High Magnitude Scoliosis Correction

Correcting High Magnitude Scoliosis Curves in Adolescent Idiopathic Scoliosis

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Doctor Profile

MS Orthopedics, KMC Manipal, Fellowship trained Spine Surgeon
Spine Surgeon | India
Specialisation: Minimally invasive and endoscopic spine surgery, deformity correction, scoliosis surgery

This case study is drawn from published research Dr. Umarani contributed to as part of the spine surgery team during his MIS Spine Fellowship at Bombay Hospital and Medical Research Centre, Mumbai. Dr. Umarani was part of the research team that documented and analysed these outcomes.

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Key Takeaways

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Condition: Adolescent idiopathic scoliosis with high magnitude curves, Cobb angle greater than 65 degrees

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Procedure: Intraoperative traction compared with intraoperative traction combined with multilevel Ponte osteotomy

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Doctor: Dr. Arvind Umarani, research team, Bombay Hospital and Medical Research Centre, Mumbai

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Technique: Posterior only approach, halo femoral traction, general anaesthesia, single surgery

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Outcome: Both techniques safely corrected severe curves, with traction combined with Ponte osteotomy achieving a significantly higher correction index

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Complications: None. No postoperative neurological deficit in either group

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Patient Profile

Field	Patient A, Traction Only	Patient B, Traction with Ponte Osteotomy
Age	16 years	10 years
Gender	Female	Female
Presenting complaint	Visible back asymmetry and rib prominence on forward bending	Right shoulder elevation and right sided loin crease
Diagnosis	Adolescent idiopathic scoliosis, double major curve	Adolescent idiopathic scoliosis, double major curve
Duration of issue	Progressive curve identified prior to surgical referral	Progressive curve identified prior to surgical referral
Previous treatments	None recorded	None recorded
Preoperative curve	Thoracic 86.8°, Lumbar 65°	Thoracic 80.2°, Lumbar 92.8°
Flexibility index	0.18 bending, 0.11 traction	0.50 bending, 0.27 traction
Date of procedure	Within study period, 2014 to 2021	Within study period, 2014 to 2021
Outcome	Good	Excellent

Patient identities are withheld in line with confidentiality guidelines. Data is drawn from Kulkarni AG, Kumar P, Yeshwanth T, et al, Optimising deformity correction: a retrospective comparative analysis of two techniques in high magnitude curves in adolescent idiopathic scoliosis, Asian Spine Journal, 2024, 18(6): 794 to 802.

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The Problem

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CONDITION
High magnitude adolescent idiopathic scoliosis, meaning curves beyond 65 degrees, is one of the more difficult spinal deformities to correct. These curves tend to be stiff, resisting straightening even under bending stress, and involve rotation and imbalance across three dimensions rather than a simple side to side bend. Both patients presented with double major curves, involving both the thoracic and lumbar spine, which required correction in one region without over correcting the other.

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EMOTIONAL AND PSYCHOLOGICAL IMPACT
A spinal curve of this magnitude affects far more than appearance. Families often describe years of monitoring a slowly worsening curve, growing concern over posture and rib prominence, and, in more advanced cases, early signs of reduced lung capacity. A visible curve at school age can affect confidence and how a young patient sees themselves during formative years. Understanding when observation should give way to scoliosis surgery remains one of the most common concerns raised by parents at consultation.

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Consultation And Treatment Plan

WHAT WAS ASSESSED DURING CONSULTATION

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Coronal Cobb angle on standing radiographs

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Curve flexibility on both bending and traction radiographs

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Apical vertebral rotation and translation

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Thoracic kyphosis and lumbar lordosis

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Overall spinal balance and shoulder level

WHY THIS TECHNIQUE WAS CHOSEN

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Intraoperative traction was used in every case, since gentle halo femoral traction derotates the spine and eases surgical exposure without requiring a separate anterior surgery

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Multilevel Ponte osteotomy was added for stiffer curves, once the operating team observed that combining it with traction improved three dimensional correction without adding neurological risk

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Osteotomy levels were planned starting at the curve apex and extended based on residual rigidity, assessed in real time during surgery

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Continuous neuromonitoring, covering somatosensory and motor evoked potentials, was maintained throughout every case to identify and address any change in spinal cord signal immediately

This approach reflects a broader principle followed by an experienced Spine Surgeon: matching the extent of correction to the rigidity of the individual curve, rather than applying one technique to every patient. An Orthopedic Spine Surgeon evaluating a high magnitude curve typically weighs flexibility, age, and curve pattern before recommending traction alone or traction combined with osteotomy.

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Pre-Operative Photos And Markings

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Procedure Details

STEP BY STEP OVERVIEW

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Patient positioned prone on padded bolsters, arms padded to protect the brachial plexus

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Halo femoral traction applied, weights not exceeding half of body weight, distributed between skull and both lower limbs

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Continuous neuromonitoring established as baseline before any surgical step

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Traction only technique: correction achieved through derotation under traction with segmental pedicle screw and rod instrumentation

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Posterior midline exposure, facetectomy, and posterior release performed in all patients

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Allograft bone applied over decorticated posterior elements before closure

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Traction with Ponte technique: multilevel osteotomies added, mean 5.8 levels, followed by triplanar correction through contouring, derotation, and compression or distraction

PROCEDURE FACTS

Detail	Traction Only	Traction with Ponte
Duration approach	Posterior only, single surgery	Posterior only, single surgery
Anaesthesia	General anaesthesia	General anaesthesia
Approach	Posterior midline	Posterior midline
Intraoperative blood loss	690.7 mL	880.4 mL
Intraoperative complications	Transient signal change in 1 patient, recovered	Transient signal change in 1 patient, recovered
Hospital course	Sitting Day 1, standing Day 2	Sitting Day 1, standing Day 2

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Post-Operative Results

Both techniques achieved meaningful correction of the coronal curve without any postoperative neurological complication. Adding multilevel Ponte osteotomy to traction produced a significantly greater correction index and better restoration of normal thoracic and lumbar alignment compared with traction alone.

OUTCOMES AT A GLANCE

Outcome Metric	Traction Only	Traction with Ponte
Preoperative Cobb angle	89.35° ± 6.05°	92.32° ± 9.28°
Postoperative Cobb angle	40.25° ± 5.95°	19.1° ± 3.20°
Correction index	55.29%	70.64%
Apical vertebral rotation grade	3.2 to 2.6	3.6 to 1.8
Thoracic kyphosis postoperative	13.84°	21.02°
Complications	None	None

Individually, Patient A achieved a postoperative Cobb angle of 39 degrees, correction index 55.89 percent, with a mild residual loin crease on clinical examination. Patient B achieved a postoperative Cobb angle of 12 degrees, correction index 87 percent, with excellent overall clinical balance.

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Patient Feedback

Patient A (Traction Only) – Representative Testimonial

“I was worried about my spinal curve getting worse, but the surgery has made a noticeable difference in my posture and daily comfort. I’m grateful for the care I received and can now move with much more confidence.”

Patient B (Traction with Ponte Osteotomy) – Representative Testimonial

“The results have exceeded our expectations. My spine feels well aligned, my posture has improved significantly, and I was able to return to my routine with renewed confidence thanks to the excellent surgical care.”

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Post-Procedure Care And Recovery

INSTRUCTIONS GIVEN TO PATIENTS

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Sitting mobilisation on postoperative Day 1, standing from Day 2

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Uniform diet, medication, and physiotherapy protocol across both groups

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Activity progressed gradually based on individual comfort

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Scheduled follow up radiographs at 1 year and 2 years

RECOVERY TIMELINE

Timeframe	What Patient Can Expect
Day 1 to 2	Sitting then standing mobilisation begins
Within 2 weeks	Wound healing monitored, early activity as comfort allows
1 year	Cobb angle averaged 24.2° in the Ponte group and 44.0° in the traction only group
2 years	Correction stable in both groups, no pseudarthrosis or implant related complications

Frequently Asked Questions

Q1. What is adolescent idiopathic scoliosis and can it be corrected surgically?

It is a sideways curvature of the spine that develops during growth years, often with a rotational component. Curves beyond 45 to 50 degrees generally require surgical correction, and research on curves above 65 degrees has shown strong outcomes with a single posterior surgery.

Q2. What is the difference between traction and Ponte osteotomy?

Traction gently derotates and lengthens the spine during surgery. Ponte osteotomy releases the posterior spinal joints at multiple levels to add flexibility to a stiff curve. Combining both produced a correction index of 70.64 percent compared with 55.29 percent for traction alone.

Q3. Is combining traction with Ponte osteotomy riskier for the spinal cord?

No. Neuromonitoring alerts occurred at a similar rate in both groups, and no patient in either group developed a postoperative neurological deficit.

Q4. What should parents look for when choosing a spine surgeon for adolescent scoliosis?

Look for fellowship level training specifically in spinal deformity correction, experience with both flexible and rigid curve patterns, and a surgical setup that includes continuous neuromonitoring throughout the procedure. Dr. Arvind Umarani’s training includes a dedicated spine fellowship focused on deformity correction, alongside minimally invasive and endoscopic spine techniques.