Chapter Clinical Summary
Academic synthesis, diagnostic methodology, and surgical recommendationsThe use of plaster immobilization in the spine dates back to the early 20th century, having been systematized by Risser with casts under lateral compression. In 1964, Cotrel introduced the EDF (elongation, derotation, flexion) concept with corrective straps. The method fell into relative disuse due to inconsistent outcomes and the advance of surgical instrumentation, but was redefined by Mehta with the manual derotation technique without straps for infantile idiopathic scoliosis. This reformulation demonstrated that early application, before 18 to 24 months, can achieve complete curve resolution in selected cases. Currently, serial casting is recognized as a growth-preservation strategy in early-onset scoliosis. The method allows controlling deformity, delaying or eliminating definitive surgical interventions and growing systems, ensuring that thoracic spine growth and pulmonary development occur at normal rates.
This chapter aims to train the reader in the practical application of the serial plaster jacket using the EDF technique modified by Mehta for early-onset scoliosis. By the end of the study, the professional should master patient selection, pre-treatment planning with imaging exams, and cast application. In addition, they will learn to measure clinical outcomes, prevent and manage complications such as pressure injuries, and apply a reproducible decision algorithm in medical practice.
Serial casting under general anesthesia is indicated as initial treatment in idiopathic and syndromic early-onset scoliosis. In children under two years of age with curves between 45 and 60 degrees, it enables deformity cure. In older children or those with non-idiopathic curves, it acts by delaying the indication for arthrodesis or growing rods. In congenital scoliosis, it aims to limit the progression of the compensatory curve. In neuropathic scoliosis, it requires careful analysis due to the risk of rib cage deformation from hypotonia/osteopenia and higher propensity for respiratory complications.
Planning requires a detailed neurological examination and magnetic resonance imaging of the neuraxis to rule out intraspinal anomalies or tumors. Radiographically, the Cobb angle, Mehta's rib-vertebra angle difference (RVAD), and thoracic spine height are evaluated. Setup requires a table for cephalic and pelvic traction; in the absence of a Risser table, the chapter describes an alternative frame assembled with PVC pipes. The procedure is performed under light general anesthesia with nasogastric tube insertion, Guedel cannula, and ocular and auricular protection.
Traction (50% proximal and 50% distal) is applied with hips flexed at 45 degrees. Manual derotation is performed by positioning one hand posteriorly on the apex of the rib prominence and the other on the contralateral anterior hemithorax, with the aid of a mirror and support from two assistants. Bony prominences are padded with felt and cotton. After applying conventional and synthetic plaster, asymmetric windows are created: the anterior window is wider on the convexity for thoracic expansion, and the posterior window is located on the concavity to allow rib-cage expansion without crossing the midline.
Cast changes occur every 2 months (up to 2 years of age), 3 months (up to 3 years), and 4 months (from 4 years onward), not exceeding four consecutive casts without global reassessment. At cast change, a period of 2 to 4 hours of bare skin is observed after gentle hygiene. The most frequent complication is Medical Device-Related Pressure Injury (MDRPI), located on the ilium, axillae, and apical vertebra. Long-lasting respiratory complications or deficits from repeated anesthesia are not supported by the literature when adequate monitoring is performed.
The knowledge presented directly guides decision-making in the clinic and operating room. In the diagnostic phase, screening with magnetic resonance imaging prevents the inadvertent application of traction forces in patients with intraspinal malformations. Calculating the RVAD and the child's age defines whether the primary objective will be complete resolution or postponing surgery. During execution, the correct application of three-dimensional forces without excessive lateral compression prevents rib cage deformities. Precise creation of the asymmetric anterior window ensures adequate pulmonary expansion, while the posterior window on the concavity favors curve correction. In follow-up, the skin care protocol is vital. Careful inspection of anchorage zones (iliac crest, axilla, and apical vertebra) combined with a cutaneous rest interval of 2 to 4 hours prevents MDRPI progression. If superficial lesions occur, padding reinforcements and local dressings allow continuing treatment without premature interruption.