Characterization of complex vertebral transposition (gamma deformity) > 180 degrees: clinical and radiographic outcomes of halo gravity traction and vertebral column resection (VCR)

Abstract

Study Design Prospective case seriesObjective Results of surgical treatment of complex vertebral transposition "Gamma Deformity" > 180 degrees with halo gravity traction (HGT) and vertebral column resection (VCR). Summary of background dataWe recently published a novel classification system for complex spine deformities of which complex vertebral transposition > 180 degrees (Gamma; type 3) was described. Halo gravity traction (HGT) has been shown to mitigate surgical risk in complex spine deformity correction and in some cases obviates the need for three-column osteotomy. However, we are not aware of report of its utilization in treating Gamma deformities with or without vertebral column resection (VCR). Methods A consecutive series of 13 patients with Gamma deformity (GD) were prospectively enrolled at a single site in West Africa. Standard radiographs and 3D computerized tomography (CT) were done to assess coronal and sagittal vertebral transposition (CVT and SVT). The HGT with 50% of body weight was applied over several weeks followed by VCR. Demographics, operative data, radiographic parameters, and complications data were collected. Results 13 pts with GD underwent HGT for an avg of 110 days prior to definitive surgery. Etiologies were Congenital-11 pts and Neurofibromatosis-2 pts. Average age: 17.8 years; Pts were reviewed at 3 months post-op and at minimum 2-year follow-up. Preop myelopathy was present in five patients. Pre-op CVT avg 75% and was corrected in all cases post-op. SVT avg 211 deg and improved with HGT by 36% and corrected to 53 deg (74% correction) post-op. Thoracic kyphosis avg -42 deg and averaged 48 deg post-op. Intra-op spinal cord monitoring (SCM) alerts occurred in 8 pts (61%). Post-operative LEM deficits occurred in 5 pts: 2 fully recovered by 3 months and 2 year follow-up, while the remaining 3 improved but had residual motor deficits at final follow-up. There was one post-operative mortality. Conclusion The management of complex vertebral transposition (Gamma deformity) > 180 degrees with HGT prior to VCR is not only effective in some patients, but also associated with high SCM alerts and neurologic injury rates. Myelopathic patients with thoracic deformities are at higher risk of developing permanent neurologic deficits. Surgeons should be aware of this rare and unusual deformity and consider HGT and VCR bearing in mind the technical challenges and high complication rate.

Clinical Outcomes of 3-column Osteotomy at Growing Rod Graduation

“…It should be noted that anterior and anterior-posterior combined surgeries were also involved in the mentioned study. In deformities with increasing complexity, rate and severity of the complications can also be expected to rise: in 13 patients with complex vertebral transpositions, 3 patients had residual motor deficits after posterior VCR, even when combined with halo gravity traction to reduce the risk 28. In our study, 2 complications occurred that altered the treatment course, 1 was classified as grade 2 and resolved with local measures, and 1 was grade 3 which required an unplanned intervention and complete resolution.…”

Radiological and Pulmonary Results of Surgical Treatment of Severe Idiopathic Scoliosis Using Preoperative Halo Gravity Traction Compared with Less Invasive Temporary Internal Distraction in Staged Surgery in Adolescents

“…This involved utilizing 8-10 pins to optimize distraction, thereby decreasing the likelihood of pin pullout and instability in the Halo ring during traction. Traction initiation commenced at 2-3 kg and was incrementally augmented to a maximum of 50% of the patient's body weight, mirroring protocols detailed in prior studies [4,10,20]. Subsequent to the completion of the HGT regimen, corrective measures for the spinal deformity were undertaken through a conventional posterior approach employing segmental screw instrumentation via a free-hand technique, alongside posterior column osteotomy, as documented in the pertinent literature [27][28][29][30][31].…”

“…Severe and rigid scoliosis is a form of spinal deformity in which the Cobb angle of the main curvature is greater than 90 • and flexibility is less than 30% [1,2]. Severe and untreated scoliosis can have a serious impact on a patient's health and quality of life, and the surgical correction of large curves is difficult because it is associated with a high risk of neurological injury, especially when a large curve is attempted in one procedure [3][4][5][6][7]. Additionally, if left untreated and still progressing, serious deformities of the spine can lead to dysfunction of the entire body, causing disorders of the nervous and circulatory-respiratory systems, which, in turn, affect the growth, appearance, and long-term mortality of patients [7,8].…”

“…However, various alternative methods have also been introduced for managing severe spinal deformities, such as temporary internal distraction (TID) and its various adaptations, anterior release (AR), posterior release (PR), and thoracoplasty with rib osteotomy (TP), as well as different forms of three-column osteotomies like pedicle subtraction osteotomy (PSO) and vertebrectomy (commonly known as vertebral column resection (VCR)) [16][17][18][19][20][21][22][23][24][25]. Techniques involving gradual traction, whether external or internal, are typically viewed as safer compared with the more aggressive three-column osteotomy (3CO) approach, with a confined and acceptable incidence of complications [3,4,6,[10][11][12][15][16][17]20,24,26].…”

Osteotomies for the Treatment of Adult Spinal Deformities

“…Even when a 3CO is unavoidable, one might consider choosing a lower grade, as Hengwei et al 62 reported similar radiographic and clinical outcomes after Grade-4 and Grade-5 thoracic osteotomies. Likewise, use of halo-gravity traction prior to VCR might improve the efficacy and safety of the surgical procedure in patients with a complex deformity 63 . There might also be other workarounds such as the use of transpedicular, anterior opening-wedge osteotomy with lamina preservation for a select group of patients 64 .…”