Abstract: Posterior Vertebral Column Resection (VCR) for Severe Pediatric and Adult Spinal Deformity: Indications, Results, and Complications of 43 Consecutive Cases
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
Study Design: Prospective, clinical series.
Objective: To examine the indications, correction rates, and complications of a posterior vertebral column resection (VCR) approach for severe pediatric and adult spinal deformity.
Summary of Background Data: The ability to treat severe pediatric and adult spinal deformity through an all-posterior VCR approach has obviated the need for a circumferential anterior and separate posterior approach in both primary and revision settings. To date, no North American clinical series involving primarily thoracic-based deformities has been published on this technique
Methods: Between 2002 and 2006, 43 consecutive patients underwent a posterior-only VCR for severe scoliosis (S) (n=7, mean 85.3°, range 45-150°); global kyphosis (GK) (n=12, mean +92.5°, range 70-+118°); angular kyphosis (AK) (n=10, mean +72.7°, range 44-+135°); or kyphoscoliosis (K+S) (n=14, mean total K+S 193.7°, range 149-275°) by a single surgeon. There were 31 pediatric (ave. age 13), and 12 adult (ave. age 52) patients with 19 primary and 24 revision cases. All patients underwent a 1-level (n=25), 2-level (n=15), or 3-level (n=5) VCR utilizing pedicle screws, anteriorly positioned cages (n=31), and intraoperative spinal cord monitoring. 40 out of 43 (93%) were performed at L1 or cephalad in spinal cord (SC) territory; the remainder were in the upper cauda equina (L2 and/or L3).
Results: The major curve correction was 73° (69%) for the S cases, 44° (54%) for the GK cases, 48° (63%) for the AK cases, and a combined 110° (55%) for the K+S cases. 7 patients (18%) lost intraoperative NMEP data during correction with data returning to baseline following prompt surgical intervention. All patients following surgery were at their baseline (n=40) or showed improved SC function (n=3), while no one worsened. 2 patients had nerve root palsies postop (unilateral quad deficit in a revision L2 & L3 VCR, unilateral foot drop in a revision T12 & L1 VCR with preop 4/5 strength) resolving spontaneously 6 months/2 weeks respectively. No patient thus far has required revision surgery for any neurologic, wound, instrumentation, or fusion complication.
Conclusion: A posterior-based VCR is a safe but challenging technique to treat severe primary or revision spinal deformities with no spinal cord-related, wound, instrumentation, or fusion complications thus far. Intraoperative SCM (especially motor-evoked potentials) is mandatory to prevent spinal cord-related neurologic complications.
Précis: The ability to treat severe pediatric and adult spinal deformity through an all-posterior VCR approach has obviated the need for a circumferential approach in primary and revision settings. This is the largest North American series to date of a posterior-based VCR procedure for severe pediatric and adult spinal deformity. Intraoperative use of spinal cord monitoring, (specifically NMEP) is mandatory to prevent neurologic complications. Although technically challenging, a single stage approach offers dramatic correction in both primary and revision surgery of severe spinal deformities.
Key Points:
1. The ability to treat severe pediatric and adult spinal deformity through
an all-posterior VCR approach has obviated the need for a circumferential approach
in primary and revision settings.
2. Acceptable spinal deformity correction can be obtained through this all-posterior approach, similar if not superior to patients treated with a circumferential and anterior and separate posterior approach.
3. The use of spinal cord monitoring, especially some type of motor tract monitoring is imperative to maintain neurologic function during these challenging procedures.