Early Onset Scoliosis

Guidelines for Management in Resource-Limited Settings

Alaaeldin (Alaa) Azmi Ahmad, Aakash Agarwal, Alaaeldin (Alaa) Azmi Ahmad, Aakash Agarwal

• Publisher: CRC Press
• Year: 2021
• Print ISBN: 9780367370312
• eBook ISBN: 9781000298666
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This book follows a context-based approach to management of early-onset scoliosis (EOS) in countries with limited resources in education, finance, and research. Due to the great variety in etiology, onset age, progression rate, and severity associated with EOS, it calls for a unique treatment plan. This book enumerates the optimal provision of surgical and non-surgical services, from education/training of local surgeons, to effective teamwork, to implementing an effective data collection system; helping the surgeon to gain a hands-on experience. It also illustrates the successful execution of deformity correction using real life experiences from countries in Asia, Africa, and Latin America.

Key Features

• Discusses biomedical principles that will help to get universally standard implants that are credible and affordable for countries with limited resources.
• Specific surgical Guidelines and the ability to develop evidence-based practice for this service would be an interesting read for surgeons working in global organizations as well as to local surgeons.
• First book to focus on countries with limited resources for the management of early onset scoliosis.

1  Introduction

Alaaeldin Azmi Ahmad

Contents

Introduction

Discussion

Why Is This Book Necessary Now?

What Makes This Book Important?

Conclusion

References

Introduction

Early onset scoliosis (EOS) includes all scoliotic deformity for children under 10 years of age. It is a life-threatening disease, unlike adolescent idiopathic scoliosis, which makes early intervention crucial. Most of the patients in this category have complex spine problems with associated comorbidities. These patients require a multidisciplinary approach in a resource abundant facility with management subspecialised in spine deformity. Ironically, the incidences of EOS are higher and more widespread in countries with limited resources (CLRs), and except for a very sporadic provision of exemplary management of such patients in Asia, Africa, and Latin America, these patients have no access to solutions with which developed nations are equipped. None of the previously published books on EOS has a theme dedicated to this problem and the accompanying solutions to this vacuum. This book will be the first to give guidelines based on the successful programmes run by the most experienced doctors and global thinkers. The upcoming chapters will lay out a roadmap on how to implement this service within the context of a limited-resource region, unlike the past publications dealing with the assumption that you have all the resources within your reach and the only missing link is the surgical technique; clearly this is not the case here. Below are several reasons explaining why there is a lack of publications about EOS services in CLRs.

1. 1. The treatment two decades ago for EOS was similar to the management undertaken for adolescent deformity, i.e. correction and fusion under the concept that a straight, shorter spine is better than a long, crooked spine. Accordingly, there was no need to explore and write about EOS as a separate problem that demands a specific management, until it became known that pulmonary function would be compromised unless certain nonfusion techniques were employed.
2. 2. The heterogenicity of this population with different etiological backgrounds presented unique challenges in management for these patients. Many authors refrained from writing about the management of this particular problem because there is still a lack of consensus as too few evidence-based studies have been conducted.
3. 3. A long-standing myth that a very small number of children suffer from this problem; we know now that 20% of adolescent children with scoliosis had juvenile idiopathic scoliosis, which is a part of EOS. If we now calculate 20% of adolescent idiopathic scoliosis cases in the United States, for example, juvenile idiopathic scoliosis refers to 20% of 6 million or 1.2 million cases. We would think this magnitude of occurrence needs more attention, especially when management is a life saving measure.
4. 4. Surgery was relegated as a low-priority status in global health and was viewed as an expensive measure that would compromise other large-scale global health initiatives.
5. 5. Many short-term missions were used as an alternate (excuse) to not implement permanent EOS management services and thus EOS management were discounted from the aegis of global health initiatives.
6. 6. Misconception of high per unit cost of pedicle screws making surgery infeasible, inability of local surgeons to learn and implement the treatment, wait and watch approach, and reduced relative priority in the spine training programs, from surgeons or organisations that deal with spine surgery across the globe.

All these factors were a reason for the unavailability of a book focussing on implementing this service in low- and middle-income countries (LMICs). Even with the evolved interest in this service, most of the publications were about the updated management for EOS concerning developed countries and written mostly by experts in these countries. This is the first book that will give guidelines for the surgeons and global organisations that are interested in improving global health concerning EOS in LMICs.

Discussion

Why Is This Book Necessary Now?

1. 1. An increased awareness of the importance of the problem, experiencing a higher rate of than was thought, and the benefits of early management in these cases and thus reducing complexities and complications of late intervention is evidenced in the increase in symposiums related to EOS in the annual international congresses, such as the Scoliosis Research Society (SRS), the North American Spine Society (NASS), AO Spine, Eurospine, etc.
2. 2. The added advantage of the nonfusion techniques on adolescent idiopathic scoliosis and the role of tethering in preserving spine mobility has attracted attention to the nonfusion techniques, which are now a mainstay principle for the management of EOS.
3. 3. The epidemiological shift with the global industrialisation gave importance to surgery as an important health factor. In addition, people living in LMICs are now less likely to die from communicable diseases, and they live to an age at which cancer and cardiovascular problems are more prevalent [1].
4. 4. Recently, international societies have shifted their attention, making surgical care a fundamental component of global health [2].
5. 5. Global activity has changed from short-term missions with a focus on service to capacity building through long-term sustainable programmes with special focus on education.
6. 6. The change of perception of highly specialised surgery has changed. Whereas such procedures were considered to be cost-inefficient global activity, they are now viewed as a necessary activity that augments other health facilities (such as laboratory services, radiology development, blood banking services, anaesthesia services, etc.).
7. 7. Awareness of the effects of globalisation, especially with coronavirus affecting the world, developed countries fear that the vulnerable health systems in the developing world would increase the chance of reemergence of infectious diseases. This necessitates the global community to uniformly improve the health system for developing countries and approaches for subspecialised surgeries.

What Makes This Book Important?

This book will provide guidelines instead of a prescription because we are dealing with a complicated and heterogenous health problem within a context of limited resources that varies from region to region. We were keen to look at the problem holistically, and any discussion on the surgical aspect is futile without understanding the capabilities of individual regions. Furthermore, aspects such as industry and its relationship with the facility, economic status, education, and training process are pertinent to this subject matter. This book shares experiences of the pioneers who have worked in LMICs, making the information relevant to the readers working in LMICs around the world. Most of the chapters are from authors practising in Asia, Africa, Latin America, and a few selected surgeons from developed countries working to implement this programme in developing countries. An important thing to be discussed is the training process to improve the surgical skills of the local surgeons through newly evolved teaching methods that include artificial intelligence (AI). With the spread of digital education and worldwide internet access, we have new training tools that were not established before, such as YouTube videos, webinars, discussion groups, and blended learning, that efficiently share knowledge without financial burden in limited-resource settings. Recently, there has been a move toward using augmented simulation and virtual-reality training programmes, though they are still expensive for most limited-resource regions. However, given its potential, companies are trying to make these new learning tools accessible to surgeons in limited-resource settings, thereby exposing them to pre-, intra-, and postoperative protocols and eliminating the need for frequent travel. Also, the readers will be informed of legal issues related to the licenses that are of a concern to surgeons and organisations dealing with these programmes. We think this book is mandatory for any surgeon, health worker, nongovernmental organisation, and other health officials in developing countries who are interested in implementing this important service. If you are based in an LMIC, this book will provide you with a holistic guideline to assist in building a road map toward implementing this service within the region of interest. It will provide you with necessary platform and background information to further customise an execution plan, such as the hospital plan, access to instruments, relations with international organisations, and the impact of this service on the health system in your area. If you are a surgeon or an officer in a global organisation interested in implementing surgical services in LMICs, this book will give you an overview of the problem that doctors and health workers involved in this activity face, the auxiliary factors in play, and the limitations within their practices. This will give you realistic guidelines that will overcome many problems during implementation of this service and will help to avoid duplication of services and unnecessary efforts toward management of EOS in LMICs. With these guidelines, we hope that the dynamics of the relationships between the surgeons from developed countries and LMICs will evolve, from being a one-sided exchange to a two-way street of positive feedback and comprehension. This will help to position local orthopaedic surgeons as a central part of the planning and execution of global EOS surgery initiatives. This requires durable training programmes that help surgeons relegate increasing responsibilities to local doctors with each visit [3].

Conclusion

This book is the first to address the challenges involved in the management of EOS services in a limited-resource setting, i.e. LMICs. It provides guidelines for the local surgeon on how to deal with the EOS cases effectively while overcoming specific preoperative, operative, and postoperative difficulties that come with the dearth of financial and organisational resources. It aims not only to enhance the medical and surgical skill of the local surgeon in this challenging setting, but also to boost the self-confidence necessary for overcoming the numerous institutional barriers. This book also addresses surgeons travelling to these countries, explaining how to best understand this challenging logistical, legal, and organisational context and how to most effectively contribute to the elevation and support of local surgeons through sustainable mentoring and other partnership programmes. By providing the various guidelines based on real-life experiences and successful programmes, this book ultimately aims to facilitate the improvement and expansion of paediatric spine deformity service in these underserved communities.

References

1. 1. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLOS Medicine. 2006;3(11):e442.
2. 2. DeVries CR, Price RR. Global Surgery and Public Health: A New Paradigm. Jones & Bartlett Publishers; Sudbury, MA, 2012.
3. 3. Ahmad AA. What’s important: Recognizing local power in global surgery. Bone & Joint Surgery. 2019;101(21):1974.

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Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgments
• Editors
• List of Contributors
• List of Abbreviations
• Chapter 1 Introduction
• Chapter 2a Economics and Implementing Early-Onset Scoliosis in Limited-Resources Facilities
• Chapter 2b Mismatch in Expectations between Industry and Countries with Limited Resources
• Chapter 2c Organisational Deficiencies in Developing Countries and the Role of Global Surgery
• Chapter 3a Blended Learning in Training Paediatric Deformity Surgeons
• Chapter 3b Evidence-Based Medicine in Low- and Middle-Income Countries
• Chapter 4 Normal and Abnormal Development and Growth of Spine and Thoracic Cage
• Chapter 5 Pulmonary Evaluation and Management of Early-Onset Scoliosis
• Chapter 6 Conservative Management of Early-Onset Scoliosis
• Chapter 7 Anaesthetic Management of Early-Onset Scoliosis
• Chapter 8a Biomechanics of Surgical Intervention Associated with Early-Onset Scoliosis
• Chapter 8b Principles of Surgical Management
• Chapter 8c Preoperative Diagnosis and Management
• Chapter 8d Principles of Intraoperative Management of Early-Onset Scoliosis
• Chapter 8e Postoperative Management for EOS Children
• Chapter 8f Principles of Management of Long-Term Complications in EOS
• Chapter 8g Management of Spinal Tuberculosis in Young Children
• Chapter 9a Guidelines for Management in Limited-Resource Settings: Pakistan Experience
• Chapter 9b China Experience
• Chapter 9c Egyptian Experience of Surgical Management of Early-Onset Scoliosis
• Chapter 9d Mozambique Experience
• Chapter 9e Chile Experience
• Chapter 9f Evolution of Experience and Practise in Two Nations
• Chapter 9g Experience of EOS Management in Two Worlds-II
• Chapter 9h Cross-Border Spine Surgical Treatment: Issues to Consider
• Chapter 10 Future Considerations
• Index