Analysis of Percentile Weight Changes in Failure To Thrive Children undergoing Growing Rod Insertion. ICEOS 2012 Walsh A, Lui DF, Kelly M, O'Neill F, McDevitt F, Harrington M, Noel J, Kiely PJ Our Lady’s Children’s Hospital Crumlin, Dublin, Ireland

Introduction Traditionally classified by subtype: Neuromuscular Congenital Idiopathic Early Onset Scoliosis Dickson et al 0-5y Heterogenous group Early Onset Scoliosis can be challenging. It can have a variety of aetiology including neuromuscular disorders, Congenital Hemivertebrae and idiopathic These children characteristically have poor nutritional status and many lie below the 5th percentile for weight: Commonly reffered to as Failure to thrive

Issues in Early Onset Scoliosis Thoracic Insufficiency Syndrome Coined by Campbell et al Pulmonary Function continues to develop until the age of 8y Role of chest wall and spine are combined in development of child Failure to thrive Poor nutritional status due to an increased energy expenditure <5th Weight Percentile Characteristically poor nutritional status¹ 1 DL Skaggs, WN Sankar,J Albrektson, TAL.Wren,RM. Campbell, Weight Gain Following Vertical Expandable Prosthetic Titanium Ribs Surgery in Children With Thoracic Insufficiency Syndrome SPINE Volume 34, Number 23, pp 2530–2533

Objectives of Treatment First Line Treatment: Body Cast and Bracing Surgical: Early Fusion vs Growing Rods? Modern techniques aim to stabilise spine without hindering growth Growing Rods Spinal Rods (multiple types) Vertical Expandible Prosthetic Titanium Rib (VEPTR) Aim to reach maturity and plan elective Spinal Fusion

Objective of study To Evaluate the percentile weight changes of patients pre and post insertion of the growing spinal instrumentation Focus on Children with Failure To Thrive (<5th Percentile)

Methods Retrospective chart review 2007-2012 51 Patients Pre- and post- operative percentile weights were calculated: Online paediatric centile calculator Centers for Disease Control and Prevention: BMI Percentile Calculator for Child and Teen English Version. BMI Percentile Calculator for Child and Teen English Version]. Available from: http://apps.nccd.cdc.gov/dnpabmi/. Weight of instrumentation was subtracted from weight gain observed (Average Equipment Weight – 0.1kg) Cobb Angles Operative morbidity Statistical Analysis by SPS 16.0 (IBM)

Results 21 male; 30 female Avg Age 8.62 (Range= 3-15) 84% Complete data (43 of 51) Average follow up was 19 months (range 6-48 months) Age Range: Adolescents – PH: 15yrs at insertion, Comorbidities – Horseshoe Kidney and hydronephrosis, Previous Acute Renal Failure and Von Williebrand Disease - SLN: 14yrs at insertion, Comorbidities – Factor 12 Deficiency. Dropped from 68th Centile to the 51st - AMcN: 15 yrs at insertion, Comorbidities – Spinal Muscular Atrophy, Dropped from the 31st Centile to the 3rd

Aetiology Number Of Children Diagnosis EOS 23, , NM 14, Congenital 13, Atypical 1 Diagnosis

Instrumentation Number Of Children

Cobb Angle P < 0.01 Cobb Angle 66 to 41 Cobb Preop Cobb Postop

Centile Weight Change Box plot Weight Centile 25 to 35 Weight %ile Preop Weight %ile Postop

Subgroup: Failure To Thrive 13 patients < 5th Percentile Weight Status (Units) Percentile: 3.2 to 7.2 (Range 3-20) 18.4kg to 24 kg 4 of 13 improved; The rest stayed on same centile P<0.01 P=0.05

Complications of Growing Rod Insertion

Case EM Spina Bifida

Case : Growing Rods PREOP Sitting Prone

Case : Growing rods PREOP

Growing Rods: VEPTR POSTOP

Discussion How can we measure post operative outcome? Percentile Weight gain reflects a positive outcome after spinal growing rod insertion In patients with TIS may reflect decreased energy expenditure assoc with cardiopulmonary function Limitations: Failure to thrive (<5th Percentile) may not achieve a major percentile advancement The presence of those 13 children who lay on or below the 5th centile skews our data as any weight gain which they may have experienced would not have registered in the centile chart

Conclusion Early Onset Scoliosis continues to pose significant surgical challenges Growing Rods allow continued development without fusion Significant Cobb Angle Improvement Significant Mean increase in Percentile Weight and Actual weight Significant Improvement from FTT