Vertebral column resection for the treatment of severe spinal deformity

Abstract

The ability to treat severe pediatric and adult spinal deformities through an all-posterior vertebral column resection (VCR) has obviated the need for a circumferential approach in primary and revision surgery, but there is limited literature evaluating this new approach. Our purpose was therefore to provide further support of this technique. We reviewed 43 patients who underwent a posterior-only VCR using pedicle screws, anteriorly positioned cages, and intraoperative spinal cord monitoring between 2002 and 2006. Diagnoses included severe scoliosis, global kyphosis, angular kyphosis, or kyphoscoliosis. Forty (93%) procedures were performed at L1 or cephalad in the spinal cord (SC) territory. Seven patients (18%) lost intraoperative neurogenic monitoring evoked potentials (NMEPs) data during correction with data returning to baseline after prompt surgical intervention. All patients after surgery were at their baseline or showed improved SC function, whereas no one worsened. Two patients had nerve root palsies postoperatively, which resolved spontaneously at 6 months and 2 weeks. 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.

Level of evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Figures

Fig. 1A–D

The patient is a 17 + 8-year-old girl with severe idiopathic kyphoscoliosis. (A) She had a 135° coronal plane deformity bending to only 121° (11% flexibility) and a +140° kyphosis deformity. Thus, she had 275° of total kyphoscoliosis deformity. (B) Preoperatively, she was placed in halo-gravity traction for 4 weeks to stretch out her spinal column and to improve her nutritional and respiratory statuses. Her ultimate coronal plane deformity corrected to 102° and her sagittal plane to + 89°. (C) She underwent a two-stage T10 vertebral column resection with PSF from T2 to L4. Her ultimate coronal plane correction was to 39° (72% correction) with sagittal plane correction to + 24° (88%). (D) Pre- and postoperative clinical photographs show marked correction of her trunk with a concomitant seven-rib thoracoplasty performed to gain full access of her posterior spinal column because of her severe deformity.

Fig. 2A–E

The patient is a 14 + 7-year-old boy 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. (A) He had a chin-on-chest deformity and a +135° cervicothoracic kyphotic deformity. (B) 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. (C) He then underwent a posterior T4 and T5 vertebral column resection and an occiput to T11 posterior instrumentation and fusion. At 3 years postoperatively, he had a stable construct and alignment with marked correction of his kyphosis to + 41°. (D) One-year postoperative computed tomographic 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 postoperatively. (E) His 3-year postoperative clinical photos demonstrate the improved head and neck positions.