Eur J Orthop Surg Traumatol DOI 10.1007/s00590-014-1477-1

ORIGINAL ARTICLE

Osteotomies/spinal column resection in paediatric deformity Bahadir Gokcen • Caglar Yilgor • Ahmet Alanay

Received: 20 March 2014 / Accepted: 29 April 2014 Ó Springer-Verlag France 2014

Abstract The spinal deformities in paediatric population differ from those in the adult population. Vertebral osteotomies are indicated when the deformity is too rigid to be corrected either with instrumentation alone or with the addition of soft tissue releases. When surgical intervention is to be carried out, correcting the deformity and ceasing progression should be aimed at as well as allowing further growth and improving pulmonary function. Osteotomies in the spine surgery should aim to achieve an appropriate balance in both sagittal and coronal planes. Varied clinical and radiological scenarios necessitate different osteotomy types. The purpose of this article is to introduce each osteotomy type and discuss their indications, prerequisites and complications. Osteotomy options for correcting spinal deformities are Ponte osteotomy, Smith-Petersen osteotomy, pedicle subtraction osteotomy, bone-disc-bone osteotomy and vertebral column resection. All the osteotomy types are technically demanding. Appropriate selection of the type of the osteotomy depends on the surgeons’ experience, type of the deformity, magnitude of the curve, remaining growth potential and operative goals. Neuromonitoring should be an indispensible part of the B. Gokcen Department of Orthopaedics and Traumatology, Istanbul Florence Nightingale Hospital, Istanbul, Turkey C. Yilgor Department of Orthopaedics and Traumatology, Kiziltepe State Hospital, Mardın, Turkey A. Alanay (&) Acibadem Maslak Hospital Comprehensive Spine Center, Acibadem University School of Medicine, Department of Orthopaedics and Traumatology, Bu¨yu¨kdere Cad. No: 40, Maslak, 34457 Istanbul, Turkey e-mail: [email protected]

procedure. Spine osteotomies are effective procedures for the treatment of paediatric spine deformities if experienced surgical team performs them. Keywords Severe

Scoliosis  Kyphosis  Osteotomy  Paediatric 

The spinal deformities in paediatric population differ from those in the adult population. Although spinal deformities are complex and dynamic conditions, they are more flexible in children in regard to adults. Obtaining satisfactory result is demanding even when the deformity is flexible. Cosmetic concerns are more important in the paediatric population. Vertebral osteotomies are indicated when the deformity is too rigid to be corrected either with instrumentation alone or with the addition of posterior ligament and simple facet joint releases. Osteotomies in the spine surgery should aim to achieve an appropriate balance in both sagittal and coronal planes for satisfactory cosmetic results. This can be achieved by anterior-only, anterior and posterior combined (circumferential) or posterior-only approaches. Since growing is an ongoing process, a deformed section influences the growth of the remaining spine. It also affects the chest wall, lungs and extremities. When surgical intervention is to be carried out, correcting the deformity and ceasing progression should be aimed at as well as allowing further growth and improving pulmonary function. Therefore, respecting spinal growth is one of the most important issues to be taken into account while planning an osteotomy in children. Osteotomies and fusion are usually performed for short segments to prevent the detrimental effects of fusion. In case of long deformities, hybrid approach such as combining osteotomies with growing rod techniques may be an alternative procedure.

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Appropriate surgical approach depends on the surgeons’ experience, type of the deformity, magnitude of the curve, remaining growth potential and operative goals [1–4]. Even though the spinal osteotomies have satisfactory results in severe deformities, they have an increased risk of complications. Performing a detailed pre-operative assessment of the risks and benefits and discussing the procedure with the patients’ family should be the mandatory first step when planning spinal osteotomies. Traditionally, severe spinal deformities were addressed using separate anterior and posterior approaches [5–7]. Recently, posterior-only approaches became more popular. Osteotomy options for correcting spinal deformities are Ponte osteotomy (PO), Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), bone-disc-bone osteotomy (BDBO) and vertebral column resection (VCR) providing correction of the sagittal and multiplanar deformity. Varied clinical and radiological scenarios necessitate different osteotomy types. The purpose of this article is to introduce each osteotomy type and discuss their indications, prerequisites and complications.

Osteotomies

posteriorly fused spines, respectively. Smith-Peterson osteotomy was first described as a treatment for sagittal imbalance due to ankylosing spondylitis [12]. Ponte procedure was described including multiple Chevron osteotomies with spinal instrumentation in Scheuermann’s kyphosis [13]. SPO can be performed at any level in thoracolumbar spine. Although 5°–7° of correction was mentioned in some previous studies [14, 15], it is approximated that 10° of correction per level can be achieved with SPO. The surgical technique of SPO involves removal of all posterior ligaments (supraspinous, intraspinous and ligamentum flavum) and facet joints to obtain posterior release. Compression of the osteotomy sites provides correction of kyphosis. Since this correction involves opening of the anterior column, a mobile anterior disc is required. During the correction, strong segmental fixation is mandatory to prevent loss of the reduction achieved. Additionally, compression leads to narrowing of the neural foramina, which necessitates a preceding wide facetectomy to prevent nerve root impingement [4]. In a scoliotic deformity, correction with SPOs can lead to posterior column shortening and anterior column lengthening leading to coronal balance decompensation towards the concavity of the deformity. SPOs can be performed asymmetrically to overcome this phenomenon in order to correct the coronal imbalance as well as the sagittal imbalance. Such asymmetrical SPOs involve larger osteotomies at the convex side, and both sides are compressed equally [16]. If the desired deformity correction is achieved and posterior column is closed bone-to-bone centrally and laterally by multilevel SPOs, anterior grafting and reconstruction are not required [4, 16]. Contrarily, if the anterior disc level opens extensively (greater than 10 mm in height) due to substantial correction, anterior disc space grafting may be necessary [17]. It is important that the anterior disc is mobile—the taller the disc, the more effective the SPO. If the disc is severely degenerated and/or collapsed, placement of structural interbody graft anteriorly would allow for greater correction of posterior closure of the SPOs. In a study comparing Smith-Peterson osteotomy and PSO, single-level PSO caused nearly twice as much bleeding than three levels of SPOs; however, SPO had a greater tendency towards coronal decompensation than PSO [16]. In our clinical experience, SPOs are technically easier and safer to perform when compared to other spinal osteotomy types. SPOs cause less blood loss, decreased risk of neurological injury and require shorter operative durations.

Ponte osteotomy, Smith-Peterson osteotomy

Pedicle subtraction osteotomy

Ponte and Smith-Peterson osteotomies are facet-based osteotomies. They can be performed in non-fused and

Pedicle subtraction osteotomy was first described by Thomasen in 1985 [18]. PSO is a transpedicular V-shaped

General indications A thorough history is accompanied by evaluation of the patient’s general health status and the whole locomotor system as well as a neurological documentation. Ability to sit, stand and walk is evaluated. Patients’ deformity should be compared in standing and prone positions to assess flexibility. Radiological evaluation starts with standing whole-spine radiographs in antero-posterior and lateral views (sitting radiograph may be obtained in non-ambulatory patients). Supine bending, lateral fulcrum and lateral flexion and extension radiographs demonstrate the flexibility of the deformity. Axial traction X-rays under general anaesthesia give more detail about the flexibility [8–11]. Patients with a flexible deformity can frequently be treated by ligamentous soft tissue release and wide facet joint excision using multiple segment pedicle screws and pre-contoured rods. Patients with rigid deformities often require additional osteotomies. In most case scenarios, apical facet-based osteotomies such as Ponte and Smith-Peterson osteotomies are sufficient for the flexibilization of the curve. More rigid and severe deformities are best treated by three-column osteotomies such as PSO SPO, BDBO and VCR. Surgeons’ experience is another important aspect when deciding for the most appropriate osteotomy.

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wedge osteotomy. Heining et al. [19] also described an osteotomy, which was almost the same as PSO. He described an eggshell osteotomy which also is a transpedicular decancellation closed-wedge osteotomy. The typical indication for the PSO is a patient who has a positive sagittal imbalance of greater than 10 cm [1, 16, 20, 21]. One of the most common scenarios in the field of paediatric spine deformity requiring the use of one or multiple PSOs is a patient who previously underwent fusion for idiopathic scoliosis, usually with instrumentation and fusion to L3 or L4, in whom the lumbar spine was fused with a component of hypolordosis and the discs subsequently degenerated at L3–L4, L4–L5 and L5–S1 [22]. Using PSO, more correction can be achieved than SPO. PSO can approximately obtain 15°–20° and 30°–40° of focal sagittal correction at each segment in thoracic and lumbar spine, respectively [20–24]. The osteotomy technique involves removal of the posterior elements—pedicles, facet joints—below and above, decancellation or the wedge osteotomy of the vertebral body and closure of the osteotomy site by hinging on the anterior cortex. Unlike SPO, anterior mobile disc is not required and, adversely, rigidity of the anterior column is helpful in terms of added stability during osteotomy closure. This osteotomy does not lengthen the anterior column, does not create an anterior bone defect and provides a more stable correction. PSO has the advantage of obtaining correction through all three columns, thereby maximizing the healing potential while avoiding stretching on the major vessels and viscera anterior to the spine [20]. PSO also can be performed in an asymmetrical fashion to achieve combined significant sagittal and coronal balance. While PSO was described in thoracic spine [21], it is most useful in the lumbar spine. If PSO is performed in thoracic spine, it is critical not to retract the thecal sac. The L2 or L3 level is more comfortable for performing PSO. On the other hand, PSO performed at the lower lumbar spine (especially L5) has increased risk for neurological injury. In the surgical technique, pedicle screw fixation is performed first, and then a wide laminectomy is performed for upper and lower levels of the planned osteotomy site. Upper and lower exiting nerve roots are identified bilaterally and protected during the procedure. Osteotomy is carried out through the pedicles until reaching the anterior vertebral body. The anterior cortex of the body should be preserved to act as a hinge and to avoid translation during closure of the osteotomy site. Osteotomy line should be horizontal to the sacrum to avoid any translation. Then, the posterior cortex of the vertebral body is pushed down towards the vertebral body cavity with reverse curettes or osteotomies. Placing a temporary rod on the contralateral side while working on one side will avoid any translocation during osteotomy. Then, the osteotomy site is closed over

the rods, while the hips and knees are hyperextended to facilitate closure of the osteotomy. Additional compression will help bone-to-bone closure of the osteotomy site. After closing the osteotomy site, any dural buckling or nerve impingement should be controlled to avoid neurological injury. Although PSO provides satisfactory clinical and radiological results, it is more challenging and known to be more prone to complications. Cho et al. reported an estimated blood loss for patients undergoing three or more SPOs versus for patients undergoing PSOs. The patients undergoing PSOs have nearly twice as much bleeding than patients undergoing SPOs [16]. In another study, Van Loon et al. [25] reported average estimated blood loss values for PSO as a part of a posterior-only approach to be 3,800 ml (range 2,500–6,000). Pseudarthrosis after PSO in paediatric population is reported less frequently in regard to adults. During primary cases, interbody arthrodesis above and below the osteotomy site should be carried out in order to avoid pseudarthrosis. Interbody fusion can be achieved via a TLIF or an ALIF procedure. Bone-disc-bone osteotomy The aim of the BDBO is to resect the disc with its adjacent endplate(s). Spinal deformities with the disc space as the apex or centre of rotational axis (CORA) and severe sagittal plane deformities that necessitate further correction than a simple PSO can provide are the main indications for BDBO. It has three different types, each providing different amounts of correction rates ranging from 35° to 60° (Fig. 1). In the surgical technique, pedicle screws are placed at least two levels below and three levels above the planned osteotomy level. Afterwards wide laminectomies are performed for the vertebrae above and below the disc space planned to be resected. Then, a wedge osteotomy just below the pedicle of the upper adjacent vertebra and a straight osteotomy through the upper end plate of the lower adjacent vertebra including the disc tissue are performed. A titanium mesh cage can be placed anteriorly if lengthening of the anterior column is desired. Finally, the osteotomy site is closed bone-to-bone, which decreases the risk of pseudarthrosis. The advantages compared to PSO include correction of the deformity at its apex CORA, higher correction rates, potential decrease in pseudarthrosis rates due to disc removal and better stability in Type 1 osteotomies since there are four pedicle screws close to the osteotomy site. The major advantage compared to VCR is its applicability at the lumbar spine without sacrificing the nerve roots while providing correction rates closer to that of VCR (Figs. 2, 3, 4, 5).

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Fig. 2 Pre-operative antero-posterior and lateral X-rays of a 14-yearold patient who was diagnosed with congenital kyphoscoliosis at age 7. After tethered cord release, she was implanted with VEPTR. When this instrumentation failed after two revisions, posterior instrumentation and fusion were applied at age 10. Then she received multiple debridements for infection. Later her implants were removed. Her deformity progressed after the implant removal, and she had severe back pain with no neurological compromise

alternative to VCR in patients with severe and rigid thoracolumbar and lumbar deformities, particularly when the apex of the deformity is at a disc level. Vertebral column resection

Fig. 1 Types of BDBO. a Type 1: provides approximately 35° of correction, b Type 2: provides approximately 35° of correction, c Type 3: provides approximately 60° of correction

In a series of 12 patients with kyphosis and kyphoscoliosis, Enercan et al. [26] reported an average of 38° of correction in sagittal plane without any neurological injury or pseudarthrosis in a series of patients that include both paediatric and adult patients, during a 2-year follow-up after BDBO. Domanic et al. [27] reported an average of 49° of correction with Type 3 BDBO in a group of patients who had severe rigid kyphotic deformities. In summary, BDBO is an effective procedure that provides correction in the sagittal plane and may be an

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Some spinal deformities are not amenable to correction with Ponte, Smith-Peterson or pedicle subtraction osteotomies. VCR plays a very important role in the treatment of severe spinal deformities that cannot be acceptably corrected by less aggressive methods. Among various osteotomy options, VCR provides the greatest amount of correction [28, 29]. Usually VCR is performed for the treatment of Type 1 congenital kyphosis, a sagittal decompensation with a Type 2 coronal malalignment, a hemivertebra with its adjacent discs, a sharp angular thoracic deformity, spondyloptosis, previously fused and malaligned severe deformity and spinal tumour (Figs. 6, 7, 8, 9). The VCR technique involves complete resection of one or more vertebral segments with the posterior elements and the entire vertebral

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Fig. 3 Pre-operative computerized tomography views of the same patient. a anterior view, b lateral view, c posterior view

Fig. 4 Post-operative antero-posterior and lateral X-rays of the same patient. Cobb angle was corrected from 40° to 19° for scoliosis, and 104° to 42° for kyphosis

body including adjacent discs. The decision for the number of vertebral bodies to be resected is based on the rigidity and characteristics of the spinal deformity. Resection can

be done through a combined anterior–posterior approach or a posterior-only approach [2–4, 30, 31]. In 1922, MacLennan [32] first described VCR technique as a combined anterior and posterior procedure. The VCR procedure has been modified by a number of surgeons including Luque and Bradford [33, 34]. In 2002, Suk et al. [28] described posterior-only approach for VCR requiring a shorter operative time with less intraoperative instability of the spine. Several years later, Lenke [35] popularized this technique. It enables translational and rotational correction of the spinal column and provides a controlled manipulation of both the anterior and posterior columns simultaneously through a single approach. Posterior VCR is a technically demanding procedure with a high rate of neurological injury and should be performed by experienced spine surgeons and spine team under neurological monitoring. An additional wake-up test can also be performed. Furthermore, in revision cases, spinal angiography may be required. In contrast to other osteotomy types, VCR usually is not a bone-to-bone contact osteotomy and requires structural allografts, autografts or cage to reconstruct the vertebral column after resection. In the surgical technique, pedicle screws are inserted except for the levels to be resected. The screws are connected on one side with a temporary rod contoured to the shape of the deformity to prevent any instability or neurological injury. A wide lateral dissection is performed to enable resection of the transverse process in the lumbar spine or rib in the thoracic spine. Wide laminectomy is

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Fig. 5 Postero-anterior right and left lateral photographs of the same patient. a pre-operative clinical status, b second-year follow-up clinical status

performed one level above and one level below the level planned to be resected, which prevents neural impingement after correction. At the thoracic level, the exposed nerve roots are ligated off to avoid traction on the spinal cord. Preparation of the lateral vertebral body is important. The soft tissues and great vessels anterior to the vertebral body are protected. Careful subperiosteal dissection is done on the working site (opposite to the stabilizing rod) to follow the lateral wall of the vertebral body until the anterior aspect is easily palpable. It is usually more convenient to start the osteotomy from the concave side. Otherwise the bleeding from the convex side may obscure the view on the

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concave side and may make it difficult to resect the bony structures at the concave side. Then discs below and above the planned resection level are removed, in a piecemeal fashion, followed by resection of the pedicle and vertebral body on one side using rongeurs, curettes, osteotomies and a high-speed drill. A thin shell of bone at the anterior part along with the anterior longitudinal ligament is preserved to prevent translation and at the posterior wall to protect the dura. A reverse curette is usually used to remove the thin shell of the posterior bone at the working side and adjacent to the dural tube. After resection of the posterior wall, another temporary rod is inserted at the working side

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Fig. 6 Pre-operative antero-posterior and lateral X-rays of a 5-year-old female patient who was diagnosed with lipomeningocele and previously treated with in situ fusion. She is ambulant with an apparent trunk imbalance

and securely locked to the screws with slight compression to shorten the vertebral column. The resection of the remaining vertebra is done after the temporary rod at the opposite side is removed. After completion of the resection, a second rod is placed at this side. A final evaluation of the spinal canal is done to confirm that there is no bone or disc tissue compressing the spinal cord. Deformity correction is performed gradually by compression, in situ contouring and replacing the kyphotic rods with rods precontoured to the physiological contours. A mesh cage may be required to fill the gap after resection and is usually placed anteriorly to prevent overshortening of the spinal column, which may cause a dural buckling that risks the spinal cord. A mesh cage placed anteriorly may also increase the rotational stability. Spinal cord monitoring is critical during these manoeuvres. An H-shaped structural allograft can be placed over the laminectomy site between the spinous processes, and a final compression is done to secure the stabilization [30]. Closure of the osteotomy site with an H-shaped allograft may help preventing haematoma formation and may increase fusion rates.

Satisfactory curve correction rates with VCR were reported in several series that include combined children and adults or all paediatric patients. Jensen et al. [36] reported 78 % correction rates. In Suk et al. [37] series, 59 % correction of the main and 51 % correction of the minor curves were reported. Lenke et al. [35] reported curve improvements that vary between 51 and 60 % for scoliosis, global kyphosis, angular kyphosis and congenital scoliosis. Hamzaoglu et al. [30] reported an average correction of 62 % in coronal and 72 % in sagittal planes. In a very recent study, Jeszensky et al. [38] reported the mean correction of scoliosis to be 57 % and of kyphosis, 51 % in their early onset spinal deformity series of four patients with a mean age of 3.7. Overall and neurological complication incidences with VCR, on the other hand, are also reported to be quite high. Jensen et al. [36] had a complication rate of 43 %. Suk et al. [37] reported a 34.3 % rate of overall and 17.1 % rate of neurological complications. Letko et al. [39] reported 14 post-operative complications in 16 patients with previously untreated idiopathic scoliosis. Lenke et al. [35] reported a

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Fig. 7 Pre-operative computerized tomography views of the same patient

40 % overall rate of complications and 11.4 % rate of neurological complications. More recent papers, however, report lower rates of neurological complications. Hamzaoglu et al. [30] reported 1.96 % rate of transient nerve palsies in 102 patients. Lenke et al. [40] had a 27 % rate of intraoperative spinal cord monitoring change; however, no patient was reported to have a complete permanent paraplegia. Jeszensky et al. [38] reported no spinal cord-related complications. A recent report in paediatric patients demonstrated that neuromonitoring changes that occur during decompression and bone resection generally respond to increasing the blood pressure [41]. Changes unresponsive to improvement in the hemodynamics responded well to osteotomy closure. Unresponsive changes during osteotomy closure were treated with reopening the osteotomy, cage adjustment and less correction [41]. In summary, VCR is safe and powerful procedure for the treatment of severe paediatric spinal deformities. With the posterior-only approach, VCR provides significant improvement in radiographic and clinical image. Nevertheless, it is a technically demanding procedure with possible risks for major complications. Therefore, only a highly experienced surgical team should perform it. During the procedure, spinal cord neuromonitoring is mandatory to prevent catastrophic neurological injuries.

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Fig. 8 Pre-operative magnetic resonance imaging views of the same patient

Conclusion Osteotomies in the paediatric spinal deformity are proven to be highly efficient. They are powerful techniques enabling the spine surgeon to balance the spinal column. Achieving a well-balanced and aligned spinal column is the main goal of spine surgery. The discussed osteotomies enable the spine surgeon to make corrections both in sagittal and coronal planes. All the osteotomy types are technically demanding. Pre-operative planning is very important as well as the operative procedure itself for obtaining satisfactory results. Pre-operative assessment of the deformity provides an understanding of the three-dimensional characteristics of the deformity, and its clinical influence and the amount of angular correction needed. Neuromonitoring should be an indispensable part of the procedure. Patient’s general health status and surgeons’ experience also significantly influence successful outcomes.

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Fig. 9 First-year follow-up antero-posterior and lateral X-rays of the same patient

In conclusion, we consider spine osteotomies to be effective procedures for the treatment of paediatric spine deformities if experienced surgical team performs them. Conflict of interest Dr. Gokcen and Dr. Yilgor have nothing to disclose. Dr. Alanay is a consultant and receives research grant from DePuy & Synthes.

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spinal column resection in paediatric deformity.

The spinal deformities in paediatric population differ from those in the adult population. Vertebral osteotomies are indicated when the deformity is t...
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