Congenital scoliosis (CS) is a spinal deformity caused by abnormal development of the spinal vertebrae during embryonic life, which is often detected after birth, with a neonatal prevalence estimated to be 0.05% to 0.1% [1]. Peking Union Medical College Hospital [2] reported that it accounts for 5.19% of all scoliosis deformities, second only to idiopathic scoliosis in incidence. Clinically, there are three main types: Type I – impaired vertebral body formation, mainly including wedge-shaped vertebrae and hemivertebrae; Type II – vertebral body malunion, mainly including one side of the “bone bridge” and block vertebrae; and Type III – both impaired vertebral body formation and malunion. The majority of CS is progressive, and surgery is the main treatment method. A review of the literature is summarized as follows. Zhang Xin, Department of Orthopaedics, Qinghai Provincial People’s Hospital 1 Principles of Surgery The surgical objectives are [3] to stop or delay the progression of scoliosis, to maintain spinal balance as much as possible, and ideally surgery should also minimize inhibition of spinal and thoracic growth and minimize the possibility of neurological injury. The surgical plan ultimately depends on the age of the child, the type and location of the deformity, and the experience of the surgeon [3]. The risk of neurologic injury is significantly higher with surgery than with idiopathic scoliosis, and the main preventive measures include: routine MRI; early detection and treatment of spinal deformities; early orthopedic treatment before severe deformity occurs; the use of intraoperative shortening techniques to avoid stretching and lengthening of the spinal cord; the use of motor and sensory evoked potentials for monitoring whenever possible [4] and in conjunction with arousal testing [5]; and the use of controlled hypotension to minimize hemorrhage; Neurosurgery and orthopedic surgery should be performed simultaneously if necessary; postoperative monitoring should also be close, as delayed paraplegia can occur within a few days after surgery, especially within 72 h [5]. 2 In situ fusion is a simple and safe prophylactic procedure that is most commonly used in young children (<5 years of age) with isolated or short-segmented unilateral bridges/hemivertebrae prior to the onset of the typical deformity [3], and prophylactic in situ fusion is also feasible for types with a higher risk of progression, such as fully segmented hemivertebrae [5]. Short-segment in situ fusion in young children has the advantage of less spinal growth loss and good long-term outcome [5]. The main disadvantages [3] are essentially no orthopedic effect and no growth modification. Traditional surgery does not use internal spinal fixation, and the fusion level [3] includes all vertebrae within the measured Cobb's angle and usually extends one segment up and down, with postoperative external immobilization in a plaster cast for about 6 months. The success of the procedure depends on a thorough commissurotomy, decortication operation, and adequate bone graft. Due to the small iliac crest and limited source of autogenous bone in children, allograft bone can be substituted and effective fusion results obtained [5]. Whether posterior in situ fusion is combined with anterior fusion depends on the growth potential of the anterior disc and the size and location of the scoliosis. Preoperative X-rays, CT and MRI can help to evaluate the disc quality and the growth potential of the adjacent cartilage endplates. Young children who fail to combine anterior fusion with the presence of a healthy disc in the anterior region can suffer from the postoperative complication of increased deformity, the "varus phenomenon" [6]. Anterior fusion can be performed using traditional open, thoracoscopic-assisted, and posterior transforaminal approaches, depending on the location of the deformity and the surgeon's habits [7, 8]. 3 Convex epiphyseal block was first reported by Maclennan as early as 1922, and the main indications [3, 5, 9] are patients <5 years of age with isolated convex hemivertebrae, normal or near-normal growth on the concave side, and a Cobb's angle of <40°-50°. Winter RB et al. [10] emphasized that it is suitable for patients who are <6 years of age, <7 segments, and have growth potential on the concave side. and children with growth potential on the concave side. The main contraindications [3, 5, 9] are types with no growth potential on the concave side, such as unilateral bridges, and it is not recommended for those with combined retroconvex deformities. Anterior and posterior one-stage surgeries often require multiple fusions of one normal segment above and below the deformity to increase growth on the concave side to improve scoliosis, and postoperative orthopedic casts can achieve some orthopedic results, usually with 4-6 months of immobilization. Long-term follow-up [5, 10] showed that only 0 ° ~ 20 ° of long-term orthopedic effect can be obtained, combined with convex epiphyseal block and the use of posterior approach spinal internal fixation to assist the concave side of the bracing/convex side of the pressurization can increase the orthopedic effect [10]. 4 Hemilaminectomy Hemilaminectomy directly removes the deformity-causing factors, which results in good orthopedic outcomes and shorter fusion ranges, and is the most ideal treatment for hemivertebral deformity scoliosis. The best indication [11] is for children <5 years of age with thoracolumbar, lumbar and lumbosacral hemivertebrae that cause trunk imbalance. The procedure can be performed using a staged anterior/posterior approach, a one-stage anterior-posterior approach, or a posterior approach, depending on the surgeon's habits and experience. The one-stage anterior/posterior approach requires only one anesthesia and can fully visualize the disc tissue above and below the hemivertebral body and remove it completely, but the operation time is relatively long, and it may require changing the position and re-sterilizing the towel during the operation, which increases the complexity of the operation [12]. Hedequist et al. [13] reported their experience of one-stage anterior/posterior hemivertebral body resection in treating 18 children (mean age, 3 years old) with satisfactory fusion and no neurological complications. Satisfactory fusion was obtained without neurological complications, and the correction rate reached 70%. Equuschick et al [14] also reported the recent efficacy of one-stage anterior and posterior treatment of lateral lordosis in 15 cases of completely segmented hemivertebral deformity (average age 11.8 years), with a correction rate of 68.9%, and the lordosis was corrected from preoperative 31° to 16°. Wang Jinguang et al [15] reported the efficacy of lateral anterior and combined anterior and posterior approaches in correcting scoliosis in 18 cases of hemivertebral spondylolisthesis: Cobb's angle was corrected by an average of 36.7°, with a correction rate of 77%; there was a low rate of loss and good fusion after 18 to 28 months of follow-up. It was concluded that the clinical effect of combined lateral anterior and anterior-posterior hemivertebrectomy was satisfactory, and the anterior surgery was suitable for thoracolumbar and lumbar single hemivertebral deformity. One-stage posterior hemivertebrectomy can achieve equally successful clinical results, and the ideal indication [5] is a hemivertebra located in the thoracolumbar or lumbar segments with kyphotic deformity.Ruf and Harms [11] reported their experience with one-stage posterior surgery in 25 children aged 1-6 years, including both thoracic and lumbar cases, with the coronal Cobb's angle corrected from a preoperative 45° to 14° with no fusion at a 3-year follow-up. 45° to 14° with no neurologic complications. Equuschick et al [16] reported the clinical results of one-stage posterior hemilaminectomy for the treatment of lateral kyphosis of completely segmented hemivertebrae in 18 cases (mean 11.3 years old): the coronal Cobb's angle was corrected from preoperative 42° to 14° in the coronal plane, and 49° to 14° in the sagittal plane at the follow-up. It was concluded that compared with the anterior and posterior one-stage approaches, the posterior approach can shorten the time and reduce the trauma, and is suitable for hemivertebral deformities in the thoracic to lumbar segments. 5 Internal fixation orthopedic fusion Some new, small-sized internal fixation instruments began to be used in CS, and the material was mainly titanium alloy to facilitate the need for postoperative MRI.Hedequist et al [17] reported the treatment experience using internal fixation.The average age of the children was 3.3 years old, and the average preoperative Cobb's angle was 41°.With more than 2 years of follow-up, the internal fixation A more satisfactory orthopedic result was obtained without pseudoarthrosis and neurologic complications. Internal fixation orthopedic fusion can partially or completely correct congenital spinal deformities, and the efficacy depends on the characteristics of the deformity itself, its severity, and the size of the operation. Specific information about the deformity can be obtained preoperatively with good imaging, and special X-rays including traction, supine flexion, and pivot flexion images can be used to understand scoliotic flexibility and to help select the extent of fusion. Posterior internal fixation orthopedic fusion is a relatively safe and effective surgical option for mild to moderate children >10 years of age with relatively normal segmentation and flexibility who do not have severe trunk deformities. Combined anterior surgery is required in two cases: (1) in children with significant growth potential and a deformity with a well-defined intervertebral disc space on imaging, there is a risk of “varus phenomenon” with the posterior approach alone [6]; and (2) in children with moderate deformity and poor flexibility, combined with an anterior approach is required in order to achieve spinal balance and satisfactory fusion results. Treatment of severe congenital scoliosis with rigid imbalance is challenging and requires careful preoperative planning and communication with the family about the risk of neurologic injury. Osteotomies or laminectomies for poorly segmented bridges or fused vertebrae improve orthopedic outcomes but also greatly increase the risk of spinal cord injury and intraoperative bleeding. Surgery is often performed using either a combined anterior and posterior approach or a one-stage posterior approach. Anterior approaches involve discectomy and osteotomy at single or multiple segments, depending on the size of the deformity, and are often open, and osteotomy or resection of the posterior structures may be staged or more commonly accomplished under one-stage anesthesia. Pressurization, shortening, and flattening of the convex side of the vertebral body through anterior or posterior internal fixation is performed while minimizing the risk of spinal cord and nerve root injury; internal fixation of the concave side is necessary to increase stability. One-stage posterior surgery, such as transpedicular osteotomy or laminectomy, can achieve similar results, but is difficult and often associated with the risk of hemorrhage and nerve injury. In adults with kyphosis, transpedicular osteotomy or laminectomy may be a better option. The main disadvantages of posterior surgery [5] include: poor visualization of the anterior column structures during intraoperative hemorrhage, difficulty in dealing with spinal cord and dural problems intraoperatively, and the risk of perioperative displacement of the osteotomy site. Before posterior surgery, the imaging data should be carefully analyzed to recognize the anatomical characteristics of the deformity, and intraoperative operations of compression and shortening of the spinal column should be adopted to avoid traction and lengthening of the spinal cord as much as possible. For CS with kyphosis or extreme rotation, a posterior approach can be used to obtain exposure of the anterior column. congenital lateral kyphosis/posterior kyphosis often requires circumferential osteotomy to obtain orthopedic and decompression needs. due to the posterior position of the parietal vertebrae of the thoracic curvature and the presence of kyphosis, the anterior approach to open up the thorax is not feasible due to poor exposure, and the transverse resection of the rib cage vertebral body can be taken to obtain the exposure of the anterior column through a posterior incision. smith et al. reported that Smith et al. reported their experience with this approach to vertebral body resection and osteotomy in the treatment of 16 cases of congenital kyphosis, which resulted in a satisfactory outcome in 13 cases, with the average kyphosis angle improving from 65° to 34° preoperatively, concluding that the transverse costovertebral resection approach is worthwhile in the surgical treatment of complex thoracic kyphosis. 6 Non-fusion surgery The spine grows fastest in the first 5 years of life, and 5-year-olds are already 2/3 as tall as adults, but their thoracic capacity is much less than that of adults. children with CS are often short in stature and have a shortened torso, and long-segment spinal fusion further reduces the height of the torso and the thoracic capacity, which can lead to the occurrence of thoracic insufficiency. showed that thoracic fusion involving more segments in children <5 years of age can lead to decreased lung function, so the choice of surgical options for children <5 years of age with deformities involving longer segments or with long compensatory curves is a difficult issue. In recent years, studies have reported that the "growing rod technique" may be a better option for young children with early progressive CS without rib fusion, and Harrington [5] reported non-fusion surgery for scoliosis in 1963 and concluded that it should not be performed in children aged <10 years.