KidsMD Health Topics

Spine problems

  • We're fortunate that Boston Children's is large enough that we can sub-specialize. We're able to make real advances in our respective fields by concentrating on our sub-specialties, like spine or hips, rather than every surgeon doing every procedure. This way, we can offer advanced techniques that you won't see in volume at other institutions.

    Spinal Program Team, Boston Children's Hospital Orthopedic Center

    If your baby or child has been diagnosed with a spinal problem—from a complex congenital (present at birth) condition to a less severe overuse injury—we know that you and your family are under stress. So, at Children’s Hospital Boston, we’ll approach your child’s treatment with sensitivity and support—for your child and your whole family.

    If your child’s condition is serious, you can have peace of mind knowing that the team in the Boston Children's Spinal Program has treated a large volume of spinal problems that few pediatric hospitals have seen—and can provide expert diagnosis, treatment and care.

    The Boston Children's Hospital approach

    Boston Children’s Spinal Program is known for clinical innovation, research and leadership. We offer the most advanced diagnostics and treatments—several of which were pioneered and developed by our own researchers and clinicians.

    One of the first comprehensive programs, Boston Children’s Orthopedic Center is the largest and busiest pediatric orthopedic surgery center in the United States, performing more 6,000 surgical procedures each year. Our program is the nation’s preeminent care center for children and young adults with developmental, congenital, neuromuscular and post-traumatic problems of the musculoskeletal system.

    Some of our team’s unique accomplishments include our:

    • development of the Boston Brace, a custom bracing system widely used throughout the United States and Europe
    • unique experience in the treatment of adolescent hip conditions
    • success with the Expansion Thoracostomy and VEPTR(vertical expandable prosthetic titanium rib) procedure: In 1998, Children’s was selected as a site for the first extensive VEPTR use outside San Antonio, where it was developed. Boston Children’s has the second most extensive VEPTR experience in the nation.
    • experience with, and emphasis on, treating infantile (early-onset) scoliosis   

    Spinal conditions that we treat in infants and children include:

    Each year, our Spinal Program caregivers provide comprehensive evaluation, diagnosis, consultation, treatment and follow-up care for children during more than 6,000 outpatient visits. And every year, our orthopedic surgeons perform more than 300 spine procedures on babies, children, adolescents and young adults.

    We offer orthopedic care in lots of places

    Boston Children’s physicians provide orthopedic care—including for scoliosis and other spine problems—at locations in Lexington, Peabody, Weymouth and Waltham, as well as at our main campus in Boston. 

    If you come from far away, we can help

    As an international pediatric orthopedics center, Children’s treats young patients from all over the world. Our International Center assists families residing outside the United States: we facilitate the medical review of patient records; coordinate appointment scheduling; and help families with customs and immigration, transportation, hotel and housing accommodations.

    Spine problems: Reviewed by John Emans, MD
    © Boston Children’s Hospital, 2010

    Orthopedic Center
    Boston Children's Hospital

    300 Longwood Avenue
    Fegan 2
    Boston MA 02115

    Boston Children's Hospital at Waltham
    9 Hope Avenue
    Waltham MA 02453

    Boston Children's Hospital at Lexington
    482 Bedford Street
    Lexington MA 02420

    Boston Children's North
    10 Centennial Drive
    Peabody MA 01960

    Boston Children's Physicians South
    Stetson Medical Center
    541 Main Street
    Weymouth MA 02190

  • At Boston Children’s Hospital, our team pioneers innovative spine treatments. And because our research informs our treatment, we’re known for our science-driven approach. We’re home to the world’s most extensive pediatric hospital research enterprise, and we partner with elite health care and biotech organizations around the globe. But as specialists in family-centered care, our physicians never forget that your child is precious, and not just a patient.

    In dealing with your child’s spine problems, you may want to know the basics about how the spine works.

    What is the spine?

    Made up of many individual bones called vertebrae, the spine is joined together by muscles and ligaments. Flat, soft discs separate and cushion each vertebra from the next. Because the vertebrae are separate, the spine is flexible and can bend. Together the vertebrae, discs, muscles and ligaments make up the vertebral column or spine.

    Different regions of the spine are named differently. The cervical spine refers to the neck, the thoracic spine to the chest, and the lumbar and sacral spines to the lower back.

    What are normal and abnormal spine curves?

    The normal spine is strong and mobile. While it varies in size and shape from person to person, the healthy spine has natural front-to-back curves that enable us to walk, balance, sit, stand and twist—all of which are complex interactive movements. When these natural front-to-back curves become too large, they can present a potential problem:

    • When the backward curve in the thoracic spine is too great, the condition is called kyphosis (thoracic hyper-kyphosis, “round back”).

    • When there’s not enough backward curve in the thoracic spine, the condition is called hypo-kyphosis.

    • When the natural outward curve in the thoracic spine is actually reversed, curving into the chest, the condition is called thoracic lordosis.

    • When the inward curve in the lower back is too great, the condition is called hyper-lordosis (“swayback”).

    Although the spine has natural curves from front to back, it shouldn’t curve sideways very much. A side-to-side curve is called scoliosis, and may take the shape of an “S” (double curve) or a long “C” (single curve). The spine is also rotated or twisted, pulling the ribs along with it to form a multidimensional curve.

    When do normal spine curves develop?

    • in utero: During fetal development, the primary curves develop (thoracic and sacral).

    • as babies: All infants start life with a C-shaped spine. Their secondary curves (cervical and lumbar) develop as they become:

      • able to lift the head (cervical)
      • able to sit up (cervical)
      • able to crawl, stand and walk (lumbar)
    • as children: As children grow, their natural spinal curves continue to develop into a normal spine.

    What are some of the spine problems that Boston Children’s treats in infants and children?

    • scoliosis: a condition in which the spine, in addition to the normal front to back curvature, has an abnormal side-to-side “S-” or “C”-shaped curvature. The spine is also rotated or twisted, pulling the ribs along with it. The condition isn’t rare. It mainly affects girls—many of whom have mild forms of scoliosis, are never even aware of it, and never need treatment.
      • idiopathic scoliosis: the most common form of scoliosis. “Idiopathic” simply means that there's no definite cause. Nothing you or your child did caused it, and there’s nothing you could have done to prevent it. Fortunately, most cases are self-limiting and require no intervention. Scoliosis does tend to run in families, and girls are eight times more likely to have it than boys.
      • Idiopathic scoliosis has three main types, corresponding to the age at onset:
    • adolescent idiopathic scoliosis: the most common form, mainly affecting girls, often not needing intervention
    • juvenile idiopathic scoliosis: about 10 percent of cases, affecting children aged 3 to 9 years, usually progressive
    • infantile (early-onset) idiopathic scoliosis: rare (up to 5 percent of cases), more often affecting boys from birth to age 3 years
    • neuromuscular scoliosis: scoliosis that's associated with disorders of the nerve or muscular systems like cerebral palsyspina bifida, myopathy, muscular dystrophy or spinal cord injury
    • congenital scoliosis: The spine forms and develops between three and six weeks after conception. Congenital scoliosis results from abnormal in utero spinal development, such as a partial or missing formation or a lack of separation of the vertebrae.
    • kyphosis (thoracic hyper-kyphosis, adolescent hyper-kyphosis, Scheuermann’s kyphosis): a spine affected by kyphosis shows evidence of a curvature of the back bones (vertebrae) in the upper back area, giving the child an abnormally rounded or “humpback” appearance. Kyphosis is a type of spinal deformity and should not be confused with poor posture.
    • spondylolisthesis: a progression of spondylolysis in which there’s a forward displacement of one vertebra on the other. This condition can be low-grade and treated like spondylolysis (see next). Or it can be high-grade—an uncommon but severe slippage.
    • spondylolysis: a disruption of the normal bony ring within a vertebra; occurs in the area between the facet joints (pars interartilularis). This condition, which can include tiny stress fractures, is not present at birth and affects about 5 percent of the population. It can be spontaneous or can be associated with adolescent sports like football, gymnastics, wrestling and skating.
    • spina bifida (myelodysplasia): a condition in which there’s abnormal development of the back bones, spinal cord, surrounding nerves and the fluid-filled sac that surrounds the spinal cord. This neurological condition can cause a portion of the spinal cord and the surrounding structures to develop outside, instead of inside, the body. The defect can occur anywhere along the spine.


    Spinal problems can be:

    • congenital (present at birth)
    • neuromuscular (associated with a neuromuscular condition such as cerebral palsy or spina bifida)
    • idiopathic (definite cause unknown)
    • the result of bone dysplasias (genetically abnormal bone growth)
    • related to metabolic conditions (internal body chemistry)
    • related to connective tissue disorders
    • related to differences in leg lengths
    • related to spinal cord injury with paralysis
    • related to infection
    • related to tumors


    For details see symptoms for:

    When to seek medical advice

    Several spinal problems can be seen at or shortly after birth—or sometimes evenbefore birth using a prenatal ultrasound. Others, such as idiopathic scoliosis, will usually develop as the child grows, most often during the child’s adolescent growth spurt. Congenital scoliosis is present at birth, but may not be apparent until later. Consult your pediatrician if your family has a history of spinal problems, or if your child is:

    • developing side-to-side curvatures (scoliosis)
    • developing asymmetry of her shoulders or waist
    • developing a round upper back (kyphosis)
    • experiencing unusual back pain

    Who’s at risk

    Risk factors for developing spinal problems vary from condition to condition. Common risk factors and predispositions for some spinal conditions can include:

    • a family history of scoliosis
    • other birth defects
    • neuromuscular conditions
    • metabolic conditions that affect bones
    • syndromes that affect neurologic function
    • other genetic syndromes


    For details see complications for:

    Long-term outlook

    The long-term outlook depends greatly on the nature and severity of the spinal condition, as well as the nature and severity of any underlying (neuromuscular or other) conditions. Most spinal problems are compatible over time with full normal function, normal appearance and good general health.

    For details see the long-term outlook for:

  • At Boston Children's Hospital, we know that the first step in treating your child is forming an accurate and complete diagnosis.

    Most spinal problems are detected by a child’s parents or pediatrician, or by school screenings. Once a problem is detected, doctors will use medical and family histories, physical exams and diagnostic tests to determine the nature and extent of your child’s spinal condition. Testing can include:

    For details see diagnostics for:

    Our Orthopedic Clinical Effectiveness Research Center (CERC)

    The Clinical Effectiveness Research Center (CERC) was established by the Orthopedic Center to improve the quality of life for children with musculoskeletal disorders. This collaborative clinical research program is unique in the nation and is playing an instrumental role in establishing, for the first time, evidence-based standards of care for pediatric orthopedic patients throughout the world.

  • How we'll treat your child's spinal problem depends on the complexity and severity of her condition. Whether her spinal condition is congenital-, idiopathic- or neuromuscular-related, the Boston Children's Hospital Spinal Program provides comprehensive treatment—including evaluation, diagnosis, consultation and follow-up care.

    • simple observation and monitoring: Once an abnormal spine curve has been detected, it's important to monitor the curve as the child grows. In many cases, your child's spinal condition may need only close monitoring during skeletal growth. Your physician will determine your child's treatment plan and follow-up based on her x-rays and physical exams.
    • physical therapy: Some spinal problems are helped by physical therapy. Our physical therapy team's goal is to maximize our young patients' physical functioning. Our physical therapists work closely with specialists in our Spinal Program to also provide exercise programs and additional therapies to address the pain and muscular imbalance that can be associated with spinal abnormalities.
    • bracing: Bracing can be an important part of treating spinal problems. For example:
      • In neuromuscular scoliosis, bracing helps positioning and function.
      • In idiopathic scoliosis, bracing can help control or correct curves. The brace holds your child's spine in a straighter position while she's growing in order to partly correct the curve or prevent it from increasing. A bracing program may help avoid surgery.
    • casting: Casting is commonly used for early-onset (infantile) idiopathic scoliosis.
    • surgery: If surgery becomes necessary, our Spinal Program's orthopedic surgeons use the most advanced surgical techniques for correcting spinal problems, such as:
      • spinal fusion: the most common surgical procedure for treating spinal problems
        • Usually, a fusion and instrumentation are combined to correct and solidify the curve.
      • for younger, growing children:
        • dual posterior growing rods (for early-onset scoliosis): control spinal deformity while allowing spinal growth with periodic lengthenings
        • expansion thoracostomy/VEPTR™ (titanium rib) procedure to control chest and spine deformity while permitting growth of both chest and spine
        • vertebral stapling (a minimally-invasive surgical alternative to bracing for scoliosis in some circumstances)

    For details see Treatment & care for:

    Coping and support

    At Boston Children's, we understand that a hospital visit can be difficult, and sometimes overwhelming. So we offer many amenities to make your child's—and your own—hospital experience as pleasant as possible. Visit The Center for Families for everything you need to know about:

    • getting to Boston Children's
    • accommodations
    • navigating the hospital experience
    • resources that are available for your family

    In particular, we understand that you may have a lot of questions when your child is diagnosed with a spine problem. How will it affect my child long term? What do we do next? We can help you connect with a number of resources to help you and your family through this difficult time, including:

    • patient education: From the office visit to pre-op to the recovery room to physical therapy and recovery, our nurses and physical therapists will be on hand to walk you through your child's treatment and help answer any questions you may have—Will my child need surgery? How long will her recovery take? How should we manage home exercises and therapy? We will help you coordinate and continue the care and support you received while at Children's.
    • parent-to-parent: Want to talk with someone whose child has been treated for a spinal problem? We can often put you in touch with other families who've been through the same procedure or process that you and your child are facing, and who will share their experiences.
    • faith-based support: If you're in need of spiritual support, we'll connect you with the Boston Children's chaplaincy. Our program includes nearly a dozen clergy—representing Protestant, Jewish, Muslim, Catholic and other faith traditions—who will listen to you, pray with you and help you observe your own faith practices during your hospital experience.
    • social work: Our social workers and mental health clinicians have helped many other families in your situation. We can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to coping with illness and dealing with financial issues.
  • For more than a century, orthopedic surgeons and investigators at Children’s Hospital Boston have played a vital role in the field of musculoskeletal research, pioneering treatment approaches and major advances in the care and treatment of ailments such as scoliosis, polio, tuberculosis, hip dysplasias and traumas to the hand and upper extremities.

    Our pioneering research helps answer the most pressing questions in pediatric orthopedics today—providing children with the most innovative care available.

    At Boston Children’s Orthopedic Center, we take great pride in our basic science and clinical research leaders, who are recognized throughout the world for their respective achievements. Our orthopedic research team includes:

    • five full-time basic scientists
    • 28 clinical investigators
    • a team of research coordinators and statisticians

    Clinical Effectiveness Research Center

    The Orthopedic Clinical Effectiveness Research Center (CERC) helps coordinate research and clinical trials to improve the quality of life for children with musculoskeletal disorders. This collaborative clinical research program is unique in the nation and plays an instrumental role in establishing—for the first time—evidence-based standards of care for pediatric orthopedic patients throughout the world.

    Major areas of focus for the CERC include:

    • spinal disorders
    • hip disorders
    • upper extremity disorders
    • brachial plexus birth palsy
    • trauma/fractures

    Spinal program

    Physicians in the CERC Spinal Program are active in several areas of ongoing basic and clinical research based at Children’s and the Harvard Orthopaedics Biomechanics Laboratory. Research topics include:

    • congenital scoliosis and idiopathic scoliosis
    • spondylolisthesis and spondylolysis
    • bone density studies of braced patients
    • in vitromechanical testing of lumbosacral fixation devices
    • computer-assisted strength analysis of vertebral metastases

    Ongoing studies

    Ongoing clinical studies include:

    Spine Studies Partially Sponsored by the Spinal Deformity Study Group: The mission and purpose of the Spinal Deformity Study Group (SDSG) is to create a means and forum whereby multi-center studies can be developed and conducted both efficiently and effectively. The SDSG is comprised of fifty national and international spine surgeons from 35 participating sites worldwide. Drs. Emans and Hresko are members of the SDSG.

    • (SDSG) Prospective Pediatric and Adolescent Scoliosis Study

    This is a prospective multi-centered study focused on the outcomes of pediatric and adolescent idiopathic scoliosis. The main purpose of this observational study is to develop a prospective comprehensive radiographic and clinical database on consecutively treated pediatric and adolescent scoliosis surgical cases to assess outcome measures in patients with operative idiopathic scoliosis being treated with current surgical techniques.

    A secondary objective is to obtain data on currently available surgical approaches to treat idiopathic scoliosis in the thoracic, thoracolumbar, and lumbar spine.

    • (SDSG) Prospective Pediatric and Adolescent Kyphosis Study

    The main objective of this prospective multi-center, observational study is to assess outcome measures in pediatric and adolescent patients with kyphosis, who are being treated non-operatively or operatively with current surgical techniques. Secondarily, data on currently available surgical approaches to treat pediatric kyphosis in the thoracic and/or thoracolumbar spine will be collected.

    • (SDSG) Prospective Study of Deformity Management and Pulmonary Function in Early-Onset Scoliosis

    The goal of this prospective multi-center study of children with “idiopathic” scoliosis is to document concomitantly: 1) control of spinal deformity, 2) growth of the thoracic spine longitudinally and transversely at a rate commensurate with the number of vertebrae involved and 3) increasing lung volume, absolute and relative to body size.

    • (SDSG) The Effect of Surgery on Sagittal Spino-pelvic Measures of Balance in Developmental Spondylolisthesis and Its Relation to Clinical Outcome

    The short-term goal of this prospective multi-center, observational study is to confirm the predictive value of sagittal spino-pelvic measurements in the surgical treatment of L5-S1 developmental spondylolisthesis. The long-term objective is to determine the optimal surgical treatment for L5-S1 developmental spondylolisthesis based on x-ray evaluation of sagittal trunk balance and functional outcome.

    Other Multicenter Studies of Importance: By combining efforts with other centers, the Division of Spine Surgery at Children’s in Boston is able to more quickly reach valid research conclusions applicable to clinical practice.

    • Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST)

    BrAIST is a multicenter randomized trial funded by the National Institutes of Health. Children’s Hospital Boston is one of 18 pediatric centers in North America participating in this clinical trial. The overall goal of this research is to determine whether bracing can slow or halt curve progression in patients with Adolescent Idiopathic Scoliosis (AIS), alleviating the need for surgical correction.

    The secondary aims of this study are to 1) investigate the effect of the diagnosis and treatment of AIS on the overall physical and mental well-being of subjects over time, 2) determine the relationship between bracing dose (wear time) and curve progression and 3) develop a predictive model for curve progression based on patient characteristics at their initial presentation and after bracing or watchful waiting.

    • Dual Growing Rod Instrumentation with Limited Fusion for the Treatment of Early Onset Scoliosis

    This multi-center project is sponsored by the Growing Spine Study Group (GSSG). Initially a retrospective study, it has become a prospective observational study with 14 clinical centers from around the world contributing data. The main goal is to determine how successful dual growing rods and Vertical Expandable Prosthetic Titanium Rib (VEPTR™) devices are in correcting progressive scoliosis in very young children.

    Secondarily, researchers want to know if children who undergo successful surgical intervention with these devices, to control their curve during growth, need to go on to receive a definitive final fusion, or if the hardware can be removed and the curve simply observed over time for possible progression.

    Recently, the study was modified to include a non-operative cohort of patients who are treated for early onset scoliosis with non-surgical methods, such as bracing and casting. Outcomes associated with operative and non-operative treatment will be compared in hopes that the most effective methods of correction can be identified.

    • Skeletal Complications in Neurofibromatosis Type 1 (NF1)

    This study is being conducted by researchers at Boston Children's Hospital and Beth Israel Deaconess Medical Center. The goal is to identify cell types associated with and responsible for skeletal defects and impaired bone healing associated with NF1.

    A large proportion of patients with NF1 display skeletal abnormalities such as alterations in bone size and shape, the presence of scoliosis, and a tendency to develop pseudoarthrosis. Tissue samples from patients with and without NF1 will be analyzed by microscopic examination. We hope the results will lead to a better understanding of the cells predominantly responsible for skeletal defects in NF1 and lead to new strategies for treating this patient population.

    Ongoing laboratory studies include:

    • Basic science studies
    • Biomechanical/instrumentation studies

    Orthopedic basic science laboratories

    Working in our labs are some of the leading musculoskeletal researchers in the nation. These labs include:

    National study on surgical outcomes

    Boston Children's Hospital is one of a select group of hospitals involved in a prospective national study to determine the surgical outcomes of patients with complex spinal deformities, including idiopathic scoliosis, early onset infantile scoliosis, kyphosis and spondylolisthesis. The Division of Spinal Surgery is actively involved in the development of non-operative, minimally-invasive and non-fusion techniques for treatment of spinal deformity.

    Children speak: What's it like to be a medical research subject?

    View a video of a day in the life of Boston Children’s Clinical and Translational Study Unit, through the eyes of children who are “giving back” to science.

  • Testing their metal: Titanium rib procedure gives patients room to breathe

    Zoe LambertWhen you meet 4-year-old Zoe Lambert, the first thing you notice is her left shoulder. It sits higher than the right one and makes it look as though she got halfway through a child's shrug of "I don't know" before giving up.

    If you knew the health problems she's had in her short life, however, and realized that a metal rib in her chest allows her to bend at the waist and wave at you through her legs with an upside-down smile, her raised left shoulder would take on greater significance. Instead of an indifferent "I don't know," you might actually see the result of her severe birth defects as expressing a defiant, "What else have you got?"

    Zoe's mother Arlene had a complication-free pregnancy, and none of her seven ultrasounds revealed anything abnormal. But when Zoe was delivered at a hospital in their small hometown of Plymouth, Pa., it took her grandmother, Johanna, only one look to realize that all the prenatal tests had missed something very significant. Johanna says Zoe looked pasty and had a webbed neck, and scans done in the hour after her birth revealed that, in Johanna's words, "the hospital had never seen anything like Zoe before." Less than 24 hours later, she was flown to a hospital in Hershey, Pa., where she was diagnosed with VACTERL syndrome, an extremely rare collection of birth defects. When combined, the worst of the defects was likely to cause Zoe's rib cage to collapse in on itself, a situation that would prevent her lungs from growing and would most likely end up suffocating her.

    Alphabet soup

    VACTERL is an acronym for vertebral, anal, cardiac, tracheal, esophageal, radial (lower arm bone) and/or renal (kidney) and limb—making Zoe's problems sound more like the index of a medical textbook than the problems of a single patient. She had atrial and ventricular septal defects (holes between the upper and lower chambers of her heart, which have since closed on their own), has only one kidney, and her intestines are twisted. But the "V" for vertebral was the most troubling letter in the acronym for little Zoe. She was missing the three vertebrae containing the nerves that provide bowel and bladder control; two additional vertebrae in her neck were fused; she had severe scoliosis (curvature of the spine); three hemivertebrae (or missing pieces of spine); and several ribs that were fused, plus one rib that hadn't formed at all.

    From the day she was born, Zoe needed extensive medical treatment. When she was 6 months old, some of her vertebrae were surgically fused in an effort to lock her spine in place and stop the progress of her scoliosis. By the time she turned 2, however, it was obvious that the spinal fusion had failed and that the progress of Zoe's curvature was impairing her lung capacity and causing heart problems. The situation was quickly becoming life threatening.

    A doctor in Hershey told Arlene that her daughter's only hope was an investigational procedure known as a titanium rib implant. "When I heard the word 'investigational,' I was upset, but I realized this was the only thing that would help Zoe," says Arlene.

    The Lamberts did some research on the Internet and found that the surgery had been developed by Robert Campbell, MD, an orthopaedic surgeon at Christus Santa Rosa Children's Hospital in Texas. Instead of traveling to and from Texas, they decided to come to Boston Children's Hospital, where John Emans, MD, chief of the Division of Spinal Surgery, and his colleagues had been hand-selected by Campbell as the second team in the world to perform the innovative surgery.

    x-ray, zoe lambert, titanium rib recipient, spine problems, rib braces, spine braces, chest braces

    Braces for the chest

    The idea behind the titanium rib procedure is deceptively simple: it performs the same basic function on a patient's chest and ribs that braces perform on teeth. The patient's fused ribs are first separated, and then a lightweight titanium rod is attached vertically to the ribs and/or spine to act as a stabilizer and keep the bones in place. The rod is lengthened regularly, expanding very much like a curtain rod, to keep the fused ribs apart, enlarge the chest, keep the spine more aligned and allow the chest and lungs to continue to grow.

    With the help of a multi-disciplinary team that includes specialists from General Surgery and Pulmonology, Emans has performed more than a dozen initial titanium rib operations and many subsequent lengthenings. These experiences, combined with those of Campbell's team, have shown that the surgery works well for major chest and rib abnormalities such as severe congenital rib fusions and scoliosis. And unlike spine fusions, a common procedure for people with scoliosis, the titanium rib procedure allows for more growth of the chest and spine. "For children who have small chests as a result of these problems, this can be a life-saving procedure," says Emans. "And instead of having the spine of a 2-year-old their whole life as a result of fusion surgery, the titanium rib allows them to grow more than they otherwise would."

    What surgeons don't know at this point is how their patients will fare in the long run. "It will take a number of years—maybe as many as 15—to see how these children do," says Emans. "Many of them were under the age of 2 at the time of the procedure, so we'll need to wait until they have stopped growing to fully evaluate the results."

    Campbell, who has performed the operation on more than 130 children, feels that surgeons have only touched the surface of the titanium rib procedure's potential. "It works well for children with VACTERL, and is a superb way to replace ribs, especially in kids with cancer of the chest wall," he says. "But I think we're going to be surprised by how many uses this surgery will have in the future. For the first time, we're able to treat three-dimensional problems with three-dimensional thinking and techniques."

    Just as Campbell advised Emans on his titanium rib procedures, he sees Emans performing the same function for surgeons at other qualified hospitals throughout the country. "Dr. Emans will serve as a mentor so other programs can begin performing this surgery," says Campbell. "He is a superb teacher and never ceases to amaze me with his ingenuity."

    The pair are currently recruiting patients for an FDA-mandated clinical trial that is expected to come to an end later this spring, and Emans hopes that the surgery will be generally available at qualified centers around the country by the end of the year.

    Straightening the S

    Living within a few miles of a qualified center has been a blessing for Susan Wilson and her daughter, Samantha. Shortly after Samantha's birth, Timothy Hresko, MD, assistant in Orthopaedic Surgery at Children's, found that she was suffering symptoms of respiratory distress and quickly realized that her chest and lungs had stopped growing. He diagnosed her with congenital kyphosis, an abnormal, backward curvature of the spine. This was compounded by the fact that she also had short ribs, some of which were fused while others had large spaces between them.

    In 2000, Emans performed titanium rib surgery on both the right and left sides of Samantha's chest. Since then, Susan has noticed a vast improvement in her daughter's breathing and is amazed how different Samantha looks. "Before the operation she was shaped like an 'S' and doctors said she would never sit straight or walk well," she says. "But now she stands straight and does everything a typical 3-year-old can do."

    Because of the other physical problems related to her VACTERL, Zoe Lambert is not yet able to do all of the same things as other 4-year-olds. She will need intensive rehabilitation to learn how to control her bowels and bladder, and her twisted intestines continue to cause problems that have led her to be rushed to many hospitals, including Children's, for emergency treatment. But Emans' work has taken what were the most dangerous of her problems—those of her spine and ribs—and moved the "V" for vertebral to the bottom of a long list of concerns.

    Zoe now tests near the normal range on physical therapy exams and is able to climb on and off chairs—something she couldn't do before surgery. It is the simple things, though, that have made the biggest difference in Zoe's life and the lives of her mother and grandparents. Every year for more than a decade, the Lamberts have gone to the beach for summer vacation, and last summer, Zoe, who has always loved her trips to the ocean, was finally able to get in the water and play with all the other kids. Zoe's mother put her in bathing suits and little bikinis, the outline of the titanium rod showing faintly through the skin of her small body. Asked to describe her feelings at seeing her daughter grow up and be able to enjoy things like playing at the beach, Arlene states it simply: "She's here. And if it wasn't for Dr. Emans and the surgery, she may not have been."

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