Focus. N. Kabirian, B.A. Akbarnia * ORIGINAL ARTICLE Update on spine based surgical treatment of early onset scoliosis: what do we know in 2012?

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1 50 Evolution in diagnosis and treatment of scoliosis ORIGINAL ARTICLE Update on spine based surgical treatment of early onset scoliosis: what do we know in 2012? N. Kabirian, B.A. Akbarnia * San Diego Center for Spinal Disorders, La Jolla (CA), USA * Corresponding author: akbarnia@ucsd.edu Abstract: Background. Progressive Early-Onset Scoliosis (EOS) is one of the most challenging problems in pediatric orthopaedics. Extensive research efforts are underway to understand different aspects of natural history, diagnostic measures and treatment options. Objective. Update on spine-based surgical techniques for treatment of progressive EOS. Methods. Review of the literature and experts opinions. Results. Our first report of dual growing rod technique in 2005 showed good scoliosis correction at final follow-up and annual T1-S1 growth of 12.1 mm after the initial correction. Since then, dual growing rod technique has been used in EOS in many different etiologies and has shown the efficacy to correct scoliosis and allow for spinal growth. Complication rate has always been a concern, as the patient has to undergo repeated surgeries for lengthening. Using submuscular, dual GR rods vs subcutaneous single GR rod technique will decrease the complication rate. Younger age at initial surgery and abnormal sagittal alignment (especially thoracic hyper- or hypokyphosis) have also shown to be associated with higher complication rate. A new technology, Magnetically Controlled Growing Rod (MGCR), has been shown safe and effective in both pilot animal and human studies. Growth-guided techniques also aim to alleviate the need for surgical lengthening while it directs the spinal growth. Conclusions. Treatment of Early-Onset Scoliosis (EOS) is a long commitment for the patient and the treating surgeon. Different techniques are available, each with unique capabilities and potential drawbacks but all with the goal of correcting the deformity and allowing for growth of spine and lungs and eventually improve the quality of life of these children. Keywords: Early-Onset Scoliosis (EOS), growing rods, Magnetically Controlled Growing Rods (MCGR), growth guided technique, Shilla I - INTRODUCTION The differentiation between Early-Onset and Late-Onset Scoliosis (EOS) was first made by Ponseti and Friedman [1] and reemphasized later by Dickson [2] as the scoliosis identified before the age of 5, corresponding with the spinal growth pattern described earlier by Dimeglio and Bonnel [3]. The management of EOS patients is a long and multidisciplinary process and the longer the course of the treatment is, the higher the rate of complications would be. The primary goals of any treatment in EOS are to control the progression of the deformity and allow for spinal growth until the skeletal maturity, and also to increase the capacity of the thorax to allow for growth of the lungs. Non-operative treatment in carefully selected EOS patients has shown to delay the need for surgical intervention, help the child gaining more physiologic reserve and experience less complication in the course of surgical treatment [4, 5]. Brace, if it is worn timely, can sometimes be quite effective as the sole treatment in some cases of early onset scoliosis, especially in curves less than 50 degrees. The ideal child for this method of treatment is idiopathic, young (less than five years) in a good family setting. Compliance and regular follow-up are another keys for success. A lack of compliance and follow-up, unfortunately, all too often impact the ultimate outcome in these situations. Syndromic and neuromuscular children; however, have fared less well with bracing and casting. There are other important goals that have to be considered carefully in the treatment of these patients. Improvement of the patient s sagittal and coronal balance, minimizing the psychosocial burden of the disorder and its long-term treatment on patients and their families are also of significant importance. Surgical treatment is indicated when non-operative methods fail or are not realistic. However, deterioration of pulmonary function is the most important surgical indication and often requires aggressive treatment. The key in successful surgical management of EOS is in a meticulous preoperative planning. Patient s nutritional status, cardio-pulmonary reserve and soft tissue coverage of the implants should be also critically examined. Historically an early spine fusion was the only surgical technique available when the curves could not be controlled and managed non-operatively. The negative consequences of early fusion on pulmonary and thoracic development [6] have been a strong motivating factor in the development of growth friendly surgical techniques aimed at reducing morbidity and mortality. Skaggs classified growth friendly techniques for the treatment of EOS into three categories of distraction-based, compression-based and guided growth procedures.[7] The common procedures in the first group are growing rods and VEPTR. Compression (tethered) Vol N quarterly june ArgoSpine NEWS&JOURNAL - Argospine and Springer-Verlag France DOI /s

2 Evolution in diagnosis and treatment of scoliosis 51 based techniques are used less commonly in EOS population, therefore are not discussed in this paper. Guided growth techniques include the classic Luque-Trolley as well as the more recently described Shilla growth guidance system. II - TECHNIQUE OF DUAL GROWING RODS FOR EOS Dual growing rod is a distraction-based implant technique that expands from the upper to the lower foundation. Foundation levels are the only segments to be fused, with no further fusion between foundations. The current technique includes using 2 sets of laminar hooks (two downgoing, two upgoing in a claw form) or 4 pedicle screws for upper foundation and most commonly four pedicle screws for the lower foundation [8] (Fig. 1). Dual growing rod technique has several technical pearls. Solid fusions at both upper and lower foundations are important to provide stability and to accept the loads of the distractive forces on both ends. Our data strongly supports using dual rods vs. single rod and submuscular vs. subcutaneous implantation to reduce the implant related complications. Growing rods usually span from upper thoracic spine (T2-T3) to upper lumbar spine (L2-L3). Attention to sagittal alignment of the spine is very important in appropriate contouring of the rods. Tandem connectors should be placed at thoracolumbar junction and should include enough length of the rods inside the connector for future lengthenings. Despite a wide variation in opinions, Yang et al. [9] showed some general consensus among surgeons in treatment of EOS with GR technique including curve size, diagnosis, age, lengthening intervals and final fusion methods. Mean curve size and lengthening interval were greater in practice than in surgeons opinions. In practice, most growing rods are used for curves over 60 degrees in patients under age 10, in all diagnoses. Most surgeons surgically distract the spine every 6-9 months. Spinal distractions are more effective in early lengthenings and gradually slow down. Sankar and Skaggs reviewed 38 patients from 5 centers who had at least 3 lengthenings and a minimum of 2 years follow-up and found that T1-S1 gain decreased significantly with repeated lengthening over time (law of diminishing return) [10]. Neuromonitoring is commonly used for all index and lengthening GR procedures despite the study by Sankar et al. [11] which showed a very low incidence of iatrogenic neurological deficit during these procedures. They did not feel that it was necessary in routine lengthening surgery in patients who did not have history of previous neurological deficit. III - RESULTS AND OUTCOMES The early experience with a large series of single growing rod procedures from Minnesota was reported by Klemme et al. in The average initial curve corrected from 67 to 47 at final definitive fusion. Growth across the nonfused spinal segments averaged 1 cm per year [12]. Akbarnia et al. in 2005, reported the 2-year follow-up results of dual growing rod surgery. There was an average of 6.6 lengthenings per patient with an interval of 7.4 months. Scoliosis improved from 82 to 38 after initial surgery and was 36 at last follow-up. T1-S1 length increased 1.21 cm per year (growth) after initial correction (Fig. 2). The space available for lung ratio in thoracic curves improved from 0.87 to 1.0. Complication rates were reported as 48% [8]. In another report in 2008, they recognized the value of more frequent lengthening, which resulted in average growth of 1.46 cm per year. Those children with more frequent lengthening ( 6 months), had a statistical improvement in growth rate (1.8 cm versus 1 cm per year) and Cobb correction (79% vs. 48%) [13]. The results of growing rod treatment in different etiologies have also been studied in patients with congenital, neuromuscular and syndromic origin [14, 15-17]. Dual growing rods have been used in management of different types of EOS. It appears that the outcomes of EOS treatment may not be the same in different etiologies. Akbarnia et al. [18] reviewed 133 patients younger than 10 with curves over 40 degrees who had no previous surgery and had 2 years of followup. The idiopathic EOS had maximal scoliosis correction and minimal correction loss. The idiopathic EOS also had greatest growth per year. Congenital EOS group had the least correction and the greatest loss of correction. It also had the least distraction after the initial growing rod surgery. a b c d e f Figure 1: a-b) Preoperative Antero-Posterior (AP) and Lateral (Lat.) radiographs of a 4.5-year-old girl with progressive Early-Onset Scoliosis; c-d) AP and Lat. radiographs of the patient after initial dual growing rods surgery. Hooks are used at the upper foundation; e-f) AP and Lat. radiographs of the patient at the latest follow-up undergone 6 successful lengthenings with maintenance of the curve and gradual growth of the spine. Upper foundation is revised and pedicle screws used as anchors. Argospine and Springer-Verlag France DOI /s ArgoSpine NEWS&JOURNAL - quarterly june Vol N 1-2

3 52 Evolution in diagnosis and treatment of scoliosis a b Pre Index Post Index Post L1 Post L2 Post L3 Post L4 Post L5 Post L6 Cobb T1-S1 T1-T12 (31 to 11 ). The average T1-S1 height that was achieved was 8.7 cm. They compared the results of the SMA group with a group of 80 IIS/JIS and found no difference in the complication rate. Sponseller et al. [20] have examined the result of GR in Marfan syndrome. Ten patients with Marfan syndrome and EOS diagnosed under the age of 3 underwent GR treatment (3 single GR, 7 dual GR). The average scoliosis correction was 51% (31% for single, and 60% for dual) and overall average height, which obtained was 115 mm over the average follow-up of 87 months. The authors found an increased risk of cerebrospinal fluid leak and they also suggested of extension of instrumentation into the pelvis in patients with significant thoracolumbar/lumbar kyphosis. Scoliosis Research Society outcome questionnaire is not applicable to EOS patients because of the inability of the young children to read and complete it. An objectively assessed, new outcome questionnaire for EOS (EOSQ) has been recently designed and validated by Vitale et al. The authors found this tool as a practical way to assess the QOL of the EOS patients who underwent surgical treatment [21] Pre Index Post Index Post L1 Post L2 Post L3 Post L4 Post L5 Post L6 Figure 2: a) Examples of correction and maintenance of the main coronal Cobb angle and b) spinal growth (T1-T12, T1-S1) are shown over the course of treatment. El Sebaie et al. [19] retrospectively reviewed the results of 19 patients with congenital scoliosis who underwent GR surgery at a mean age of 6.9 years. Scoliosis improved from 66 to 47 while T1-S1 length increased from a mean of mm to mm, showing an annual growth rate of 11.7 mm. Their space available for the lung ratio also improved from 0.81 to 0.94 at last follow-up. Compared to idiopathic EOS, increased length of the T1-S1 and scoliosis correction were smaller; however, this study showed the safety and efficacy of the GR in a small number of patients with congenital scoliosis. Growing rods also have been studied in neuromuscular and syndromic EOS. McElroy and Sponseller et al. [17] reviewed the results of 26 patients (17 female, 9 male) with CP who underwent GR surgery at a mean age of 7.6 years. Primary Cobb angle was 86 preoperatively, 40 after initial surgery, and 52 at latest follow-up, yielding a correction of 39%. From preinitial to latest follow-up, T1-S1 length increased 76 mm. Patients had 4.4 ± 3.1 lengthenings at an interval of 10.3 months. Complications from a total of 137 operations included deep wound infection (7), superficial wound infection (2), rod fracture (5), anchor dislodgement (2), and wound dehiscence (2). McElroy and Sponseller [16] in another study reviewed the results of GR surgery in 15 Spinal Muscular Atrophy (SMA) patients with EOS and found that the GR surgery was effective in control of coronal deformity (89 to 50 ) and pelvic obliquity IV - COMPLICATIONS Complications in the course of surgical treatment of EOS patients are very common mainly due to associated comorbidities and repeated surgical distractions of the GR. In our original study [8] of the dual growing rod technique 11 of 23 patients (48%) had 13 complications throughout the treatment process. All the unplanned surgeries were for the treatment of infection but all implant-related complications were addressed at the time of planned lengthening. The study by Bess et al. [22] has the largest cohort of EOS patients reviewed for complications. Of 140 EOS patients, there were 177 complications in 81 patients (58%) with an average of 2.2 (1-7) complications. The complication rate per surgical procedure was 20%. One hundred and three (58%) of the 177 complications were managed with planned procedures or did not require additional surgical intervention. The remaining 74 a b c Figure 3: a) Preoperative and b) Postoperative AP radiographs of an EOS patient treated with guided growth (Shilla) technique; c) AP radiograph of the patient 6 years after initial surgery. (Courtesy of Richard E. McCarthy, MD, Department of Orthopaedic Surgery, University of Arkansas, USA, with permission). Vol N quarterly june ArgoSpine NEWS&JOURNAL - Argospine and Springer-Verlag France DOI /s

4 Evolution in diagnosis and treatment of scoliosis 53 complications (42%) required treatment with an unplanned procedure. Yang and Sponseller studied the incidence of rod fractures [23]. In a study of 327 GR patients, they found 49 patients (17%) who had a total number of 86 rod fractures, one of the most common side effects of the GR treatment. Patients with syndromic diagnoses had the highest rod breakage; significantly greater than neuromuscular patients. The risk factors for rod breakage were single GR, shorter tandem connector, smaller diameter rod, stainless steel rod, history of previous rod fracture and ambulatory vs. non-ambulatory patient. Neither the size of preoperative scoliosis nor kyphosis was a risk factor for fracture. Length of instrumentation, anchor type, and pelvic fixation had no significant effect on fracture rates. Schroerlucke et al. [24] showed that the complication rate in EOS patient with abnormal thoracic kyphosis who underwent GR treatment is higher compared to those with normal thoracic kyphosis. Attention has also been placed on the incidence and importance of Proximal Junctional Kyphosis in EOS. Skaggs et al. [25] found that 18 (56%) out of 34 consecutive patients had PJK after GR treatment. Forty-four percent with PJK had upper anchor failure, with 7 requiring unplanned operations to revise the failed implants. In comparison, 36% of patients without PJK had upper anchor failure, which was not statistically significant (p=0.89). PJK was more common in patients with dual rods (62%) than single rods (38%) (p=0.36), and in spine-to-spine constructs (59%) compared to hybrid constructs (upper hooks on ribs) (42%) (p=0.59). El-Hawary [26] showed that higher rates of PJK were found for older children who were hyperkyphotic pre-operatively and in those who had positive post-operative sagittal balance. With a minimum two-year follow-up, 11 (27.5%) out of 40 patients developed PJK. The rates of PJK were similar between rib-based and spine-based growing distraction systems. V - FUTURE OF GROWTH-SPARING TECHNIQUES: LESS INVASIVE GROWTH MODULATION Animal studies have confirmed the neurotoxic effects of general anesthetics on developing brain during the fastest period of brain development (early childhood) and synaptogenesis including neuronal death in susceptible areas. Whether these preclinical studies exactly mirror the changes in human brain or not is not clear; however, there is some evidence that this damage is worst when exposure has been under the age of 3 years [27]. Cumulative radiation dose that each patient might be exposed to through the treatment process has also become a matter of concern. Mundis et al. [28] in a study of 24 EOS cases showed that the average ionizing radiation (IR) exposure per surgical event was 3.4 times the average annual ionizing radiation from background radiation. Average ionizing radiation exposure per year of treatment was also 2.4 times the average annual ionizing radiation from background radiation. The study showed younger patients and those undergoing revision surgery were exposed to significantly higher IR doses. Also, etiology seemed to play a role in IR exposure as the congenital patients had highest total IR from initial surgery to 1 year after surgery. Song et al. [29] also showed that average background radiation exposure is estimated to be 5 msv/year. The mean exposure for their patients (75 patients with chest wall deformity) was markedly elevated at 34 msv prior to any surgery and 10 msv/year with an average of 2 surgeries/year. Fluoroscopy and CT scans account for 85% of radiation exposure in this cohort of patients. A new technology has led to production of an ultrafast, low radiation emission facility called EOS [30]. A Magnetically-Controlled Growing Rod (MCGR) has been recently developed and both preclinical and pilot clinical phases have shown its promising effectiveness and safety in animal and human cohorts, respectively. Akbarnia et al. [31] in a prospective randomized trial showed that MCGR provided an 80% of predicted spinal height by noninvasive remote distraction in a cohort of 9 immature (7-monthold) pigs. No MCGR-related complications occurred. Akbarnia et al. [32] also assessed the safety and efficacy of a Magnetically-Controlled Growing Rod (MCGR) in 14 patients with the mean age of 8 years+10 months who were implanted with either single MCGR (5 patients) or dual MCGR (9 patients). The scoliosis was corrected from 60 to 34 and maintained at 31 at final fusion. The authors found that T1-T12 height had a monthly growth of 1.09 mm (Single MCGR) and 1.97 mm (Dual MCGR) and T1-S1 had a monthly growth of 1.27 mm (Single MCGR) and 3.09 mm (Dual MCGR). The authors believed that their preliminary results showed that MCGR was safe and provided a comparable distraction to growing rod without having major complications and the need for repeated surgical lengthenings. VI - GROWTH GUIDED TECHNIQUE The main concept behind the Growth-Guidance systems is to control the curve while allowing the spine to grow at a normal rate. The Luque-Trolley system [33] has been available for a number of years but most authors have found the results to be unpredictable and hypertrophic bone formation often develops in the course of treatment, growing over the implants and inadvertently imposes a restrictive force to stymie growth. The Shilla technique introduced by McCarthy [34] is mainly intended for single curves and only fuses the apical motion segments in order to achieve the main correction at the apex. The anchors used to hold the implants are varied and can consist of wires, tapes, or screws, which attach to rods loosely and guide the future growth. There is no distraction and technically no stimulation of the growth. The screws are placed through the muscle layers without violating the periosteum, to minimize the rate of autofusion. The limitation of the system is to rely upon the growth of the vertebrae and there is no study comparing the growth rate vs. the distraction-based techniques. However the technique reduces the need for multiple lengthening surgeries. Longer-term results need to confirm these initial findings. No funds were received in support of this manuscript. Argospine and Springer-Verlag France DOI /s ArgoSpine NEWS&JOURNAL - quarterly june Vol N 1-2

5 54 Evolution in diagnosis and treatment of scoliosis /+/ References. a Ponseti IV,, Friedman B (1950) Prognosis in idiopathic scoliosis. J Bone Joint Surg Am 32A(2): z Dickson RA (1994) Early-Onset Idiopathic Scoliosis. In: Weinstein S (ed), The Pediatric Spine: Principles and Practice. Raven Press, New York, pp e Dimeglio A, Bonnel F (1990) Le rachis en croissance, Springer- Verlag, Paris, pp r Sanders J, D Astous J, Fitzgerald, et al. (2009) Derotation Casting For Progressive Infantile Scoliosis. J Child Orthop 3: t Sanders JO, D Astous J, Fitzgerald, et al. (2009) Derotational casting for progressive infantile scoliosis. J Pediatr Orthop 29(6): y Karol LA, Johnston C, Mladenov et al. (2008) Pulmonary Function Following Early Thoracic Fusion in Non-Neuromuscular Scoliosis. J Bone Joint Surg Am, 90(6): u Skaggs D., et al. Classification of treatment of early-onset scoliosis. Presented at 2nd International Congress of Early Onset Scoliosis and Growing Spine, Montreal, Quebec, Canada, November 7-8, 2008, i Akbarnia BA, Marks DS, Boachie-Adjei, O et al. (2005) Dual growing rod technique for the treatment of progressive early-onset scoliosis: a multicenter study. Spine 30 (17 Suppl): S o Yang JS, McElroy MJ, Akbarnia BA et al. (2010) Growing rods for spinal deformity: characterizing consensus and variation in current use. J Pediatr Orthop 30(3): p Sankar WN, Skaggs DL Yazici M et al. (2011) Lengthening of dual growing rods and the law of diminishing returns. Spine (Phila Pa 1976) 36(10): q Sankar WN, Skaggs DL, Emans JB et al. (2009) Neurologic risk in growing rod spine surgery in early onset scoliosis: is neuromonitoring necessary for all cases? Spine (Phila Pa 1976) 34(18): s Klemme WR, Denis F, Winter RB, et al. (1997) Spinal instrumentation without fusion for progressive scoliosis in young children. J Pediatr Orthop 17(6): d Akbarnia BA, Breakwell LM, Marks DS, et al. (2008) Dual Growing Rod Technique Followed for Three to Eleven Years Until Final Fusion; The Effect of Frequency of Lengthening. Spine33(9): f Elsebaie H, Yazici M, Thompson GH, et al. (2009) Growing Spine Study Group, Safety and Efficacy of Growing Rods for Pediatric Congenital Spinal Deformities. J Child Orthop 3: g Demetracopoulos C, Sponseller P (2007) Spinal deformities in Marfan syndrome. Orthop Clin North Am38(4): h McElroy MJ, Shaner AC, Crawford TO, et al. (2011) Growing rods for scoliosis in spinal muscular atrophy: structural effects, complications, and hospital stays. Spine (Phila Pa 1976) 36(16): j McElroy MJ, Sponseller PD, Dattilo JR et al. Growing rods for the treatment of scoliosis in Cerebral Palsy: A critical assessment. Free paper presented at the 5th International Congress on Early Onset Scoliosis and Growing Spine (ICEOS), Orlando (USA), k Akbarnia BA, et al. Outcomes of growing rod technique in Early-Onset Scoliosis: Does the etiology matter? Presented at SRS annual meeting 2010, Kyoto, Japan, l Elsebai HB, Yazici M, Thompson GH, et al. (2011) Safety and efficacy of growing rod technique for pediatric congenital spinal deformities. J Pediatr Orthop 31(1): 1-5. m Sponseller PD, Thompson GH, Akbarnia BA, et al. (2009) Growing rods for infantile scoliosis in Marfan syndrome. Spine (Phila Pa 1976) 34(16): ù Corona J, Matsumoto H, Roye DP, Vitale MG (2011) Measuring quality of life in children with early onset scoliosis: development and initial validation of the early onset scoliosis questionnaire. J Pediatr Orthop 31(2): w Bess S, Akbarnia BA, Thompson GH, et al. (2010) Complications of Growing-Rod Treatment for Early-Onset Scoliosis: Analysis of One Hundred and Forty Patients. The Journal of Bone and Joint Surgery, Am 92(15): x Yang, JS, Sponseller PD, Thompson GH, et al. (2011) Growing Rod Fractures: Risk Factors and Opportunities for Prevention. Spine (Phila Pa 1976). c Schroerlucke SR, Akbarnia BA, Pawelek JB, et al. (2011) How Does Thoracic Kyphosis Affect Patient Outcomes in Growing Rod Surgery? Spine (Phila Pa 1976). v Skaggs D, Myung KS, Lee CI (2011) Proximal Junctional Kyphosis in Distraction-Based Growing Rods. Paper presented at the 46 th annual SRS meeting, Kentucky (USA). b El-Hawary R, et al. (2011) Sagittal Spinopelvic Parameters Help Predict the Risk of Proximal Junctional Kyphosis for Children Treated with Posterior Distraction Based Implants. Free paper presented at the 5 th International Congress on Early Onset Scoliosis and Growing Spine (ICEOS), Orlando (USA), n Sun L (2010) Early childhood general anaesthesia exposure and neurocognitive development. Br J Anaesth 105 Suppl 1: i61-8., Mundis GM, Nomoto EK, Hennessy MW, Akbarnia BA (2012) Longitudinal Analysis of Radiation Exposure During the Course of Growing Rod Treatment for Early Onset Scoliosis. Accepted for Podium Presentation at International Meeting on Advanced Spinal Techniques (IMAST) 19 th annual meeting, July 18-21, Istanbul, Turkey. ; Song KM, et al. (2011) Iatrogenic Radiation Exposure to Patients with Early Onset Spine And Chest Wall Deformities. Presented at 5 th International Congress on Early-Onset Scoliosis (ICEOS), November 19-20, Orlando, Florida : Deschênes S, Charron G, Beaudoin G, Labelle H, Dubois J, Miron MC, Parent S (2010) Diagnostic imaging of spinal deformities: reducing patients radiation dose with a new slot-scanning X-ray imager. Spine 35(9): A Akbarnia BA, Mundis GM Jr, Salari P, et al. (2011) Innovation in Growing Rod Technique: A Study of Safety and Efficacy of a Magnetically Controlled Growing Rod in a Porcine Model. 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6 Evolution in diagnosis and treatment of scoliosis 55 /+/ About Behrooz A. Akbarnia San Diego Center for Spinal Disorders 4130 La Jolla Village Drive, Suite 300 La Jolla, CA United States of America Ph: Fax: Dr. Akbarnia earned his medical degree at Tehran University Medical School in Iran and moved to the United States in 1968 to continue his training. He completed his Residency at Albany, New York and Fellowship in Minneapolis, Minnesota. Dr. Akbarnia subsequently became Professor and vice Chairman of Orthopedic Surgery at St. Louis University. Currently, Dr. Akbarnia is a Clinical Professor in the Department of Orthopaedic surgery at the University of California, San Diego and Medical Director of the San Diego Center for Spinal Disorders in La Jolla, CA. Throughout his career, Dr. Akbarnia has received many awards and honors including the prestigious Walter P. Blount Humanitarian Award at the 2008 Scoliosis Research Society Meeting for his contributions in the field of spine surgery and lifetime service award from Western Orthopaedic Association. Dr. Akbarnia served as President of Federation of Spine Associations in 1994 and President of the Scoliosis Research Society in He is also an active member of the American Academy of Orthopedic Surgeons, the American Orthopedic Association, the Pediatric Orthopedic Society of North America, and the North American Spine Society, to name a few. He has been guest lecturer in many countries around the world and has published over 200 peer-reviewed and invited articles and book chapters and has edited two books. He is the president and founder of Growing Spine Foundation, which supports the Growing Spine Study Group, an international research group working to study and improve the care of young children with Early Onset Scoliosis. Argospine and Springer-Verlag France DOI /s ArgoSpine NEWS&JOURNAL - quarterly june Vol N 1-2