M ASTER S T ECHNIQUES: VCR & GROWING R ODS

Transcription

1 M ASTER S T ECHNIQUES: VCR & GROWING R ODS LAWRENCE G. LENKE, MD The Jerome J. Gilden Distinguished Professor of Orthopaedic Surgery Professor of Neurological Surgery Chief, Spinal Surgery Co-Director, Spinal Deformity Service Director, Advanced Deformity Fellowship (ADF) Washington University Medical Center Saint Louis, Missouri 8 th International Congress on Early Onset Scoliosis and Growing Spine (ICEOS) Warsaw, Poland November 20-21, 2014 Masters Tips & Tricks

2 2 MASTER S TECHNIQUES: VCR & GROWING RODS I. INTRODUCTION/TERMINOLOGY a. Neurosurgery 2014;74(1): b. Fox VCR Study Group Definition: 3-column circumferential vertebral osteotomy creating a segmental defect with sufficient instability to require provisional instrumentation c. Indications i. Pathology dependent 1. Type of deformity (scoliosis, kyphosis, lordosis) 2. Coronal/sagittal/combined imbalance 3. Curve magnitude 4. Stiffness (preop & intraop) 5. Bone density (proxy for PS purchase) ii. Surgeon dependent 1. Operative goals 2. Surgeon experience/comfort level (PSOs, post. HV exc., costotransversectomy approach) iii. Risk dependent 1. Minimization 2. Avoid complications 3. Able to obtain enough correction w/o resorting to VCR d. Contraindications i. VCR stuck dura dorsally and/or ventrally from prior decompression/post. interbody fusion ii. Unfamiliar w/technique iii. Lack of SCM (?) during procedure ( risk!) e. Preoperative planning i. Complete radiographic evaluation ii. Total spine MRI iii. 3D CT scan ± actual model iv. Pulmonary/nutrition analyses v. Cardiac/anesthesia clearance

3 3 II. SPECIFIC INDICATIONS/TECHNIQUES a. Posterior VCR i. Procedure of last resort ii. Severe & stiff deformities/autofused spinal columns iii. For primary IS spine-on-chest wall x-rays iv. Marked kyphoscoliosis/lordoscoliosis v. Performed primarily in thoracic/tl region vi. Resection of all post. elements, facet joints /, pedicles, nearly all vertebral body & discs / vii. Tremendous correction ability as spine is disarticulated at apex & proximal/distal limbs slowly brought together viii. Performed via staged ant./post. approaches or post.-only (in single or staged fashion) b. Surgical technique i. Exposure, costotransversectomy, pedicle screw placement ii. Laminectomy, temporary rod placement, vertebral body exposure iii. Lateral vertebral body access and removal, discectomies

4 4 iv. Posterior vertebral body impaction, compression closure v. Anterior cage insertion, final correction, placement of rib pieces over laminar defect III. OUTCOMES a. VCR (data from multicenter pediatric VCR Fox Consortium) Multicenter analysis of 147 consecutive vertebral column resections for severe pediatric spinal deformity. SRS AM, Kyoto, Japan, September 2010, Spine 2013;38(2): i. Complications 1. 86/147 (59%) total complications 2. 68/147 (46%) intraop a. 39/147(26.5%) SCM loss or actual neuro deficit b. 33/147(22.4%) EBL >2L 3. 43/147 = 29% postop a. 21/147(14.3%) respiratory b. 7/147 (4.8%) infections ii. No intraop/postop deaths iii. No permanent paraplegias: 1 pt. w/persistent neuro dysfunction b. Neurologic Highest Risk (data from Myelopathic Patients Who Lack SCM Data Have the Highest Risk of Spinal Cord Deficits following Posterior VCR Surgery. SRS Annual Meeting, Kyoto, Japan, September 2010) i. Postop neuro status pts./8yrs with intraop SCM same as preop 3. 4/26 without intraop SCM (15%) transient paraplegia ii. Characteristics 1. 3 KS & 1 AK

5 5 2. Apex proximal to mid-thoracic T prior ASF w/segmental vessel ligation 4. All preop neuro status acute, progressive myelopathy iii. F/U neuro status c. Benefit of SCM multicenter pediatric VCR Fox Consortium i. Prompt response to SCM changes pts./7 surgeons 2. 39/147 (27%) critical change/scm loss or failed WUT pts. (13%) worsening neuro status immediate postop 4. 1 permanent neuro decline d. Intraop SCM reliability (data from Can Intraoperative Spine Cord Monitoring Reliably Help Prevent Paraplegia during Posterior VCR Surgery? SRS AM, Louisville, KY, September 2011) i. Loss of SCM data 1. 15/90 pts. either lost (n=13) or had degraded data meeting warning criteria (n=2) 2. All 15 SCM data returned following prompt intervention 3. All woke w/intact LE function! ( SCM SAVES ) IV. COMBINE VCR WITH GROWING INSTRUMENTATION IN EOS PATIENTS a. Unique situation more angular deformity w/growth potential / resected area b. Use of preop HGTx very beneficial & may often obviate actually performing VCR procedure c. Growing instr. can consist of growing rod or Shilla-type construct d. Risk/benefits ratio of VCR with definitive fusion vs. VCR & long fusion w/growth instr. e. Need to question viability of spine growth w/3 fusion areas i. Proximal anchors ii. Apical VCR fusion iii. Distal anchors f. Goal is either GR construct alone w/apical correction from HG Tx or apical VCR w/short segmental fusion i. HGTx highly beneficial in both scenarios ii. Need for additional surg. w/growth in most short segment apical fusion in EOS a patient population

6 Bibliography 1. Lenke LG, O Leary PT, Bridwell KH, et al. Posterior vertebral column resection (VCR) for severe pediatric deformity: Minimum 2-year follow-up of 35 consecutive patients. Spine 2009;34(20): Lenke LG, Sides BA, Koester LA, et al. Vertebral column resection for the treatment of severe spinal deformity. Clin Orthop Relat Res 2010;468(3): Lenke LG. Posterior vertebral column resection (VCR). In: Lenke LG, ed. Scoliosis Research Society e-text Spinal Deformity Suk SI, Chung ER, Kim JH, et al. Posterior vertebral column resection for severe rigid scoliosis. Spine 2005;30(14): Suk SI, Kim JH, Kim WJ, et al. Posterior vertebral column resection for severe spinal deformities. Spine 2002;27(21): Lenke LG, Newton PO, Sucato DJ, et al. Multicenter analysis of 147 consecutive vertebral column resections for severe pediatric spinal deformity. Paper #90, Scoliosis Research Society 45 th Annual Meeting, Kyoto, Japan, September 21-24, Powers A, O Shaughnessy BA, Lenke LG. Posterior thoracic osteotomy (vertebrectomy). In: Wang JC, ed. Advanced Reconstruction: Spine. Rosemont, IL: AAOS & NASS, Instructional Course Lecture 58, Rosemont, IL: AAOS (in press August 2011) 8. Cho SK, Lenke LG, Bolon S, et al. Myelopathic patients who lack intraoperative spinal cord monitoring data have the highest rate of spinal cord deficits following posterior VCR surgery. Paper #60, Scoliosis Research Society 45 th Annual Meeting, Kyoto, Japan, September 21-24, Cho SK, Lenke LG, Bolon S, et al. Can intraoperative spinal cord monitoring reliably help prevent paraplegia during posterior VCR surgery? Paper #41, Scoliosis Research Society 46 th Annual Meeting, Louisville, KY, September 14-17, Kang DG, Lehman Jr. RA, Tracey RW, Lenke LG. Growing rods for early onset scoliosis. Scoliosis Research Society e-text Spinal Deformity. uploaded July McCarthy RE, Luhmann S, Lenke L, McCullough FL. The shilla growth guidance technique for early-onset spinal deformities at 2-year follow-up: A preliminary report. J Pediatr Orthop 2014;34(1): Sturm PF, Anadio JM, Dede O. Recent advances in the management of early onset scoliosis. Clin Orthop Rel Res 2014;45(4):