared to preoperative angles.

Figure 1 Axial rotation of the curve apex for vertebral body tethering subjects 1 to 8 over 2 years follow-up. Pre-op, preoperative; Post-op, immediate postoperative; 1YFU, 1 year follow-up; 2YFU, 2-year follow-up.

Correlation

Pearson correlation was performed to identify associations between all spinal planes after VBT surgery. Coronal Cobb angle correction was found to be significant negatively correlated to apical axial rotation correction at 2-year follow-up (Table 3).

Table 3

Correlation between coronal, axial and sagittal plane changes over 2 years of follow-up

VBT subjects Coronal Cobb angle Apical axial rotation TK LL
R Sig. R Sig. R Sig. R Sig.
Pre-op
   Coronal Cobb angle 1.000 – – – – – – –
   Apical axial rotation −0.310 0.455 1.000 – – – – –
   TK −0.330 0.425 −0.468 0.243 1.000 – – –
   LL 0.165 0.695 −0.735 0.038* 0.532 0.175 1.000 –
Post-op
   Coronal Cobb angle 1.000 – – – – – – –
   Apical axial rotation 0.209 0.619 1.000 – – – – –
   TK 0.768 0.026* 0.014 0.974 1.000 – – –
   LL 0.489 0.219 0.140 0.741 0.322 0.437 1.000 –
1-year follow-up
   Coronal Cobb angle 1.000 – – – – – – –
   Apical axial rotation 0.120 0.776 1.000 – – – – –
   TK 0.739 0.036* −0.216 0.608 1.000 – – –
   LL 0.339 0.411 −0.011 0.979 0.509 0.197 1.000 –
2-year follow-up
   Coronal Cobb angle 1.000 – – – – – – –
   Apical axial rotation −0.776 0.024* 1.000 – – – – –
   TK 0.257 0.539 −0.705 0.051 1.000 – – –
   LL −0.143 0.735 −0.385 0.347 0.868 0.005** 1.000 –

*, significant (P<0.05); **, significant (P<0.01). VBT, vertebral body tethering; Pre-op, preoperative; Post-op, postoperative; TK, thoracic kyphosis; LL, lumbar lordosis; R, Pearson correlation coefficient; Sig., significance.

Tether breakage

Six out of 8 subjects had radiological tether breakage, all were clinically asymptomatic and not affecting daily activities or regular sports. Five of the tether breakages were after 2-year follow-up, 1 was at 15 months follow-up. The mean Cobb angle correction rate was 56.2% compared to preoperative angle. Four of the tether breakage subjects had mild apical axial deterioration ranging from 1.1°−5.4° (Table 1, Figure 1). Two remaining subjects had no tether breakage (Table 1). Notably, subject 3 with no tether breakage had the least correction rate in Cobb angle and greatest progression in apical axial rotation at 2-year follow-up compared to pre-op (Table 1, Figure 1).

Discussion

This study is the first to describe the progression of apical axial rotation in VBT subjects. At the 2-year follow-up, five out of eight subjects showed worsened axial rotation despite coronal correction, with subject 3 experiencing the greatest deterioration (as shown in Figure 1) and subject 6 with the least apical axial rotational changes (Figure 2). Notably, subject 3 (Figure 3), who had undergone the greatest apical axial rotational correction preoperatively, had a deterioration from −6.3° to −19.8°, while subject 1 (Figure 4) experienced an improvement from −11.6° to −3.4°. However, changes in axial rotation over time were highly variable between each subject and were not significant.

Figure 2 Radiographs of subject 6 with the least apical axial rotational change at 2-year follow-up. Subject had a right thoracic main curve, Lenke 1, Risser 0 at vertebral body tethering surgery and tethered levels at T5 to T11. Apical axial rotation deteriorated from preoperative −9.9° to −11.0° at 2-year follow-up. Coronal Cobb angle improved from 51.8° to 31.9° at 2-year follow-up.
Figure 3 Radiographs of subject 3 with the greatest apical axial rotational change at 2-year follow-up. Subject had a right thoracic main curve, Lenke 1, Risser 2 at vertebral body tethering surgery and tethered levels at T6 to T12. Apical axial rotation deteriorated from preoperative −6.3° to −19.8° at 2-year follow-up. Coronal Cobb angle changed from 49.8° to 49.3° at 2-year follow-up, no improvement in Cobb angle.
Figure 4 Radiographs of subject 1 with the most improvement in apical rotational change at 2-year follow-up. Subject had a right thoracic main curve, Lenke 1, Risser 0 at vertebral body tethering surgery and tethered levels at T6 to L1. Apical axial rotation improved from preoperative −11.6° to −3.4° at 2-year follow-up. Coronal Cobb angle improved from 44.0° to 6.1° at 2-year follow-up.

Previous PSF studies typically show improved apical axial rotation with sustained Cobb angle after surgery (34,35). One study interestingly highlighted derotation of 2.7° at 2-year follow-up, overlooking a significant 10° axial correction compared to preoperative angles in their PSF cohort (36). In contrast, our VBT subjects experienced apical derotation at 2-year follow-up compared to preoperative angles, despite significant corrections in the coronal Cobb angle over time. Furthermore, we found a significant negative correlation between the apical axial rotation and the coronal Cobb angle correction at the 2-year follow-up. Our result suggests that the coupling effect, where the correction of one spinal plane results in the spontaneous correction of other spinal planes, may not hold true in VBT subjects, despite previous findings in PSF (30). This underscores that VBT may not necessarily correct axial rotation to the same extent as coronal plane deformities, emphasizing the importance of assessing both spinal planes when evaluating treatment outcomes.

Regarding VBT tether breakage, a study suggested that breakage within the first year always leads to a loss of Cobb angle correction, while clinical impact is limited if breakage occurs after 1 year (32). Our study echoes; all breakages were asymptomatic, with Cobb angles remaining corrected by mean of 56.2% at 2-year follow-up. Notably, subject 3, without tether breakage, exhibited the most derotated apex compared to the preoperative angle, suggesting that axial rotation in VBT may be influenced by various factors. Unfortunately, the small number of subjects included in this study limits further analysis to identify factors contributing to axial plane corrections. These observations highlight the need for further comprehensive investigations to enhance the understanding of correction in AIS when VBT is the treatment of choice.

Previous studies have utilized scoliometer measurements to evaluate rib cage rotation post-VBT and have revealed improvements of up to 8° at the 2-year follow-up (13,27,29). However, it should be noted that the rib cage and spine do not rotate in the same way. In this study, 3D measurements of apical axial rotation were used to provide a more definitive and objective way of measuring changes at the vertebral level in VBT over time. This approach allows for a better understanding of the impact of VBT on spinal rotation and provides a more accurate assessment of treatment outcomes.

Consistent with earlier studies (11-25), we found that the correction of the coronal Cobb angle at the 2-year follow-up was consistent, and the sagittal parameters exhibited great stability. Specifically, the parameters for TK (15-17,19,21,24-27) and LL (13,17,24,25,27) only deviated by 5° and 7°, respectively, from established data, and by 2° and 4° from our study. Additionally, TK had normalized at the 2-year follow-up (27). The congruence of the coronal and sagittal parameters with established data strongly suggests that the axial plane measurements conform to acceptable standards, supporting the proposed association under investigation in this study.

Using 3D analysis of the spine after VBT allowed us to measure axial rotation in each vertebra, providing data that cannot be seen on daily biplanar radiographs. However, the small sample size and retrospective aspect of this study limit its generalizability. Further studies with larger cohorts and longer follow-up periods are necessary to better understand the effects of VBT on axial rotation.

Conclusions

In summary, this is the first study to show that apical axial rotation deteriorates in VBT subjects compared to pre-op at 2-year follow-up, while coronal Cobb angle shows improvement overtime at 2-year follow-up. The progression of apical axial rotation has revealed that VBT may not necessarily correct axial rotation to the same extent as coronal plane deformities and coupling effect may not hold true. While scoliometer measurements have been used in previous studies to assess rib cage rotation post-VBT, 3D measurements of apical axial rotation provide a more definitive and objective way of measuring changes at the vertebral level and offer a more accurate assessment of treatment outcomes. The present investigation has also found that the correction of the coronal Cobb angle at the 2-year follow-up is consistent with earlier studies, and the sagittal parameters exhibit remarkable stability. Tether breakage in VBT subjects was asymptomatic and not necessarily related to deteriorations in spinal parameters. However, the study is limited by its small sample size and retrospective nature. Further studies with larger cohorts and longer follow-up periods are needed to better understand the effects of VBT on axial rotation. Overall, this study highlights the importance of considering both spinal planes when assessing treatment outcomes in VBT subjects. Both surgeons and patients should be aware of such findings prior to selecting VBT as their treatment choice.

Acknowledgments

The authors would like to thank Ms. Lai Suet Wong for her kind assistance in digital measurements.

Funding: The research was supported by Shenzhen Fundamental Research Program, China (No. JCYJ20200109150425085); Shenzhen Key Medical Discipline Construction Fund (No. SZXK2020084); Sanming Project of Medicine in Shenzhen, China (No. SZSM202211004) and HMRF (No. 07182466).

Footnote

Reporting Checklist: The authors have completed the AME Case Series reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-24-59/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-24-59/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-24-59/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee of the University of Hong Kong / Hospital Authority Hong Kong West Cluster (approval number: 19-002) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients and their parents for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Wong TKT, Kwan KYH, Cheung JPY, Cheung KMC. A case series in vertebral body tethering results in improvement in coronal Cobb angle but deterioration in axial rotation: a 3-dimensional analysis. J Spine Surg 2024;10(4):687-696. doi: 10.21037/jss-24-59

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