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

Transcription

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

2 Disclosures Medical Education Reviews JBJS Depuy Synthes Spine: Research, royalties Globus: Royalties 5/1/2017 2

3 Congenital Scoliosis: State of the Art in 1986 Prior PSF No correction Lordotic Crankshaft Restrictive lung disease Pelvic imbalance

4 Imaging Early films best to determine type (0 to 4 years of age) AP/Lat + traction Check pedicle width Posterior elements Coned films if necessary

5 Imaging Measurement error increased, possibly as high as 19 due to irregular vertebrae Compensatory curve may help to confirm or refute progression Always compare against original film 5/1/2017 5

6 Imaging MRI shows abnormalities in 26% Syrinx Chiari Tether or lipoma When to order? When exam abnormal or going to operating room Images GU tract as well

7 Prognosis Most patients have slightly short stature 70% risk of progression 50% to 50 Progression greatest after 10 years of age May cause cor pulmonale Congenital kyphosis may cause paralysis! Type 1

8 Alternatives: The (old) Gold Standard -Posterior Fusion Simplest and safest technique Cast correction Or instrumentation Thick fusion mass Explore?! Indications: Small curves Limited growth potential Type II kyphosis <50 Crankshaft after PSF!!

9 Convex Hemiepiphyseodesis Deformity correction with growth Prerequisites: Concave growth potential < 5 vertebrae < 70 curve < 6 years of age No significant kyphosis Maximum correction 10-15

10 Convex hemi-epihyseodesis Especially appealing at CT junction A&P 2 y.o. 5/1/ y.o. 10

11 Hemivertebra Excision Indication: Unacceptable deformity (esp. T1 or L5) Prerequisites: Accessible vertebra Balance achievable

12 Hemiertebra Excision Most Deforming at upper and lower ends

13 Adding on after PSF only adjunct

14 My Algorithm 1-3 level vertebral anomaly (progressive with growth remaining): Fuse If severe, consider HV resection (judgment) Lordotic or LS: A & P Neutral or kyphotic : Posterior

15 Algorithm >3 levels and immature (< 9 y o): +Fused ribs VEPTR Incise bar if present No fused ribs: GR

16 Algorithm Severe, mature PSF with osteotomies or HVR Consider VCR Prior traction may help

17 Post-Op XR

18 AnNother VCR

19 Congenital Kyphosis Treatment Type I: <~55 : Posterior fusion >~55 : Anterior + Posterior fusion

20 Stepwise Approach Develop operative plan Plain films don t show posterior anatomy CT can help with this Hedequist 2003 Consider 3D model Prerequisites Control of bleeding (TXA, FloSeal, Cottonoids, bipolar)

21 Stepwise approach Develop operative plan Plain films don t show posterior anatomy CT can help with this Hedequist 2003 Prerequisites Control of bleeding (TXA, FloSeal, Cottonoids, bipolar) 5/1/

22 Stepwise approach Insert pedicle screws before destabilization Remove lamina and transverse process Identify nerve root(s) Subperiosteal body /disc dissection Resect discs above and below

23 Extending Approach Costotransversectomy

24 Insert temporary rod on concavity Remove lateral pedicle wall and vertebral contents

25 Remove posterior vertebral wall

26 Make sure deformity corrects Watch for translation, kinking

27 Maintain anterior column height (if needed) Posterior shortening Anterior support Instrument Screws Hooks Wires

28 3-rod technique temporary or permanent Screws tend to plow Minimize craniocaudal force with screws 5/1/

29 Pitfalls Unexpected posterior fusions Or ankyloses Critical pedicles insufficient Bone density inadequate for major correction Limited ability to create lordosis Posterior shortening may help 5 y.o. 14 y.o.

30 Anterior and posterior approach -indications Pedicles unpredictable Extreme correction desired Lordotic anomaly

31 Post-op management Often need postop cast protection Arm or leg spica keep cast centered Iobst, Hall JPO 2004

32 3 y.o. with L4-5 lipomeningocele Ambulates with braces 5/1/

33 Further W/U 5/1/

34 L3-S1 fusion untether by neurosurgery 34 5/1/2017

35 6 months later What next? 5/1/

36 10 yrs later, age 13 Remains Ambulatory Neuro status unchanged 5/1/

37 Results Bradford pts 2 incisions 65% correction No neuro deficits Shimode pts all posterior 53% correction 2 transient leg pareses Nakamura pts 3-13 years 54% correction No neuro deficits

38 Hemivertebra excision 2 y.o. 10 y.o.

39 10 yr old progressive HV

40 Thank you!