ORIGINAL ARTICLE
Growing Rods for Spinal Deformity: Characterizing
Consensus and Variation in Current Use
Justin S. Yang, MD,* Mark J. McElroy, MS,* Behrooz A. Akbarnia, MD,w Pooria Salari, MD,z
Daniel Oliveira, MD,z George H. Thompson, MD,y John B. Emans, MD,J
Muharrem Yazici, MD,z David L. Skaggs, MD,# Suken A. Shah, MD, **
Patricia N. Kostial, RN, BSN,w and Paul D. Sponseller, MD*
Summary of Background Data: Growing rods are a commonly
used form of growth guidance for patients with early onset
scoliosis, but no studies exist to characterize their use among a
large group of surgeons.
Methods: A survey regarding growing rod use preferences and a
case-based survey regarding early onset scoliosis were completed
by an international group of surgeons. Two hundred and sixty-
five growing rod patients treated over 4.7 ± 2.1 years in the
Growing Spine Study Group database were analyzed to
characterize actual practice and compare it with the survey
results. All patients had at least 2 years of treatment.
Results: In the case-based survey, there was correlation
(P = 0.04, r = 0.58) between increasing curve size and choice
of growing rods over nonoperative treatment, rib-based
distraction (vertically expandable prosthetic titanium rib),
growth guidance (Shilla), and primary fusion. In practice,
growing rods were used for most types of early onset spine
deformity. Most surgeons stated that their indication for
growing rod treatment was a curve over 60 degrees (10/13) in
a patient younger than 8 to 10 years (14/17). In practice, mean
curve at rod insertion was 73 ± 20 degrees and age was 6.0 ±
2.5 years. Other factors favoring growing rods included curve
rigidity (8/17), brace intolerance (6/17) and syndromic diagnoses
(2/17). In the database, idiopathic scoliosis represented <50%
of diagnoses. The most common preferred surgical lengthening
interval was 6 months. However, in practice, lengthening
actually occurred at a mean of 8.6 ± 5.1 months. In the
database, the number of growing rod insertions per year
From the *Department of Orthopaedic Surgery, Johns Hopkins Medical
Institutions, Baltimore, MD; wUniversity of California, San Diego
School of Medicine, San Diego, CA and San Diego Center for Spinal
Disorders; zSan Diego Center for Spinal Disorders, La Jolla;
#Childrens Hospital Los Angeles, Los Angeles; yDivision of
Pediatric Orthopaedic Surgery, Rainbow Babies and Children’s
Hospital, Cleveland, OH; JDivision of Spinal Surgery, Children’s
Hospital Boston, Boston, MA; zHacettepe University School of
Medicine, Ankara, Turkey; and **Alfred I. duPont Hospital for
Children, Wilmington, DE.
None of the authors received financial support for this study.
IRB Approval: This study was approved by the Johns Hopkins Hospital
IRB.
Reprints: Paul D. Sponseller, MD, Department of Orthopaedic Surgery,
Johns Hopkins Medical Institutions, 601 North Caroline Street,
Suite 5212, Baltimore, MD 21287. E-mail: psponse@jhmi.edu.
Copyright r 2010 by Lippincott Williams & Wilkins
264 | www.pedorthopaedics.com
(P = 0.02, r = 0.96) and percentage of surgeons using dual rods
over single rods (P = 0.065, r = 0.93) increased over time.
Insertion age (P = 0.075, r =  0.87) and lengthening interval
(P = 0.006, r =  0.69) decreased as time progressed. The most
common stated indication on the survey for final fusion was
skeletal maturity (13/17), and 7/13 surgeons used Risser 3 or
more. Indications to stop lengthening included complications
such as infection or implant failure (14/17), curves progressing
past 90 degrees (8/17), and failure to distract (6/13). The most
common method of final fusion was replacement of implants
with more intermediate anchors.
Conclusions: Significant practice variation exists in growing
rod treatment, but there is some consensus on indications for
surgery including curve size, diagnosis and age, and lengthening
intervals and final fusion methods. Mean curve size and
lengthening interval are greater in practice than in surgeons’
stated aims. In principle and in practice, most growing rods are
used for curves over 60 degrees in patients under 10, in all
diagnoses. This information may form a starting point as
practice variation is studied.
Key Words: early onset scoliosis, growing rods, indications,
practice, survey
(J Pediatr Orthop 2010;30:264–270)
E arly-onset scoliosis (EOS) is a challenging condition to
treat. The roles of observation, casting, bracing, and
various forms of surgery continue to evolve. However,
performing definitive fusion before skeletal maturity may
lead to a shortened spine and pulmonary restriction
owing to a diminished thoracic cavity.1 Various types of
distraction and growth guiding techniques have been
developed to alleviate these effects, including the use of
growing rods.1 As this technology becomes more widely
used, it is important to characterize the current use of
growing rods by a large and diverse group of surgeons
over a large patient population.
The investigators carried out 2 surveys. One queried
for the surgeons’ general growing rod practices, and the
other asked for their recommended treatment for specific
cases of EOS. Survey results were compared with data on
265 growing rod patients in the Growing Spine Study
Group (GSSG) database to examine whether actual
J Pediatr Orthop  Volume 30, Number 3, April/May 2010
J Pediatr Orthop  Volume 30, Number 3, April/May 2010
practice coincided with stated preference. The investiga-
tors hypothesized that there were areas of both signifi-
cant variability and relative consensus in the application
of growing rods. We expected that most aspects of actual
practice would match the survey results, but a few aspects
would differ.
METHODS
The study had 3 components. The first was a
preference survey to query surgeons whose practice
includes EOS regarding their preferred indications,
surgical technique, clinical follow-up and final treatment
protocols for growing rod surgery. A questionnaire was
distributed to 19 surgeons who commonly use growing
rods, and 17 responded (89%). All surgeons in the GSSG
at the time of the study were queried, with the addition of
3 non-GSSG practitioners who commonly used growing
rods. The responses were tallied and analyzed.
The second portion of the study was a case-based
survey in which case scenarios for 21 patients with EOS
and a variety of diagnoses were distributed to spine and
pediatric orthopaedic surgeons. Cases were selected to
reflect the variety of patient scenarios spine and pediatric
orthopaedic surgeons may encounter in practice. The
specific diagnoses are in Table 1. The case scenarios
included both clinical and radiographic data. Surgeons
were asked to indicate their preferred treatment option
for each patient, choosing from nonoperative treatment,
spine-based distraction (growing rod), rib-based distrac-
tion (Vertically Expandable Prosthetic Titanium Rib -
VEPTR), growth guidance (Shilla) and primary fusion.
The survey was sent to 40 surgeons and completed by 17
(43%). Surgeons selected included GSSG members and
other non-GSSG practitioner who were able to treat
patients with a variety of options including those in the
survey.
The third part of the study analyzed actual practice
with respect to the survey results. From 1994 to 2007, 265
patients underwent growing rod surgery at 16 interna-
tional centers. A retrospective review of collected medical
records was performed. The data collected included age at
initial and final surgeries, sex, diagnosis, preoperative
TABLE 1. Diagnoses for 21 Patients in Case-based Survey
No. Patients Diagnoses
11 Idiopathic
3* Congenital
2* Myelomeningocele
1 Marfan syndrome
1* Sacral agenesis
1 Neuromuscular (other than CP)
1 Neurofibromatosis
1 13–Q syndrome
1 Cerebral Palsy
1 Arthrogryposis
*Total of 23 diagnoses shown for 21 patients. One patient with myelome-
ningocele and 1 patient with sacral agenesis were also diagnosed with congenital
scoliosis.
r 2010 Lippincott Williams & Wilkins
Characterizing Current Use of Growing Rods
ambulation status, postoperative bracing, initial and final
major coronal Cobb angle, initial and final kyphosis (T3-
T12), type of instrumentation, total number of surgeries,
number of rods inserted, lengthening intervals, and total
number of lengthenings. The surgeons who carried out
the cases made the relevant radiographic measurements
according to the GSSG protocol. The mean treatment
time for all patients was 4.7 ± 2.1 years. The mean
treatment time for active patients was 4.5 ± 1.9 years.
Patients who have completed treatment and reached final
fusion had an average treatment time of 5.1 ± 2.4 years.
Descriptive statistical analysis including means,
standard deviations and percentages were used to sum-
marize the data. Multivariate and singular linear regres-
sions were used to analyze database trends over time.
In each multivariate regression, one of the subse-
quent variables was treated as the outcome variable
whereas all of the others were treated as the predictor
variables: number of new patients, percentage of idio-
pathic diagnoses, percentage of new cases using dual rods,
average lengthening interval, average starting coronal
Cobb angle, average age at growing rod insertion, and
year.
In each singular linear regression, one of the
subsequent was treated as the outcome variable whereas
the year was the sole predictor variable: number of new
patients, percentage of idiopathic diagnoses, percentage
of new cases using dual rods, average lengthening
interval, average starting coronal Cobb angle, and
average age at growing rod insertion.
All of the above regression analysis was performed
using Microsoft Excel Statistical Package (Microsoft, Inc.
Redmond, WA). Regression results were considered
statistically significant when the Type I error was less
than or equal to 0.05.
RESULTS
In the preference survey, surgeons stated that their
most important indication to initiate growing rod
treatment was scoliosis curve size (13/17), with most
surgeons (10/13) setting the threshold curve at 50 degree
to 60 degree. In the database, the mean preop curve was
73 ± 20 degree, with 87% of patients more than 50
degree. Of the 13% of patients (24) receiving growing
rods with curves less than 50 degree, 3 were congenital
and 11 were idiopathic diagnoses. Additionally, the
results of the case-based survey showed that, given the
choice between growing rods, nonoperative treatment,
VEPTR, Shilla, and fusion, surgeons increasingly chose
growing rods as the curve size increased. This correlation
(P = 0.04, r = 0.58) was evident in a multivariate analysis
in which the percentage of surgeons choosing growing
rods was analyzed as a function of the diagnosis, age,
curve, and curve flexibility.
The preference survey results indicated that the
oldest skeletal age at which surgeons would initiate
growing rod treatment was 8-10 years (16/17) (Fig. 1).
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Yang et al J Pediatr Orthop  Volume 30, Number 3, April/May 2010

7 Most surgeons responding to the preference survey

6 recommended lengthening every 6 months (12/17). The
# of Surgeons out of 17

mean lengthening interval for the 265 patients in

5
4 the lengthening intervals falling at 6 months or less. Five
3 surgeons had experienced familial resistance toward
2
1
0 change in the child to require a lengthening and burden
2 3 4 5 6 7 8 9
Patient Age
FIGURE 1. Surgeons’ maximum ages for insertion of growing
rods.
In the database, the mean age at initial surgery was
6.0 ± 2.5 years, with 94% of patients <10 years.
Curve rigidity was also an indication (8/17) in the
preference survey. Other indications included brace
intolerance (6/17) and syndromes diagnoses such as
NF1 (2/17). The diagnoses in the database were
idiopathic in 82 patients (54 infantile and 28 juvenile),
neuromuscular in 58 patients, congenital in 42, and
miscellaneous disorders in 77. Flexibility data was not
collected in the database to further study this variable.
Diagnoses considered by some in the preference
survey to be contraindications to growing rods included
myelomeningocele (MM) (4/17), severe kyphosis (3/17)
and chest wall deformities (2/17). Some surgeons consid-
ered none of these diagnoses to be contraindications (5/17).
The type of anchor to use proximally and distally is
an important consideration for the surgeon. Surgeons
were not queried regarding preferred anchors in the
preference survey. Two hundred thirteen patients had
complete anchor information recorded in the database.
Cephalad anchors consisted of 77% hooks (166/213),
17% screws (36/213), 3% hooks and screws (7/213), and
1% hooks and wires (3/213). Caudal anchors consisted of
46% screws (97/213), 43% hooks (91/213), 7% hooks and
screws (15/213), 3% wires (7/213), <1% hooks and wires
(1/213) and <1% screws and wires (1/213) Table 2.
the database was 8.6 ± 5.1 months, with only 24% of
regular lengthenings. Their comments included concerns
of risk/reward after initial procedure, perception of
psychological trauma, parents not perceiving a clinical
10 11 12 13 14 of care. Scheduling of lengthening was the responsibility
of the family in 7 practices, of the surgeon in 6 and of
both in 3.
The information in the GSSG database allowed for
detailed analysis of treatment trends from 1994 to 2007.
A summary of the data is presented in Table 3.
Multivariate analysis showed that the number of
new patients per year increased as time progressed
(P = 0.02, r = 0.96). Two other trends approaching
statistical significance were a decrease in insertion age
(P = 0.075, r =  0.87) and an increase in the percentage
of surgeons using dual rods over single rods (P = 0.065,
r = 0.93) as time progressed. No trends were seen in the
percentage of idiopathic diagnoses, major coronal Cobb
angle or lengthening interval.
Next, singular linear regression was performed
using time as the predictor variable to further study
trends. As time progressed from 1994 to 2007, the number
of new patients (P<0.001, r = 0.95) and the percentage
of dual rods (P<0.001, r = 0.86) increased whereas the
age at insertion (P = 0.03, r =  0.57) and lengthening
interval (P = 0.006, r =  0.69) decreased. The initial
coronal Cobb angle and the percentage of new patients
diagnosed as idiopathic showed no significant change
over time. These relationships are shown in Figures 2 to 7.
We also studied the practice patterns regarding the
completion of growing rod treatment. In the preference
survey, surgeons were asked which factors led them to
stop distraction. Options listed includes skeletal maturity
(Risser, Tanner, bone age, chronological age, and
longitudinal growth), failure to lengthen or control the

TABLE 2. Indications and Contraindications for Growing Rod Treatment

Preference Survey Growing Spine Study
(17 Surgeons) Group Database (265 Patients)
Preoperative curve size (13/17) Most commonly selected indication 73 ± 20 degree
(10/13) Minimal curve = 50-60 degree 87% of patients >50 degree
Preoperative skeletal age (14/17) Maximum = 8-10 y 6.0 ± 2.5 y 94% of patients <10 y at growing
rod insertion
Diagnoses 21.9% Neuromuscular scoliosis
20.4% Infantile idiopathic scoliosis
15.8% Congenital scoliosis
10.6% Juvenile idiopathic scoliosis
29.1% Miscellaneous disorders
Other indications (8/17) Curve rigidity
(6/17) Brace intolerance
Contraindications (5/17) None
(4/17) MM
(3/17) Severe kyphosis
(2/17) Chest wall deformities

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J Pediatr Orthop  Volume 30, Number 3, April/May 2010 Characterizing Current Use of Growing Rods

TABLE 3. Yearly Averages From Growing Spine Study Group Database Growing Rod Patients
Starting Coronal Age at Growing Lengthening
Year New Patients Cobb Angle Rod Insertion (y) % Idiopathic % Using Dual Rods Interval (mo)
1994 4 62 8.2 75 25 20.2
1995 5 69 6.6 40 20 9.9
1996 10 72 6.9 20 30 11.4
1997 10 75 6.3 30 67 12.3
1998 15 75 6.8 13 54 10.3
1999 10 70 5.2 10 25 8.1
2000 25 72 6.6 38 45 10.5
2001 23 70 6.1 35 46 9.9
2002 23 67 6.1 35 53 9.1
2003 22 79 4.6 41 59 10.1
2004 36 80 5.9 35 74 8.5
2005 34 68 5.5 24 82 8.1
2006 38 75 6.2 31 87 8.3
2007 33 76 6.4 40 100 7.6

curve and complications of surgery. The most common
stated indication for final fusion was skeletal maturity
(13/17), and 7/11 surgeons used Risser 3 or more. One
surgeon each listed Tanner greater than 3 and bone age
(not specified). Other indications for stopping lengthening
included repeated complications (14/17), curve progres-
sion past 90 degree (8/17) and failure to distract (7/14).
Final treatment technique is an important consid-
eration. Direct comparisons were made between the
preference survey and the database, which included 61
patients who finished the lengthening phase of treatment
at a mean age of 12 ± 1.8 years.
Definitive fusion was the most prevalent final
treatment option in both the survey and the database.
Eighty-two percent (14/17) of surgeons indicated they use
definitive fusion, and 87% (53/61) of the database
patients were fused. Various methods were used to
achieve fusion. In the survey, 76% (13/17) preferred to
replace all implants and add more intermediate anchors,
6% (1/17) elected to add more intermediate anchors
but leave rods and connectors, and 0% opted for bone
grafting with existing implants and tandem connectors. In
the database, 61% (37/61) of cases replaced everything
and added more intermediate anchors, 2% (1/61) added
more intermediate anchors but left the rods and
connectors, 11% (7/61) used bone graft with the existing
implants and tandem connectors and 10% (6/61) used
other techniques.
However, 29% (5/17) of surgeons surveyed ex-
pressed that they do not always carry out fusion if the
patient is having no problems with implants. In the
database, 12% (8/61) of patients were not fused after
lengthening was completed. Specifically, 8% (5/61) of
patients had implants removed without fusion, 3%
(2/61) had growing rods left in place without fusion and
2% (1/61) were transitioned to VEPTR instrumentation
Table 4.
DISCUSSION
The literature contains several studies that discuss
indications for growing rod surgery, rod lengthening
intervals, complications and final fusion criteria at the
conclusion of treatment.1–5 However, none of the
previous studies characterizes growing rod practice over
a large patient and surgeon population. The surveys and
database analysis presented in this study represent an
analysis of consensus and variation in practice in this

FIGURE 2. Trend of new patients from 1994 to 2007. FIGURE 3. Trend of idiopathic patients from 1994 to 2007.

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Yang et al
FIGURE 4. Trend of initial Coronal Cobb Angle from 1994 to
2007.
evolving area. The GSSG patients are a treated by a
group of surgeons with a special interest in this technique
and do not represent a fair weighting of all surgical
options in practice. The analysis of this database is mainly
to further define a set of indications and practice for this
particular technique, not to exclude others.
The most widely agreed upon indication for
beginning growing rod surgery is failure of treatment
with bracing or casting.1–5 However, more specific guide-
lines have not emerged. Areas of variability include type
of ‘‘growth guidance’’ to employ and specific indications
for starting treatment. Growing rods are one of the most
common types of growth-guiding treatment used for large
curves. However, VEPTR is uniquely suited for defor-
mities with rib fusions and is also used for other types of
spinal deformity. Self-guided growing rods (Shilla) are
an emerging option as well. The relative roles of each
of these options are partially diagnosis-dependent and
remain to be defined. This definition will likely emerge
from relative assessment of the results of each treatment,
and consensus studies such as this one.
The case-based survey presented a wide range of
scoliotic conditions. Growing rods were the most favored
FIGURE 5. Trend of patient age at growing rod insertion from
1994 to 2007.
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J Pediatr Orthop  Volume 30, Number 3, April/May 2010
FIGURE 6. Trend of percentage of new cases using dual rods
from 1994 to 2007.
treatment option selected by surgeons and were chosen
31% more often than the next closest option. The choices
included spine-based distraction (growing rod) (51.5%),
non-operative treatment (19%), growth guidance (Shilla)
(10.9%), VEPTR (10.6%) and fusion (3.7%). Therefore,
among this surgeon sample, it seems that growing rods
are currently the treatment of choice except for cases
involving small curves or specific diagnosis, such as rib
fusions.
The consensus on curve size was that curves over
approximately 60 degree merit surgical intervention. Mean
curve size in the GSSG database was 73 ± 20 degree
at initial surgery. The concordance between theory and
practice was close, and the difference may reflect progres-
sion during the time between indication and operation.
In contrast, the upper boundary for growth guided
surgery relates to age and maturity. Most surgeons felt
that patients over 10 years old would not benefit from
such procedures. In practice, the database showed that
94% of patients were below this age and the mean age at
surgery was 6.0 ± 2.5 years.
In our multivariate analysis of the GSSG data-
base, we showed an increase in the number of index cases
FIGURE 7. Trend of average lengthening interval from 1994
to 2007.
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J Pediatr Orthop  Volume 30, Number 3, April/May 2010 Characterizing Current Use of Growing Rods

TABLE 4. Clinical Aspects of Growing Rod Treatment

Lengthening interval
scheduling of lengthening procedures
Family relations
Indications for final fusion
Age at final treatment
Final treatment technique
Definitive fusion technique
Preference Survey Growing Spine Study Group Database
(17 Surgeons) (265 Patients)
(12/17) Every 6 mo 8.6 ± 5.1 mo
(7/17) Family
(7/17) Surgeon
(3/17) Both
(5/17) Experienced familial resistance to lengthening
procedures
(13/17) Skeletal maturity (6/11 use Risser 4)
(14/17) Complications: infection or implant failure
(8/17) Curve progressing over 90 degree
(7/17) Failure to distract
12.1 ± 1.8 y
(14/17) Definitive fusion (53/61) Definitive fusion
(5/17) Do not always fuse if patient having (5/61) Implants removed, no fusion
no problems with implants (2/61) Rods left in place, no fusion
(1/61) Transitioned to VEPTR
(13/17) Replace everything and add more (37/61) Replace everything and add more
intermediate anchors intermediate anchors
(1/17) Leave rods/connectors and add more (1/61) Leave rods/connectors and add
intermediate anchors more intermediate anchors
(0/17) Bone graft with existing implants, (7/61) Bone graft with existing implants,
including tandem connectors including tandem connectors
(0/17) Other (6/61) Other

over time. This can be explained perhaps by the increase
use of growing rods and the addition of surgeons to the
study group. Age also trended down over time indi-
cating perhaps a shift in surgical indication. Dual rod use
increased and lengthening intervals decreased with time,
also perhaps indicating a shift in surgical preference.
Notably, variables that did not seem to change over time
included diagnosis (% idiopathic), initial coronal curve
size, and bracing. This may indicate that these variables
have been generally agreed upon as standard of practice.
Because growing rods are a complicated and long
course of treatment, several investigators emphasize the
importance of having understanding from and agreement
with the patient’s family.1,3,4 This is critical when it comes
to adhering to the recommended lengthening intervals.
Thompson et al. mention that single rods may be
lengthened when the major curve has progressed 15
degree to 20 degree.5 However, our survey showed that no
surgeons used this guideline in practice. On the other
hand, Akbarnia et al4 showed dual rod treatment to be
most effective when the lengthening interval is 6 months
or less regardless of progression. Our results showed that
most surgeons are in agreement with this practice and
have a preferred lengthening interval of 6 months.
However, only 23% of intervals fell within this time.
The mean interval was 8.6 ± 5.1 months. The survey
indicated that both scheduling factors and reluctance
by families may be factors in causing the intervals to be
longer than preferred. Until development of procedure-
free lengthening, further effort will be needed in defining
and carrying out lengthening at appropriate intervals.
Growing rod treatment can be stopped when the
child has reached a sufficient age and level of skeletal
growth.3,5–9 The management of patients at the end of
growing rod treatment is the most variable, in part
because few patients have matured to this level. There was
great variability in surgeons’ decisions to stop lengthening
growing rods. Most surgeons stated that they relied on
radiographic assessment of skeletal maturity, with the
most common method being Risser sign (Risser 3 or
more). Agreement on chronologic age did not exist, and
more sophisticated measures of maturity were not widely
used. In part, this may also be owing to emergence of
other reasons to stop lengthening, such as patient and
family resistance, failure to distract and failure to control
the curve.
When distractions are complete, depending on the
particular case, the patient’s spine is either definitively
fused, the growing rod instrumentation is left in place or
the growing rod instrumentation is removed and the spine
is left mobile.1,3–9 Despite variability in indications for
stopping distraction, strong agreement existed regarding
final treatment methods. The majority of surgeons (82%)
prefer to perform definitive fusion, and the percentage of
finished patients in the database who were fused (87%)
confirms this conclusion. A smaller portion of surgeons
(29%) indicated that they do not always perform fusion,
but the database showed that only 12% of patients were
not fused after finishing distractions. The clinical results
of rod removal and leaving the spine mobile is likely to
be the subject of future research in the field.1,4,5,7
Practice variation exists in growing rod treatment.
There is some consensus on indications for growing rod
surgery including curve size (over 60 degrees), flexibility,
diagnosis (almost all are included), and age (under 10 y).
The most common intended lengthening interval is every
6 months, but in practice this is not met. The indications
and practice of stopping lengthening is determined by

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Yang et al
diminishing clinical benefit or signs of skeletal maturity,
with little agreement beyond this.
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