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2025 Pediatric Surgery Update Course - Vertebral Body Tethering (VBT) for Scoliosis
With Dr. Lourina Flakari · hosted by Dr. Todd Ponsky
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
VBT is less invasive and more physiologic than spinal fusion, with hoped-for improved long-term outcomes due to preserved disc mobility
The tether is placed on the convex side of the spine anteriorly to partially correct the curve and modulate growth
The procedure requires a skeletally immature patient so that as they grow, they grow straighter
If VBT is performed in a mature patient, it is probably not going to work
Current indications for VBT are immature, moderately severe curves that are flexible
Hybrid techniques can be used where if the thoracic curve doesn't meet criteria, only the lumbar spine is tethered since motion is needed there
For double tethering, the patient must be positioned in lateral decubitus with convex side up, then flipped to do the lumbar side
Ports are placed on the anterior axillary line with three 5mm ports and one 15mm port for the instrument
Two to three vertebral levels can usually be accessed through each skin incision by moving the port up the next intercostal space
Segmental vessels are typically ligated on one side during VBT, which is considered safe with neuromonitoring, though taking vessels on both sides risks spinal infarct
T12-L1 levels can usually be reached through the thoracoscopic approach by bluntly dissecting along the diaphragm
L1-L4 levels are accessed through an open incision
Screws are placed under fluoroscopic guidance at each level, attempting to go straight across the vertebrae
EMG neuromonitoring is used during the procedure
The tether is threaded through each screw and a tensioning gun is used to place tension, mostly centered around the apex, to achieve correction
Patients are mobilized immediately postoperatively and returned to sports within six weeks, compared to three to six months for fusion
VBT started being performed in the mid-2000s at certain centers
VBT has exploded in popularity in recent years as data shows outcomes are improving over time
The sweet spot for VBT timing is when growth can be modulated to change the shape of the disc space and vertebrae as the patient grows
If VBT is done too soon, patients can over-correct; if done too late, nothing happens and the tether will eventually break, reverting to the previous shape
People doing VBT in adults have not had very good outcomes
Chest tube outputs tend to be high for the first six to eight hours after VBT, likely from serous fluid from opening the pleura over a large surface area
For severe scoliosis with anterior lumbar exposure, the spine can be quite deep in younger kids compared to cases where you can almost feel the spine
Removing one of the floating ribs can be helpful to give more space for lumbar exposure in the space between lower ribs and iliac crest
Double-lumen endotracheal tubes are used for VBT procedures
The first prospective VBT study from Mayo Clinic found 75% success rate at two years based on curve size and lack of revisions, down to 63% at 3.8 years with a 20% revision rate
Most VBT complications occurred early on when centers didn't know how to select the right patient, and success improves with experience
One study showed no difference in complications between chest tubes and bulb suction drains for VBT
Another study looked at postoperative tranexamic acid to reduce drainage and retention time
A study suggested that multidisciplinary collaborative approach can improve VBT outcomes