Posterior vertebral column resection in early onset spinal deformities

Abstract

Purpose Early onset spinal deformities (EOSD) can be life-threatening in very young children. In the growing spine, surgical intervention is often unavoidable and should be carried out as soon as possible. A deformed section of the spine not only affects the development of the remaining healthy spine, but also that of the chest wall (which influences pulmonary function), the extremities and body balance. Posterior vertebral column resection (PVCR) represents an effective surgical solution to address such problems. However, reports in the literature concerning PVCR are mostly limited to its use in adolescents or adults. The purpose of this study was to illustrate our experience with PVCR in EOSD and to describe the surgical technique with respect to the unique anatomy of young children. Materials and methods Four children [mean age 3.7 (range 2.5-5.2) years] with severe spinal deformity underwent PVCR through a single approach. Multimodal intraoperative monitoring was used in all cases. Surgery included one stage posterior circumferential resection of one vertebral body along with the adjoining intervertebral discs and removal of all posterior elements. A transpedicular screw-rod system was used for correction and stabilisation. Fusion was strictly limited to the resection site, allowing for later conversion into a growing rod construct at the remaining spine, if necessary. Relevant data were extracted retrospectively from patient charts and long spine radiographs. Results The mean operation time was 500 (range 463-541) min, with an estimated blood loss of 762 (range 600-1,050) ml. Mean follow-up time was 6.3 (range 3.5-12.4) years. After PVCR, the mean Cobb angle for scoliosis was reduced from 69°(range 50-99°) to 29°(5-44°) and the sagittal curvature (kyphosis) from 126°(87-151°) to 61°(47-75°). The mean correction of scoliosis was 57 % (18-92°) and of kyphosis, 51 % (44-62°). There were no spinal cord-related complications. In three patients, spinal instrumentation for growth guidance (fusion less growing rod technique) was applied. Two patients had complications: one patient had a complication of anesthesia, halo pin failure, and revision surgery with extension of the instrumentation cranially due to loss of correction; the second patient had a postoperative infection, which required plastic reconstructive measures. Conclusion PVCR appears to be an effective technique to treat severe EOSD. There are important differences in its use in young children when compared with older patients. In patients with EOSD, additional surgical procedures are often necessary during growth, and hence non-fusion instrumentation beyond the vertebral resection site is advantageous, as it permits spinal growth and the later addition of fusion.

Can Intraoperative Spinal Cord Monitoring Reliably Help Prevent Paraplegia During Posterior Vertebral Column Resection Surgery?

“…Papadopoulos et al [24] reported 22% (n 5 10) intraoperative monitoring changes in 45 severe kyphosis cases, 9 congenital and 36 tuberculous, with 1 patient progressing to complete spinal cord injury. Jeszenszky and colleagues [25] described four cases of early-onset spinal deformities treated with PVCR using MEP and SSEP intraoperatively without any neurologic sequelae.…”

Anterior correction of angular kyphosis in children: description of the technique and analysis of clinical series

“…По мнению Jeszenszky et al [11], восстановление сагиттального баланса в условиях ранних деформаций позвоночника эффективно осуществляется за счет VCR, позволяющей исправить исходную кифотическую деформацию со 126 до 55° (56 %). С учетом возраста пациентов (не старше 5 лет), обращают на себя внимание приведенные показатели кровопотери (M = 762 мл) и продолжительности операции (M = 500 мин).…”

Congenital scoliosis treated with posterior vertebral column resection in patients younger than 18 years: longer than 10-year follow-up

“…Ozturk et al 30 reported a main scoliotic curve correction of 62% for PVCR in the treatment of patients with severe congenital kyphosis, scoliosis, or kyphoscoliosis. Lenke et al 21 reported a correction rate of the major curve of 60% in pediatric patients with congenital scoliosis, and Jeszenszky et al 15 noted that PVCR corrected the major curve at a rate of 57% in patients with early-onset spinal deformities. Our main curve correction rates of 70.5% after surgery and 62.2% at the last followup were similar to but somewhat higher than those observed in these previous reports, which may have included patients with much more severe preoperative deformities.…”