Neurologic and Non-neurologic Status: Vertebral Column Resection (VCR) for Severe Pediatric and Adult Spinal Deformity

Kathy M. Blanke, RN
Washington University School of Medicine
St. Louis, MO

Scoliosis Research Society Paper 13
42nd Annual Meeting
Edinburgh, Scotland
September 5-8, 2007

Table 3: Complications of 43 Patients

One patient had loss of unilateral SSEP and NMEP data on the convexity of a large kyphoscoliosis with a failed intraoperative unilateral wake-up test. A temporary rod was placed, the procedure was aborted, and the patient's wound was closed. It was thought that the deficit was most likely due to inadvertent unilateral spinal cord compression from a cottonoid placed to control copious epidural bleeding on the convex side. Following removal of the cottonoid, the SCM data returned to baseline. Following wound closure, the patient awoke with completely normal neurologic function in both lower extremities. She remained neurologically intact and her surgery was completed one week later without neurologic sequelae.

Intraoperative NMEP data was unobtainable in three patients in this series. All three of these patients had prior surgery, while two out of three had prior intradural surgery. One of these patients failed a wake-up test following closure of the vertebrectomy defect. However, function returned following re-opening of the defect, placement of an anterior cage, then recompressing posteriorly.

Two patients had nerve root palsies after surgery. One patient who underwent a revision L2 and L3 VCR had a unilateral quadriceps deficit that was noted immediately after surgery. The patient was returned prone on the operating table where the left-sided L2 and L3 nerve roots were re-explored and further decompression was performed. The deficit resolved spontaneously six months postoperative. A second case, a revision T12 and L1 VCR with preoperative 4/5 strength of the lower extremities had a unilateral foot drop that resolved by two weeks postoperative. No patient thus far has had revision surgery for any neurologic complication. And all patients (n=4) with preoperative spinal cord myelopathy either awoke the same (n=1) or became stronger (n=3) soon after the surgery. (Figure 4)

Figure 4A-D. Patient is a 14+7-year-old male with neurofibromatosis and eight prior anterior and posterior spinal decompression and fusion attempts with a solid C2-T2 fusion mass. He was myelopathic, could stand but barely walk, with grade 3+/4- out of 5 strength in his lower extremities.

Figure 4A. He had a chin-on-chest deformity and a +135-degree cervicothoracic kyphotic deformity.

Figure 4B. His preoperative MRI showed a kyphotic T4-5 dislocation with severe compression of the spinal cord at the level. He was initially placed in gradual halo traction which was locked with his chin out of his chest to allow for fiberoptic intubation with access to his neck if required.

Figure 4C. He then underwent a posterior T4 and T5 VCR and an occiput to T11 posterior instrumentation and fusion. 1+6 years postop, he had a stable construct and alignment with marked correction of his kyphosis to +41°.

Figure 4D. A one-year postoperative CT scan shows a solid anterior fusion noted with the use of BMP-2 anteriorly. He already had a wide laminectomy defect posteriorly which would not allow for any posterior fusion. His neurologic function improved to normal by 6 weeks postoperative.

Non-neurologic
No patient required a chest tube for a pleural air leak, but a staged patient required bilateral chest tubes for pleural effusions postoperative. All patients required intermittent positive pressure breathing (IPPB) during the early portion of their postoperative hospital course for preventing atelectasis. Several patients required up to three days of postoperative ventilation, and one patient was re-intubated approximately five days postoperative for upper airway breathing difficulties following a cervicothoracic reconstruction. One patient had a DVT two weeks postoperative treated with Lovenox. Another patient had a partial bilateral brachial plexus palsy postoperative that was somewhat predicted by degraded upper somatosensory potentials intraoperatively. He awoke with grade 4/5 strength in his arms and hands which returned to normal within one month postoperative. All patients received perioperative TPN through a central venous line catheter that was placed perioperatively. No patient has had any wound related complications thus far.