Elongation, Derotation, and Flexion Casting on a Jackson Table

Editor’s note: The following article is a review of a video available via the AAOS Orthopaedic Video Theater (OVT). AAOS Now routinely reviews OVT Plus videos, which are vetted by topic experts and offer CME. For more information, visit aaos.org/OVT.

Early-onset scoliosis can have devastating pulmonary consequences to patients, which can result in decreased quality of life. Elongation, derotation, and flexion (EDF) casting has been used as a technique to both halt and occasionally reduce curve progression in early-onset scoliosis. EDF casting can be used as a curative treatment for infantile idiopathic scoliosis, especially when started prior to the age of 18 months. It can also be used for delaying implantation of spinal instrumentation in young children with early-onset scoliosis regardless of etiology.

Traditionally, EDF casting has been performed on special tables or frames, which are not always available at every institution. In addition, these frames/tables are an additional cost to the institution and take up storage space for operating room (OR) equipment. In this OVT video by Blake Montgomery, MD; Kali R. Tileston, MD, FAAOS; Japsimaran Kaur, BS; Celeste Brody, RN; Meghan N. Imrie, MD, FAAOS; James Policy, MD, FAAOS; Lawrence A. Rinsky, MD, FAAOS; and John Vorhies, MD, the authors set out to demonstrate a safe alternative to the specialized EDF casting tables using the Jackson frame, which is likely already available in most orthopaedic ORs in the United States, and compare the results versus EDF casting on a special table or frame.

The video begins by providing a list of equipment to have readily available in the OR for this procedure. Having everything readily available to keep the procedure as streamlined as possible helps to minimize the child’s time under general anesthesia.

Modified Jackson table setup
The novel aspect of this video is the discussion of Jackson table modifications (Fig. 1). The viewer is sequentially brought through each modification, starting with the standard cervical head rest followed by use of the arm holders upside down to allow for positioning of padded dowel rods between the brackets. The patient’s shoulders and sacrum are safely supported on these dowel rods during the case, which also facilitates ease of plaster or fiberglass application. Splitting the shoulder support rod centrally allows for improved access to the shoulder area and is especially useful for an over-the-shoulder cast. A padded Mayo stand or a third dowel rod is placed at the end of the bed to allow the patient’s feet to be supported for the duration of the procedure. Routing the cotton rope underneath the frame is a helpful tip to keep the stockinette from slipping off the iliac crest, therefore maintaining traction during the procedure. Although not discussed, using the upside-down arm holders as a leverage point for the stockinette is a good alternative to routing the cotton rope underneath the Jackson frame.

When preparing the patient on the surgical table, it is critical to ensure bony prominences are padded prior to application of traction, which the video effectively describes (Fig. 2). Using foam pads or even Webril for padding and securing the arms helps to ensure no inadvertent soft-tissue injury to the patient.

Surgeon preference plays a large role in certain cast modifications. For example, some surgeons prefer casts over the shoulder, whereas others prefer casts below the shoulders. Additional information or closer images in the OVT video regarding the padding for over-the-shoulder casts would have been beneficial, as these are often difficult to do well. The authors depict both techniques with emphasis on ease of fluoroscopy access and molding ease with the dowel rod modification. Final cast adjustments are made after deformity correction is achieved and confirmed with fluoroscopy. The asymmetrical cast windowing is used by the surgeons in the video, but it is not a universal technique in EDF casting.

Outcomes with modified table
In this OVT video, the surgeons then retrospectively review patients with early-onset scoliosis from 2015 to 2019 who were treated at the same institution (25 patients who underwent 74 castings). Eleven patients underwent EDF on a modified Jackson table and 14 underwent EDF on a Risser frame. The analysis found no significant difference in initial coronal Cobb angle correction or cast-related complications between groups. It found that the patients who underwent casting on a modified Jackson table had a shorter surgical time by 16 minutes.

Overall, this video is an important addition to the current technique for EDF cast application without the additional cost of a single-use piece of OR equipment. The group concluded that modified Jackson table casting is a safe alternative for EDF casting when a Risser frame is not readily available.

Ryan A. Finkel, MD, is an orthopaedic surgery resident at Cedars-Sinai Medical Center in Los Angeles. He will be starting his spine surgery fellowship at the San Diego Spine Foundation in August 2025.

Selina Poon, MD, MPH, FAAOS, is a pediatric orthopaedic surgeon and director of research at Shriners Children’s Southern California in Pasadena, California. She is also a member of the AAOS Now Editorial Board.

Video details
Title: Elongation, Derotation, and Flexion Casting on a Jackson Table
Authors: Blake Montgomery, MD; Kali R. Tileston, MD, FAAOS; Japsimaran Kaur, BS; Celeste Brody, RN; Meghan N. Imrie, MD, FAAOS; James Policy, MD, FAAOS; Lawrence A. Rinsky, MD, FAAOS; and John Vorhies, MD
Published: March 1, 2020
Time: 9:59
Tags: Pediatrics, Anatomic Disorders, Early-Onset Scoliosis, Spine, Award Winners, Scoliosis

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