Cervicothoracic Congenital Scoliosis: Treatment of shoulder balance and head tilt

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Peter Houston
5 years ago
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1 Cervicothoracic Congenital Scoliosis: Treatment of shoulder balance and head tilt David L. Skaggs, MD, MMM Professor and Chief of Orthopaedic Surgery University of Southern California Children s Hospital Los Angeles Endowed Chair of Pediatric Spinal Deformity

2 Visible Deformity Head Tilt Hemi vertebrae 3 yo girl 72 o Unilateral bar

3 2 mo 3 yrs

4 Step 2: Set Parental Expectations

5 Step 2: Set Parental Expectations Euro Spine J, 2008 Mean shoulder height difference 8mm ±6mm 28% have >10mm shoulder height difference (and self report level shoulders) T1 tilt poorly correlated with shoulder balance

6 Step 3: Surgical Techniques Congenital Cervicothoracic Scoliosis 1. Fusion 2. Resection 3. Distraction over time No role for Bracing 6

7 <5yrs Option #1 Hemi-epiphysiodesis (Fusion) <50 deg curve Posterior fusion alone Fuse 1/3-1/2 vertebrae Cant get correction from cast Winter

8 3 month old Fused St. Elsewhere 1 year after in-situ fusion Progressive deformity In situ fusion alone questionable Variable results Crankshaft Progressive Implants help?

9 2 yo congenital scoliosis Hemi Vertebrae Opposite Bar Progression likely Multiple growthplates convexity

10 2 yo congenital scoliosis Hemi Vertebrae Opposite Bar Upper anchor fixation sufficient for resection?

11 Implants allow Some compression (correction) Pedicle screws may help control anterior No Bridges Burnt Can do wedge resection when older

12 Use Downsized Implants 2 year old mm system Supra laminar C7 Transverse process T2

13 If Pedicle Screws to Long Cut them Shorter 2 yo T2

14 Adult sized implants may be too big

15 Option #2 Resection and Fusion 7yo 40 o

17 Sternal Split Mulpuri, Spine, 2005

18 I Prefer All Posterior Resection

19 Pre-Op Hemivertebrae 40o

20 1.75 unilateral vertebral resection Hooks on ribs help close wedge Difficult if lordosis Lamina hooks share load 40 o 5 o

21 If can fix in one surgery safely first choice Challenges: Strong Enough Bone for Anchors Protect with Halo 21

22 Halo Vest Useful 22

23 Pre-OP CT Angio? Single Vertebral Artery

24 Option #3 Distraction Over Time Last option

25 Brachial Plexus Palsy Injuries First rib adjacent to brachial plexus Avoid Solitary First Rib Monitor: Pulse SSEP, MEP

26 First Rib Stout OK to distract against Unilateral Bar

27 Midline Incision Adjacent to TP Plan for final fusion No Dissection of Proximal Spine Feel bump of transverse process Split muscles just lateral to TP

28 Adjacent to TP Extra-Periosteal Want ribs to hypertrophy NOT in chest No chest tube

29 No Advantage to Claw (my opinion)

30 30

31 Current Preference: Hemiepiphsiodesis + Distraction over time Stop Bad Growth Encourage Good Growth JBJS, 2013

32 Hemiepiphsiodesis + Distraction over time Distract every 1-2 years No thorocotomy!

33 Pre-op 7 years post-op

34 3yo Pre-op 5 yo 9 yo

35 9 yo

36 Complications of Distracting on Ribs 36

37 Lengthening complication Monitoring normal intra-op

38 Lengthening complication Monitoring normal intra-op Arm pain post op when arm at side****

39 Return to OR in Few Days MEPs Normal MEPs 50% Diminished

40 Lesson: Lengthen implants with arms at side when on top rib

41 Complication: Rib Mass Avulsion

42 Step 1 Rib Avulsion: Treatment Remove Devices Fuse Avulsed ribs to spine

43 Step 1 Rib Avulsion: Treatment Remove Devices Fuse Avulsed ribs to spine Step 2 (4-6 months) Replace Device Modest Distraction

44 Pre-OP Post-op 44

45 Complications: Implants Migrate Through Ribs Treatment: Put them back! Migrations inherent in non-constrained, growing systems

46 Conclusions Simple fusion Deformity acceptable < 4? vertebrae with implants Risk averse Excision Deformity concerning Well defined hemi-vertebrae < 2? vertebrae Fusion + Distraction Muliple levels involved Risk of Thoracic Insufficiency Syndrome Multiple operations acceptable Solid upper anchors

47 Conclusions Simple fusion Deformity acceptable < 4? vertebrae with implants Risk averse Excision Deformity concerning Well defined hemi-vertebrae < 2? vertebrae Fusion + distraction Muliple levels involved Risk of Thoracic Insufficiency Syndrome Multiple operations acceptable Solid upper anchors

48 Conclusions Simple fusion Deformity acceptable < 4? vertebrae with implants Risk averse Excision Deformity concerning Well defined hemi-vertebrae < 2? vertebrae No thorocotomy! Fusion + Distraction Deformity Not Acceptable Muliple levels involved Multiple operations acceptable Solid upper anchors

49 Thank You

Congenital Spine Deformity: Surgical Treatment Options. Spine Masters. Fri May , 4:10-4:25 Paul Sponseller MD

Congenital Spine Deformity: Surgical Treatment Options Spine Masters Fri May19 2017, 4:10-4:25 Paul Sponseller MD Disclosures Medical Education Reviews JBJS Depuy Synthes Spine: Research, royalties Globus: