Fusionless posterior hemivertebra resection in a 2-year-old child with 16 years follow-up

Correlation between Age and Surgical Approach for Thoracic and Lumbar Hemivertebra

Objective Hemivertebra (HV) is a congenital defect of the formation of the spinal vertebra, which can result in scoliosis or kyphosis along with the related symptomatology of spine deformity. More often than not, it is linked to other abnormalities and requires attention. Its management is surgical and it is of great importance for the physician to choose the right approach at the right time, due to its deteriorative prognosis.

Methods Due to the interest of the subject, the authors investigated the world literature between 1990 and 2018 and found 45 articles, reporting thoracic, thoracolumbar, and lumbar HV in children and its postsurgical outcome, aiming to show whether the approaches are equal in terms of the final outcome.

Results The chosen surgical method depends much on the level of the pathology. Despite this fact, after analyzing the included data, we found that the surgical techniques are unequal with regard to the purpose of achieving improvement. Age, caudal and cranial curves, segmental kyphosis, and scoliosis are factors playing a major role in this.

Conclusion If not treated, HV leads to deterioration and dysfunction. The most optimal result, however, is achieved only when the surgical approach is applied according to age and rest of the accompanying factors, which should be considered in future management planning.

[Congenital malformations of the growing spine : When should treatment be conservative and when should it be surgical?]

Congenital malformations of the spine are caused by genetic and teratogenic factors. By means of asymmetrical longitudinal growth of the spine they can lead to deformity, most commonly to scoliosis. The malformations can be classified as failure of formation, failure of segmentation and mixed-type malformations. The extent of the deformity and its progression are determined by the remaining growth potential and the location and type of malformation. Up to one third of such deformities are associated with some sort of cardiac or urogenital malformation. The treatment concept is typically determined on an individual basis. Mild deformities often remain undetected. Conservative treatment using a brace has no substantial effect on the primary curve but might be helpful in the treatment of long sweeping, flexible, secondary curves. If rapid progression is documented or expected, surgical intervention as early as possible is warranted to prevent secondary structural changes. The surgical treatment should be focused on and limited to the site of malformation. The aim of surgery is the correction of the deformity at the site of asymmetrical growth. This can be achieved either by resection of a hemivertebra or by performing a vertebral column resection or other type of osteotomy. If notable compensatory, secondary curves are present, these can be corrected with growing rod constructs. The aim of all types of treatment is the correction of existing deformity or the prevention of its progression, in order to ensure balanced growth of the healthy regions of the spine. The present paper discusses the conservative and surgical treatment modalities available to achieve these aims.

Hemivertebra Resection With Instrumented Fusion by Posterior Approach in Children

STUDY DESIGN

We conducted a retrospective study of patients with congenital scoliosis due to hemivertebra (HV) and performed resection with instrumentation through posterior approach-only with long term follow-up.

OBJECTIVES

The objective of this study was to assess results of HV resection by posterior approach-only with instrumentation between 2002 and 2011.

SUMMARY AND BACKGROUND DATA

Hemiepiphysiodesis, arthrodesis in situ and resection without instrumentation had been performed in the past with different results. Hemivertebra resection with spinal instrumentation through anterior and posterior approach has been advocated as the treatment of choice.

METHODS

A total of 67 patients with 78 HV and 70 surgical procedures were evaluated. Thirty-five of the patients were females and 32 were males. The mean age of the patients was 5.5 years (from 0.8 to 16 yr), and the mean follow-up period was 6.55 years (from 2.1 to 10.8 yr). Eighteen patients presented additional pathologies: specific syndromes, cardiopathies, thoracic, abdominal, and bone malformations. Sixteen patients had partial HV while 51 had full mobility HV. Twenty-eight of the HV were thoracic, 16 thoracolumbar, 28 lumbar, and six lumbosacral.

RESULTS

The scoliosis mean preoperative angular value was 38.55°, and the mean postoperative angular value was 19.89°. The kyphosis mean preoperative angular value was 29.98° and the mean postoperative angular value was 15.41°. One rod was used in 38 surgical procedures (54.28%) and 2 rods in 32 procedures (45.72%). We used monoaxial screws in 45 patients, poliaxial screws in 17 patients, and both monoaxial screws and poliaxial screws in one patient. Screws and hooks were used in one patient and hooks in three patients. Arthrodesis was performed in 64 patients, and no complications were registered in those without arthrodesis. Postoperative orthesis was used in 57 opportunities. Several complications during or after HV resection by posterior approach-only were reported. Two patients suffered from intraoperative neurophysiological complications, which were resolved during surgery with minimum gestures and presented no sequelae. Two patients developed superficial infections and needed toilette and IV antibiotic therapy. Two patients needed an additional surgery due to secondary curves, 4.9 yr after primary surgery on average. One patient developed crankshaft.

CONCLUSIONS

We concluded that HV resection by posterior approach-only with instrumentation is a simple, secure, reliable, less invasive and well tolerated technique that can successfully resolve this kind of congenital scoliosis in children.

Hemivertebrae resection for unbalanced multiple hemivertebrae: is it worth it?

PURPOSE

To assess the correction effect of hemivertebra resection for unbalanced multiple hemivertebrae by measuring corresponding parameters in both coronal and sagittal planes on series posteroanterior and lateral radiographs and report the related complications.

METHODS

Twelve children with unbalanced multiple hemivertebrae were operated on by hemivertebra resection through a combined anterior and posterior approach or a posterior-only procedure. Mean age at time of surgery was 9.8 years (range 2-14 years). They were retrospectively studied with a mean follow-up of 48.7 months (range 30-60 months).

RESULTS

The mean Cobb angle of the main curve was 65.3° (range 45°-92°) before surgery and 13.8° (range 4°-30°) at the last follow-up. The correction rate was 80.0% (range 65.5-92.4 %). The compensatory cranial curve was corrected from 25.8° (range 5°-53°) to 11.7° (range 0°-34°) with a correction rate of 65.9% (range 33.3-100%), and the compensatory caudal curve was corrected from 32.4° (range 17°-57°) to 7.1° (range 0°-20°) with a correction rate of 81.4% (range 53.1-100%). The angle of segmental kyphosis was 41.3° (range 12°-76°) before surgery and 17.0° (range -12° to 45°) at the final follow-up. The coronal imbalance was -1.0 cm (range -3.5 to 3 cm) before surgery and 0.0 cm (range -1.0 to 1.5 cm) at the most recent follow-up. The sagittal imbalance was 0.9 cm (range -3.2 to 3 cm) before surgery and 0.6 cm (range -3.0 to 3.5 cm) at the most recent follow-up. Complications including pedicle fractures, and pseudarthrosis were found in two patients (20 %).

CONCLUSIONS

In the patients with unbalanced multiple hemivertebrae, hemivertebra resection allows for excellent correction in both the coronal and sagittal planes, and great care should be taken to reduce the rate of complications.