Is the kyphectomy for myelomeningocele beneficial?

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1 Is the kyphectomy for myelomeningocele beneficial? Yukitaka Nagamoto, Motohiro Kitano, Yukari Imajima, Hidekazu Tobimatsu, Hiroyuki Aono Dept. of Orthop. Surg. Osaka National Hospital

Poor sitting balance Recurrent skin breakdown Poor cosmetic appearance

2 Backgrounds Myelomeningocele patients with severe kyphosis have many difficult problems. Poor sitting balance Recurrent skin breakdown Poor cosmetic appearance Respiratory problem and so on. Kyphectomy is the only definitive treatment. On the other hand, the surgery is challenging and has very high complication rate.

3 Purpose 1. To investigate surgical results and perioperative complication rates of the kyphectomy. 2. To elucidate patients and parents satisfaction of the kyphectomy.

4 Patients and Methods Retrospective study of 6 patients with myelomeningocele who underwent kyphectomy between 2004 and male;3, female;3, median age;9.5y/o (4-19) Activity of daily living: wheel-chair level Follow-up period: 5.5yrs (1-9.5) Evaluations: Radiographic parameters (kyphotic angle and sacral slope) Surgical complications Patients and parents satisfaction Sacral slope using an original satisfaction questionnaire Kyphotic angle

5 Mini Steffee Plate SLIM LOC Mini Steffee Plate Operative level ISOLA Growing rod Colorado2 Surgical Procedure Short fusion: 3 cases, Long fusion: 3 cases Kyphotic angle T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S 4M 6F 8F 9M 10M 19F L T12-L5 146 T12-L5 111 T12-L5 151 T12-L4 112 L Operative time: 11h12m Bleeding:920ml Vertebral excision Plating Rodding

6 Radiographic parameters Kyphotic angle Pre-op Post-op Final f/u (58%) Sacral slope 66 (50%) Pre-op Post-op Final f/u Surgical complications 9 complications were identified. ( ) ( ) Correction loss at the adjacent segment (fig.1) 3 Prominent implant 2 Deep infection of pressure sore from cast (fig.2) 1 Intradural hemorrhage 1 Spinal fluid leakage 1 Pressure sore in the coccygeal region 1 23 additional surgeries were needed in 4 cases. fig.1 fig.2

Patients and parents satisfaction Q1:Sitting balance Q2:Sitting

satisfactory: 5 Very satisfactory: 2 Satisfactory: 4 Neither:1

opportunity, would you want your child to have his kyphectomy

Q5:Would you recommend the surgery for others with

7 Patients and parents satisfaction Q1:Sitting balance Q2:Sitting appearance Q3:General satisfaction Satisfactory: 1 Very satisfactory: 5 Very satisfactory: 2 Satisfactory: 4 Neither:1 Very satisfactory: Satisfactory: 3 2 Q4:If given the opportunity, would you want your child to have his kyphectomy over again? Q5:Would you recommend the surgery for others with myelomeningocele kyphosis? Yes,definitely: 1 Unsure: 1 Yes,definitely: 1 Probably: 5 Probably: 4 Relatively good satisfaction despite complications

8 Surgical results of the kyphectomy authors years n surgical technique age at op f/u period kyphotic angle complication(%) Pre-op Post-op final overall minor major Altiok Warner-Fackler Garg Dunn/Warner-Fackler Samagh Warner-Fackler Akbar Warner-Fackler Niall various techniques Nolden Galveston Furderer various techniques McCall Warner-Fackler Warner and Fackler Warner-Fackler Heydemann and Gillespie Dunn/Galveston NA Current study Very high complication rate (34-77%) Major:death, deep infection, implant failure, rod dislogment, correction loss, cerebrospinal fluid leak, hydrocephalus, shunt insufficiency Minor:decubitus ulcer, superficial wound breakdown, urinary tract infection Our kyphotic correction and the complication rate were equivalent to those of the previous studies.

mature The best indication for short fusion Requirement for rigid fixation by long spinal instrument The kyphectomy is best to

9 Our surgical principles 0 4yrs 6yrs 8yrs For preschool children aged 4 to 6 yrs Flexible spine Mild kyphosis No concomitant scoliosis Skeletal immature For school children of 8 yrs or older Rigid spine Severe kyphosis Concomitant scoliosis Skeletal mature The best indication for short fusion Requirement for rigid fixation by long spinal instrument The kyphectomy is best to be done during the age of 4 to 6. At the age of 8 or older, the surgery is getting a great deal more difficult due to above reasons.

10 Case 1: 4y8m Male p.o.7y7m Pre-op Post-op Final Satisfaction Q3: Neither, Q4: Probably No additional surgery due to short fusion at appropriate age Relatively poor satisfaction despite good surgical results

11 Case 3: 8y11m Female p.o.8y2m Pre-op Post-op Correction Final loss Deep infection Satisfaction Q3: Satisfactory Q4: Yes, definitely More than 10 additional surgeries Relatively good satisfaction despite many complications

12 Conclusions In our results, the percentage correction and complication rate were 50% and 66%, respectively and the results were equivalent as compared with previous studies. Despite these all complications, almost all patients and parents were satisfied with surgical results. This is because the aims of surgery were ultimately accomplished. We strongly recommend the kyphectomy to disabling myelomeningocele patients due to severe kyphopsis after adequate informed consent including all assumed risks and benefits before surgery while the kyphosis is flexible between the age of 4 and 6. Financial disclosure information None of the authors has any potential conflict of interest.

Orthopedics. Michael Conklin, MD, Chair Sam Rosenfeld, MD Chanka Nanyakara, MD Shyam Kishan, MD

Orthopedics. Michael Conklin, MD, Chair Sam Rosenfeld, MD Chanka Nanyakara, MD Shyam Kishan, MD Orthopedics Michael Conklin, MD, Chair Sam Rosenfeld, MD Chanka Nanyakara, MD Shyam Kishan, MD Outcomes Primary Outcomes Maintenance of a stable and balanced spine. Optimize pulmonary function. Avoid restrictive