Posterior Vertebral Column Resection (PVCR) for Severe Rigid Scoliosis

The management of severe rigid scoliosis is a surgical challenge. Conventional procedures such as posterior instrumentation or combined anterior-posterior instrumentation enable limited correction. In severe rigid scoliosis, translation of spinal column is necessary for restoration of trunk balance and deformity correction. Vertebral column resection is the only option for accomplishing translation of spinal column. Anteriorposterior vertebral column resection is a challenging procedure. It is an ordeal for both the patient and surgeon, requiring a long operation with a great risk of major complications. To overcome these adversities, vertebral column resection through a single posterior approach was developed.

Purpose: To report on the technique and results of posterior vertebral column resection (PVCR) for severe rigid scoliosis.

Materials and Methods: Sixteen scoliosis patients subjected to PVCR were retrospectively reviewed after a minimum follow-up of 2 years (range, 2~6.8 years). Diagnoses were idiopathic scoliosis in 6, paralytic scoliosis in 4, failed Zielke-Harrington instrumentation in one paralytic scoliosis, failed Harrington instrumentation in one paralytic scoliosis, congenital scoliosis with unsegmented bar in 3, and Beal’s syndrome in 1. There were 10 thoracic, 2 thoracolumbar, and 4 lumbar curves. The indication for PVCR was scoliosis more than 80° with flexibility less than 25%. The average age at the operation was 29 years (range, 20~41 years) with a male:female ratio of 10:6. The spine was evaluated with 36-inch standing anteroposterior and lateral radiographs. Parameters studied were deformity correction, coronal spinal balance measured from C7 plumb line to the center of S1, sagittal spinal balance measured from C7 plumb line to the posterior-superior corner of S1, complications related to the instrumentation, and any evidence of pseudarthrosis. Clinical records were reviewed for operating time, average blood loss, and complications. The surgical technique consisted of segmental pedicle screw fixation, decompression of neural structure and resection of the vertebral column at the apex of the deformity through a posterior route, followed by deformity correction and global fusion.

Results: The numbers of vertebrae removed were 1.3 in average, and 21 total (15 thoracic and 6 lumbar). The average fusion extent was 10.6 vertebrae (range, 7~15 vertebrae). Mean operation time was 370 minutes with a mean blood loss of 7035 ml. The mean preoperative scoliosis of 109.0±19.8° was corrected to 45.6±14.8° (59 % correction) at most recent follow-up, and the minor curve of 59.3±15.2° was corrected to 29.2±11.3° (51 % correction). The mean preoperative thoracic kyphosis of 31º was corrected to 34º at most recent follow-up, and lumbar lordosis of -22º was corrected to -44º. The mean preoperative coronal imbalance of 4.0 cm was improved to 1.0 cm at most recent follow-up, and sagittal imbalance of 4.2 cm was improved to 1.6 cm. Complications were encountered in 4 patients: one complete paralysis in Beal’s syndrome who had the preoperative neurologic status of Frankel C, one hematoma, one hemopneumothorax, and one proximal junctional kyphosis.

Conclusion: Posterior vertebral column resection is an effective alternative for severe rigid scoliosis. It is a highly technical procedure and should only be performed by an experienced surgical team.