Congenital kyphosis in myelomeningocele: results following operative and nonoperative treatment

Surgical limits, pitfalls, and potential solutions in kyphectomy in myelomeningocele: three cases and systematic review of the literature

OBJECTIVES

To describe surgical treatment of 3 cases of severe and progressive thoracolumbar kyphosis in myelomeningocele and provide a systematic review of the available literature on the topic.

METHODS

Medical records and pre- and post-operative imaging of 3 patients with thoracolumbar kyphosis and myelomeningocele were reviewed. A database search was performed for all manuscripts published on kyphectomy and/or surgical treatment of kyphosis in myelomeningocele. Patients' information, preoperative kyphosis angle, type of surgery, levels of surgery degrees of correction after surgery and at follow-up, and complications were reviewed for the included studies.

RESULTS

Three cases underwent posterior vertebral column resection (pVCR) of 2-4 segments at the apex of the kyphosis (kyphectomy). Long instrumentation was performed with all pedicle screws constructed from the thoracic spine to the pelvis using iliac screws. According to literature review, a total of 586 children were treated for vertebral kyphosis related to myelomeningocele. At least one vertebra was excised to gain some degree of correction of the deformity. Different types of instrumentation were used over time and none of them demonstrated to be superior over the other.

CONCLUSION

Surgical treatment of progressive kyphosis in myelomeningocele has evolved over the years incorporating all major advances in spinal instrumentation techniques. Certainly, the best results in terms of preservation of correction after surgery and less revision rates were obtained with long construct and screws. However, complication rate remains high with skin problems being the most common complication. The use of low-profile instrumentation remains critical for treatment of these patients.

Kyphectomy and sliding growing rod technique in patients with congenital lumbar kyphosis deformity with myelomeningocele

OBJECTIVE

Neural tube defects are the most common congenital disorders after cardiac anomalies. Lumbar kyphosis deformity is observed in 8-15% of these patients. This deformity severely limits the daily lives of these patients. In our study, we aimed to correct the kyphosis angle of the patients with lumbar kyphosis associated with myelomeningocele (MMC) and allow them to continue their growth without limiting their lung capacity by applying kyphectomy and sliding growing rod technique.

PATIENTS AND METHODS

In this study, we retrospectively evaluated 24 patients with congenital lumbar kyphosis deformity associated with MMC, aged between 4 and 9 years, and who applied to Umraniye Training and Research Hospital between the dates of 2018 and 2021. We evaluated preoperative and postoperative kyphosis angles, correction rates, bleeding during operations, operation time, level of instrumentation, number of the resected vertebrae, initial levels of the posterior defects, duration of hospital stays, annual lengthening, and weight of the patients.

RESULTS

Mean age was 5.04 (between 4 and 9). Mean preoperative and early postoperative kyphosis angles were 129.8° (87-175°) and 0.79° (- 20-24°), respectively. The kyphotic deformity correction rate was 99.1%. A difference was found regarding kyphosis measurements between preoperative and early period values (p < 0.05). The annual height lengthening of patients was calculated as 0.74 cm/year and 0.77 cm/year between T1-T12 and T1-S1, respectively. Mean preoperative level of hemoglobin (Hgb) was 11.95, postoperative Hgb value was 10.02, and the decrease was significant (p < 0.05). In terms of complications, 50% (12) had broken/loosen screws, 50% (12) had undergone debridement surgery, 37.5% (9) had vacuum-assisted closure therapy, and 33.3% (8) had to get all of their implants removed.

CONCLUSION

We believe that our sliding growing rod technique is a new and updated surgical method that can be applied in these patient groups, facilitating the life, rehabilitation process, and daily care of MMC patients with lumbar kyphosis. This technique seems to be a safe and reliable method which preserves lung capacity and allows lengthening.

Does Kyphectomy Improve the Quality of Life of Patients With Myelomeningocele?

BACKGROUND

Lumbar kyphosis is a complex spinal deformity occurring in approximately 8% to 20% of patients with myelomeningocele. The resulting gibbosity may cause pressure ulcers, difficulty lying down in the supine position and sitting on the ischia without support, decreasing quality of life (QOL). Surgery is generally performed to correct kyphosis and maintain vertebral alignment, but high complication rates have been reported. Despite satisfactory radiological results, the impact of surgery and its complications on health-related QOL (HRQOL) has not yet been established.

QUESTIONS/PURPOSES

Among children with myelomeningocele undergoing corrective surgery for lumbar kyphosis: (1) What is the risk of complications and reoperation after this procedure? (2) Does this procedure improve HRQOL scores in these patients?

METHODS

Between 2012 and 2013, five surgeons at three centers treated 32 patients for myelomeningocele-related kyphosis with kyphectomy and posterior instrumentation. During that period, all surgeons used the same indications for the procedure, which were progressive postural decompensation and chronic ulceration at the apex of the deformity. Data were prospectively collected, and all patients who underwent surgery were considered in this retrospective study. The legal guardians of one patient declined to sign the informed consent form, resulting in 31 patients included. A total of 9.7% (3 of 31) were lost to follow-up before the 2-year period, and the remaining 90.3% (28 of 31) were seen at a mean of 3 years (± 9 months) after surgery. The average age was 10 years, 7 months (± 21 months) at the time of surgery. The patients had a mean kyphosis angle of 130° ± 36° before surgery. This technique involved posterior fixation using S-shaped rods inserted through the foramina of S1 and pedicle screws inserted in the thoracic spine. The patients' caregivers answered both the generic and specific (neuromuscular module) Pediatric Quality of Life Inventory questionnaires preoperatively and 2 years postoperatively. The minimum clinically important difference (MCID) considered for the instruments used was 5.

RESULTS

Reoperation was performed in 68% of patients (19 of 28), mostly to treat deep infection. In all, 18% of patients (five of 28) underwent implant removal to control infection. Eleven percent (three of 28) had a loss of reduction and pseudarthrosis. The HRQOL increased from 71 ± 11 preoperatively to 76 ± 10 postoperatively (p < 0.001), resulting in a 5-point increase (95% CI 3 to 7) in the generic questionnaire score and from 71 ± 13 to 79 ± 11 (p < 0.001), resulting in an 8-point increase (95% CI 5 to 10) in the neuromuscular Paediatric Quality of Life Inventory questionnaire score, mainly in the physical health domain on both questionnaires.

CONCLUSIONS

Kyphectomy was associated with a high risk of complications and reoperations and did not seem to deliver a substantial clinical benefit for patients who underwent the procedure. Most of our HRQOL score improvements were below the minimum clinically important difference for the Pediatric Quality of Life Inventory questionnaires. Although it seems that surgeons lack a better surgical alternative when facing the challenging health impairments these patients suffer, efforts should be made to improve the technique and reduce surgical complications. Additionally, patients and caregivers should be advised of the high reoperation rate and notified that the procedure may not result in a better QOL and should thus be avoided when possible. Future studies should verify whether decreasing the complication rate could imply improvement in the HRQOL of these patients after surgery.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Kyphectomy and interbody fixation using lag screws in a child with myelomeningocele kyphosis: a technical case report

A 5-year-old boy had a thoracolumbar-level MMC that had been repaired at the day after birth and kyphotic deformity got worse as he grew. He complained of discomfort about not being able to take a supine posture and decided to perform surgery for kyphosis. In our case, surgical correction is offered to stop the deformity progression, manage the associated pain, and finally to gain sitting and supine posture. We report the surgical procedure with 4 levels of en bloc kyphectomy and using the lag screws. Especially when lag screws are used, several complications including posterior instrumentation failure, hardware prominence and wound break down can be solved by removing the implants after bone fusion has been achieved.

Kyphectomy in neonates with meningomyelocele

PURPOSE

Kyphosis is the most severe spinal deformity associated with meningomyelocele (MMC) and is seen in approximately 15% of neonates. Our purpose is to present our clinical experience, to discuss the technique and deformity correction in kyphectomy in neonates with MMC, and to assess its long-term outcomes.

METHOD

In this prospective study, the authors reviewed eight cases submitted to surgery between 2013 and 2015. We evaluated clinical characteristics that were analyzed, as were the operative technique employed, and angle range of the kyphosis deformity postcorrection follow-up.

RESULTS

Neonatal kyphectomy was performed of six females and two males. The mean birth weight was 2780 g, and the mean age at the time of surgery was 5.6 days. There were S-shaped type deformity in lumbar region in all neonates. In the correction of the kyphotic deformity, a total vertebrae were removed from four patient, whereas a partial vertebrectomy was done in four. The mean operative time was 116 min. No patients did not require the blood transfusion. There were no serious complications, and wound closure was successful in all patients. The mean follow-up period was 4 years and 3 months (range 36-61 months), except one patient who died 1 week after discharge. The mean preoperative kyphosis of 75.6° (range, 50°-90°) improved at last follow-up to 35° (range 15°-55°). All patients had surgical procedures for hydrocephalus. Three patients had surgery for Chiari type II malformation. The mean hospital stay was 27.7 days.

CONCLUSION

Kyphectomy performed at the time of dural sac closure in the neonate is a safe procedure with excellent correction.

Surgical Management of Myelomeningocele-Related Spinal Deformities

OBJECTIVE

To evaluate the optimal timing and type of surgical treatment of myelomeningocele (MMC)-related spinal deformities and long-term follow-up of surgical treatment.

METHODS

We reviewed and presented clinical pictures, treatment strategies and results of 20 patients with MMC-related spinal deformities treated at our center between 2010 and 2017.

RESULTS

The average patient age was 6.3 years. The average preoperative neurologic status according to a modified Japan Orthopedic Association (mJOA) scale was 7.3 points (Benzel's modification). Average functional status was 41 points according to a functional independent measure scale (FIM). The average angle of kyphosis was 83.7°, that of scoliosis was 36.7°, and that of lordosis was 67° (Cobb angles). The average duration of surgery was 234 minutes, and the average total blood loss was 175 mL. The average angle of kyphosis correction was 61°, that of scoliosis correction was 25°, and that of lordosis correction was 25° (Cobb angles). The average duration of hospitalization was 16.6 days, and the average follow-up was 34.5 months. The total number of complications was 13. Reoperation was required in 9 cases. Neurologic status according to the mJOA scale improved by 0.6 point on average. Functional status according to the FIM increased by 6.6 points on average.

CONCLUSIONS

Early surgical correction of MMC-related spinal deformities improves body balance and quality of life. The dual growing rod technique is safe and effective in cases of moderate neuromuscular spinal deformities at an early age. Kyphectomy is a challenging procedure with high complication rates, especially skin problems, but there are no alternative procedures for cases of heavy rigid kyphosis.

The surgical treatment of spinal deformity in children with myelomeningocele: the role of personalized three-dimensional printed models

This study was carried out to evaluate the benefits of personalized three-dimensional printing as an aid to the performance of surgery for the correction of spinal deformity in children with myelomeningocele. We performed a retrospective review to include all such children for whom personalized three-dimensional spine models were used for surgical planning (group A) and compared them through subjective and objective criteria to a similar group that had no models (group B). The seven children in group A were younger and had more complex deformities than the 10 children in group B. The models provided a markedly improved appreciation of the complex anatomy and enabled the planning and performance of patient-specific spinal instrumentation that was secure and low profile. The efficiency of the surgery as measured by intraoperative fluoroscopy time and blood loss and the extent of the deformity correction was comparable or superior in group A.

Bilateral Rib-Based Distraction to the Pelvis for the Management of Congenital Gibbus Deformity in the Growing Child With Myelodysplasia

BACKGROUND

Congenital gibbus deformity of the spine associated with myelodysplasia is a challenging problem in the growing child and is commonly associated with skin breakdown and chronic infection. Surgical solutions including kyphectomy, flap closure of the skin, and early spinal fusion are associated with a high rate of complications and, ultimately, a short trunk due to stoppage of spinal growth. The purpose of this article is to describe our early results in using a rib-based distraction to the pelvis without vertebral resection and fusion to manage this deformity.

METHODS

This is an IRB-approved retrospective study of a consecutive single-surgeon series of using the rib-to-pelvis distraction technique in congenital gibbus deformity. There were four patients (two males, two females) with an average age of 20 months (16-25 months). The diagnosis was myelomeningocele (n = 2), congenital kyphosis (n = 1), and congenital kyphoscoliosis (n = 1). All patients were managed with bilateral rib-to-pelvis distraction using the Vertical Expandable Prosthetic Titanium Rib (VEPTR) device.

RESULTS

The average preoperative gibbus deformity measured 114 degrees (range = 108-154). The average postoperative gibbus measured 52 degrees (range = 36-80). The average length of postoperative follow-up is 66 months (range = 48-84 months). There were 10 complications; a dural leak during device expansion, rib hook migrations and postoperative infections after initial implant that resolved with irrigation, debridement, and intravenous antibiotics. One patient had skin expanders placed preoperatively to facilitate skin coverage. No patient has required vertebral resection to achieve correction of the deformity. No patient has had subsequent skin breakdown over the residual gibbus.

DISCUSSION

This minimally invasive technique effectively corrects gibbus deformity in the growing child without early vertebral column resection and fusion. Our practice is to intervene early while the gibbus is flexible and prior to skin breakdown over the deformity. These early results are encouraging, but further long-term follow-up is needed to confirm the benefits of this technique over traditional methods.

LEVEL OF EVIDENCE

IV.

Safety and Efficacy of Apical Resection Following Growth-friendly Instrumentation in Myelomeningocele Patients With Gibbus: Growing Rod Versus Luque Trolley

INTRODUCTION

Thoracolumbar/lumbar kyphosis in myelomeningocele patients is a common and severely debilitating condition, amenable only to surgical correction. Several surgical techniques have been proposed. Growth-friendly techniques should be preferred in this patient population due to an already compromised trunk height. The growing rod (GR) and Luque trolley (LT) with Galveston instrumentation are well-known growth-friendly techniques. We compared results and complications in 2 groups of patients who have undergone kyphectomy and fixation, either with the GR (group 1) or the LT with Galveston pelvic fixation (group 2).

METHODS

Ten patients undergoing GR fixation and 5 patients undergoing LT with Fackler fixation following kyphectomy (vertebral column resection or multiple eggshell) were included. GRs were lengthened every 6 months. Unplanned surgery in group 1 was defined as an unscheduled operation due to complication; all subsequent operations in group 2 were considered unplanned. Thoracic and local kyphosis and T1-S1 and T1-12 heights were measured preoperatively, postoperatively, and at final follow-up.

RESULTS

Mean age at initial surgery was 6 years and 6.5 years for groups 1 and 2, respectively. Mean age at the last follow-up was 12.5 years for group 1 and 13.1 years for group 2. Mean follow-up was 72.7 months for group 1 and 68.6 months for group 2. Preoperative, postoperative, and final follow-up kyphosis angles in that order for group 1 were 72.3 degrees (10 to 110 degrees), 16.9 degrees (-50 to +55 degrees), and 21.6 degrees (-41 to +97 degrees), and for group 2 106.6 degrees (81 to 132 degrees), 15.6 degrees (-37 to +50 degrees), and 19.2 degrees (-42 to +38 degrees), respectively. Postoperative and final follow-up in that order for mean T1-T12 and T1-S1 heights for group 1 were 14 (11.2 to 18.7) cm, 20.4 (19.3 to 25.7) cm and 21 (17.2 to 23.2) cm, 31.6 (23.6 to 41.5) cm. Postoperative and final follow-up in that order for mean T1-T12 and T1-S1 heights for group 2 were 15.9 (14.3 to 19.7) cm, 20.1 (15.5 to 24.6) cm and 24.4 (17.7 to 27.8) cm, 29.5 (25.3 to 31.3) cm. Growth per year was 1.05 and 0.84 cm for groups 1 and 2, respectively (P=0.297). Fourteen versus 4 unplanned surgeries were performed in groups 1 and 2, respectively, and an additional 4 implant revisions were performed in group 1 during planned lengthenings.

CONCLUSIONS

Both the LT and the GR system are reasonable alternatives of fixation postkyphectomy, both of which preserve growth to differing degrees. In this patient population with an already severely stunted trunk height, the surgeon must choose whether the amount of extra growth achieved by the GR is worth the risk of an increased number of surgeries.

KYPHECTOMY IN PATIENTS WITH MYELOMENINGOCELE: SURGICAL RESULTS AND COMPLICATIONS

Objectives:The lumbar kyphosis in patients with myelomeningocele is a complex deformity whose treatment is mainly surgical. The objective of this study is to summarize the results and complications obtained by the group in 2012 with respect to this group of patients.Method:Performed a retrospective analysis of the medical records and radiographs of patients consecutively operated in 2012. The technique was originally described by Dunn-McCarthy and consists of kyphectomy and posterior fixation using S-shaped Luque rods through the foramina of S1 associated with pedicle screws in the thoracic spine.Results:Six patients were included in the study. The age at surgery was 11 years and 7±22 months and the weight was 29.1±11.9 kg. The procedure lasted 271±87 minutes, with the removal of one or two (mean 1.5) vertebrae from the apex of the kyphosis. Hospitalization time was 10±9 days. The lumbar kyphosis measuring 116.3±37 degrees preoperatively was reduced to 62.5±21 degrees. All patients began to sit without support and to lie in the supine position. Four patients developed postoperative infection and required surgical debridement at the follow-up. One patient had the implant removed after a year due to loosening of the rod in the sacrum.Conclusion:The surgical technique allows excellent functional results in the correction of lumbar kyphosis in patients with myelomeningocele despite high complication rates. It is necessary to conduct studies with a larger number of patients and duration of follow-up to assess whether the use of pedicle screws will decrease the rate of loosening and pseudoarthrosis.

Kyphectomy and Pedicular Screw Fixation with Posterior-Only Approach in Pediatric Patients with Myelomeningocele

PURPOSE

Defective posterior spinal arch and paraspinal musculature lead to progressive kyphosis in patients with myelomeningocele. Kyphosis decreases the patients' functional status and quality of life. To correct or prevent further deterioration, different surgical techniques have been introduced. Our aim is to present our clinical experience in kyphectomy and pedicle screw fixation with a posterior-only approach in pediatric patients with myelomeningocele and to discuss the technique with a review of the literature.

MATERIALS AND METHODS

Four patients with lumbar and 2 patients with thoracolumbar kyphosis (female:male ratio = 1:5) secondary to myelomeningocele were operated between January 2009 and October 2012. The median age was 5.5 years (range = 3-10 years). The criteria of the patient selection for the procedure were progression of kyphosis angle, impaired truncal balance and cosmetic deformity. In this retrospective study, we performed chart reviews for demographic and clinical data. We measured the pre- and postoperative kyphosis angles by using the Cobb method on lateral x-rays.

RESULTS

The mean preoperative kyphosis angle was 114.3° (range = 91-136°). The mean operative time was 171.7 min (range = 110-220 min). The mean intraoperative blood loss was 450 cc (range = 300-700 cc). The postoperative mean kyphosis angle was 28.2° (range = 13-33°). Five patients had skin breakdown. After osteofusion was established, those 5 patients' instrumentations were explanted. No acute or immediate postoperative complications occurred. Other complications were pneumonia and urinary tract infection. In the long term, 2 patients died due to pneumonia and slit-ventricle syndrome, respectively.

CONCLUSIONS

Kyphectomy and pedicle screw instrumentation with the posterior-only approach dramatically reduces the kyphosis angle that develops in patients with myelomeningocele. The method itself is less time-consuming and leads to less intraoperative blood loss compared to other methods used for this patient population. Skin breakdown is the most common short-term complication.

Kyphectomy for congenital kyphosis due to meningomyelocele: a case treated with a modified approach to skin healing

This study is a case report of a meningomyelocele patient with congenital kyphosis who was treated with kyphectomy and a special approach to soft tissue healing. The objective of this study is to show a step by step approach to surgical treatment and postoperative care of a meningomyelocele patient with congenital kyphosis. In meningomyelocele the incidence of kyphosis is around 12-20%. It may cause recurrent skin ulcerations, impaired sitting balance and respiratory compromise. Kyphectomy has first been described by Sharrard. This surgery is prone to complications including pseudoarthrosis, skin healing problems, recurrence of deformity and deep infections. A 15-year-old male presented with congenital kyphosis due to meningomyelocele. He had back pain, deformity and bedsores at the apex of the deformity. The wound cultures showed Staphylococcus epidermidis colonisation at the apex. He was given appropriate antibiotic prophylaxis. During surgery, the apex of the deformity was exposed through a spindle-shaped incision. After instrumentation and excision of the apex, correction was carried out by cantilever technique. Two screws were inserted to the bodies of L3 and T11. After the operation, the skin was closed in a reverse cross fashion. He was sent to hyperbaric oxygen treatment for prevention of a subsequent skin infection and for rapid healing of skin flaps post operation. The patient's deformity was corrected from a preoperative Cobb angle of 135°-15° postoperative. The skin healed without any problems. Preoperative culture and appropriate antibiotic prophylaxis, spindle-shaped incision, reverse cross-skin closure and postoperative hyperbaric oxygen treatment can be useful adjuncts to treatment in congenital kyphosis patients with myelomeningocele to prevent postoperative wound healing and infection problems. Reduction screws and intracorporeal compression screws help to reduce the amount of screws and aid in corection of the deformity.

Kyphectomy in patients with myelomeningocele treated with pedicle screw-only constructs: case reports and review

OBJECT

Significant lumbar kyphosis is frequently observed in patients with myelomeningocele and has been associated with increasing functional impairment, decreased abdominal volume, respiratory impairment, discomfort, and skin ulcerations overlying the prominent gibbus. Treatment of severe kyphotic deformities can include kyphectomy, with or without ligation of the thecal sac, with posterior spinal fixation. However, most series have reported a high rate of morbidity and complications associated with surgical intervention for correction of kyphosis in patients with myelomeningocele. The authors describe a technique in which pedicle screw (PS)-only constructs are used without transection of the thecal sac to treat severe kyphosis successfully, with minimal morbidity.

METHODS

The authors retrospectively reviewed medical records and radiographic images in 2 patients with myelomeningoceles in whom kyphectomies had been performed at the authors' institution between January 2007 and July 2010. They also reviewed the existing literature for case reports or published series of patients with myelomeningocele treated with kyphectomies, to evaluate the outcomes.

RESULTS

Both patients were male and had thoracic-level myelomeningoceles that had been repaired at birth, with associated paraplegia. Neither patient had any significant scoliotic deformity associated with the kyphosis, and both had fixation from T-9 to the ilium, which was performed using PS constructs, along with L1-2 kyphectomies. The patient in Case 1 was 20 years old and was treated for progressive kyphosis and an ulcerated nonhealing wound over the gibbus. The patient in Case 2 was 10 years old and was treated for progressive pain and functional impairment. The 2 patients had a mean correction of 63%, with a mean correction of kyphotic deformity from 136° to 51°. Neither patient developed any complication in the short term postoperatively, whereas published series have reported high complication rates, including wound infection, poor wound healing, CSF leakage, pseudarthrosis, and shunt malfunction.

CONCLUSIONS

Severe kyphotic deformities in patients with myelomeningocele can be safely treated using PS-only constructs without ligation of the thecal sac. Further evaluation with a larger sample and longer follow-up are needed to detect any associated complications, such as proximal junctional kyphosis. Further evaluation may also validate whether PS-only constructs permit successful outcomes with a shorter construct and fewer instrumented levels.

Kyphectomy in children with myelomeningocele

BACKGROUND

Patients with myelomeningocele and rigid lumbar and thoracolumbar kyphosis face substantial functional difficulties with sitting and lying supine and are prone to skin breakdown over the gibbus and risk of infection. Kyphectomy, along with cordotomy and segmental spinal instrumentation down to the pelvis, is one alternative that can provide reliable correction of the deformity but also can maintain that correction over a period of time.

QUESTIONS/PURPOSES

We determined the fusion rates, deformity correction and maintenance, and perioperative complications of kyphectomy with long segmental spinal instrumentation using the Warner and Fackler technique.

METHODS

We retrospectively reviewed the charts and radiographs of 33 patients with myelomeningocele who had kyphectomy with segmental spinal instrumentation down to the pelvis between 1991 and 2006. The average age at surgery was 7.6 years (range, 3-19 years). Twenty-one patients had a minimum 2-year followup (average, 7.0 years; range, 2.4-15.7 years).

RESULTS

The average preoperative kyphosis of 124° (range, 75°-210°) improved at last followup to 22° (range, 3°-55°) with an average correction of 81% (range, 59%-98%). We identified 17 postoperative complications. Wound and skin complications were most common; 11 secondary surgeries were performed in 10 patients.

CONCLUSIONS

Surgery for myelomeningocele kyphosis is technically demanding and carries substantial risk. Kyphectomy and posterior spinal fusion and instrumentation with the Warner and Fackler technique allow correction and maintenance of sagittal alignment.

Kyphectomy improves sitting and skin problems in patients with myelomeningocele

BACKGROUND

Progressive kyphosis occurs in up to 20% of patients with myelomeningocele. Severely affected patients can develop recurrent skin breakdown, osteomyelitis, sitting imbalance, and poor cosmetic appearance.

QUESTIONS/PURPOSES

We (1) assessed the ability of kyphectomy to restore an intact skin envelope and allow comfortable seating in a wheelchair; (2) reviewed the complications of kyphectomy and spinal fusion in myelomeningocele; and (3) determined whether patients requiring unexpected reoperation had worse correction or more ulceration compared with those patients treated with a single surgery.

METHODS

We retrospectively reviewed the records of 23 children with thoracic-level myelomeningocele who were treated with kyphectomy and spinal fusion since 1980. Indications for surgery included recurrent skin breakdown (15 patients) and poor sitting balance or unacceptable cosmetic deformity (three patients). We evaluated operative technique, type of sacropelvic fixation, surgical complications, radiographic correction, and skin condition at followup. The minimum followup was 2 years (median, 4.1 years; range, 2.1-10 years); 18 of the 23 children had greater than 2 years followup and are reported here.

RESULTS

Kyphectomy achieved a sitting balance and resolved in skin ulceration in 17 of 18 patients. Seven patients had complications requiring reoperation. Three patients had multiple reoperations for early deep infection and one patient each had reoperation for late infection, pseudarthrosis, implant-related sacral pressure sore, and planned extension of proximal fusion after growth. Patients requiring multiple operations had similar correction and relief of ulceration to those treated with a single procedure.

CONCLUSIONS

Complications after kyphectomy are frequent and many children with myelomeningocele and severe hyperkyphosis require multiple procedures and lengthy hospital stays. Nonetheless, improved seating balance and resolution of skin problems was achieved in 17 of 18 patients.

Posterior kyphectomy for myelomeningocele with anterior placement of fixation: a retrospective review

BACKGROUND

Kyphosis in myelomeningocele is a rare and difficult problem. Many strategies have been used with no single procedure universally agreed on. Techniques involving anterior and posterior fixation may provide better fusion.

QUESTIONS/PURPOSES

We describe a novel procedure for anteroposterior kyphectomy in patients with myelomeningocele. Apical posterior kyphectomy is followed by the insertion of two rods distally into the vertebral bodies and sacrum. Sublaminar wires are placed superiorly and the kyphosis is reduced by sequential tightening. We determined kyphosis correction and intraoperative blood loss for this new procedure.

METHODS

We retrospectively reviewed 22 patients (average age, 7.6 years [range, 2-17 years]) who underwent apical kyphectomy from 1982 to 2008. Charts were examined and radiographs measured preoperatively, immediately postoperatively, and at final followup. Followup averaged 6.4 years (range, 0-14 years) with 19 patients having at least 2 years of followup.

RESULTS

Kyphosis decreased from a mean of 123° (range, 79°-163°) preoperatively to 40° (range, 13°-92°) immediately postoperatively and was a mean of 60° (range, 14°-126°) at final followup. Operating time was 248 minutes (range, 180-345 minutes), estimated blood loss was 765 mL (range, 140-2100 mL), and length of stay was 14 days (range, 1-57 days). Ten of the 22 patients had complications with eight requiring reoperation.

CONCLUSIONS

This anteroposterior kyphectomy provided a high level of kyphosis correction, which was largely maintained over the study period. Blood loss, surgical time, and complication rates were acceptable as compared with other techniques reported in the literature.

Uso da prótese vertical expansível de titânio para costela no tratamento da cifose congênita em portadores de mielomeningocele torácica

OBJETIVO: avaliar os resultados clínicos e radiográficos pós-operatórios da correção de cifose congênita em pacientes com mielomeningocele de nível torácico, utilizando a prótese vertical expansível de titânio para costela (VEPTR). MÉTODOS: estudo retrospectivo de 19 pacientes com mielomeningocele torácica e cifose congênita submetidos a tratamento com VEPTR, entre Outubro de 2005 e Outubro de 2008, com avaliação radiográfica e clínica pré e pós-operatória imediata. Foram avaliadas também a duração do procedimento cirúrgico, a necessidade de transfusão sanguínea e as complicações pós-operatórias. RESULTADOS: a média de idade dos pacientes foi de 70 meses ou cinco anos e dez meses (32 a 130 meses). A média de seguimento dos pacientes foi de 13,5 meses (2 a 26 meses). A duração média do procedimento foi de 117 minutos (variação de 70 a 195 minutos). Todas as crianças adquiriram equilíbrio de tronco, sendo que 13 delas não apresentavam isto no pré-operatório. A média da cifose pré-operatória foi de 115° (80° a 150°) e pós-operatória de 77° (50° a 104°), com porcentagem média de correção de 31,2% (1,1 a 61,5%). O desequilíbrio do tronco pré-operatório foi de 7,9 cm, em média (1,0 a 15,5 cm) e pós-operatório de 3,4 cm (0 a 8 cm). A correção média desse desequilíbrio foi de 50,4% (0 a 100%). Com relação ao peso, no pré-operatório a média foi de 15,4 kg (8 a 30 kg), e no pós-operatório de 20,6 kg (8,5 a 35 kg). O ganho médio de peso foi de 36,6% (9,8 a 100%). Dos 19 pacientes, cinco (26,3%) apresentaram complicações pós-operatórias. Nenhum paciente necessitou de transfusão sanguínea. CONCLUSÃO: a utilização do VEPTR nos pacientes portadores de mielomeningocele torácica com cifose congênita tem se mostrado uma alternativa eficaz e promissora de controle da deformidade em pacientes esqueleticamente imaturos.

Combination of luque instrumentation with polyaxial screws in the treatment of myelomeningocele kyphosis

Rigid congenital kyphosis in myelomeningocele is associated with an important morbidity with skin breakdown, recurrent infection, and decreased function. Kyphectomy is the classic treatment to restore spinal alignment; however, surgery is associated with morbidity and long-term complications. The purpose of this retrospective study was to examine the authors' experience using combination of Luque instrumentation with posterolaterally placed polyaxial screws in the treatment of myelomeningocele kyphosis. From June 1999 to June 2003, 7 patients were treated and followed up for an average of 68.6 months. The average age at the time of the operation was 7 year and 1 month. All patients underwent vertebral excision from just above the apex of vertebral deformity to realign the sagittal deformity. Posterolaterally placed polyaxial screws were used in combination with segmental Luque instrumentation. Kyphotic deformity averaged 104 degrees before surgery, 15.2 degrees after surgery, and 18.5 degrees at the latest follow-up. The average loss of correction was 3.3 degrees. The average blood loss was 611 mL. Complications occurred in 2 of 7 patients were superficial wound breakdown and deep wound infection that required rotational flap closure. Kyphectomy with posterior instrumentation by using Luque technique in the combination with polyaxial screws is reliable method for correcting rigid kyphotic deformity in patients with myelomeningocele. Rigidity of the construct, greater correction capacity, and low profile instrumentation by the help of posterolateral insertion of the polyaxial screws and wiring were the distinct advantages of this technique.

Retrospective review of multilevel spinal fusion combined with spinal cord transection for treatment of kyphoscoliosis in pediatric myelomeningocele patients

STUDY DESIGN

Retrospective review of cases at a single institution from 1998 to 2005.

OBJECTIVE

The authors present their surgical experience, complications, and learned insight in 9 myelomeningocele children with kyphoscoliosis treated with combined spinal cord transection and spinal fusion.

SUMMARY OF BACKGROUND DATA

Complication rates in spinal fusion for treatment of kyphoscoliosis in myelomeningocele patients are high. Spinal cord transection in combination with fusion can be an appropriate strategy in selected patients, but changes in cerebrospinal fluid (CSF) dynamics that may accompany ligation of the distal CSF circulation are not well characterized.

METHODS

Demographic, clinical, and radiologic data were examined in 9 children with myelomeningocele level at or above T12 and no residual urologic function treated at our institution with spinal cord detethering and transection, and multilevel spinal fusion. Seven children underwent kyphectomy with posterior fusion only for severe gibbus deformities, while 2 had anterior and posterior fusions for severe kyphoscoliosis.

RESULTS

Follow-up of patients ranged from 4 to 92 months (mean, 37.8 months). Eight children (89%) experienced postoperative complications involving wound infection or skin breakdown. One child presented with a CSF leak. Two children (22%) required revision of their ventriculoperitoneal shunts. The average angle of kyphosis before surgery was 122.3 (range, 48 degrees -180 degrees ), and the average postoperative angle was 38.2 (range, 4 degrees -113 degrees ), with average correction being 81.9 degrees (range, 29 degrees -124). Average correction of scoliosis, if present, was 59.5 degrees (range, 35 degrees -92 degrees ).

CONCLUSION

Combined spinal cord transection and spinal fusion allowed an average correction of kyphosis by 81.9 degrees . The complication rate was 89%, with wound concerns being the most significant. Additionally, 22% of patients required shunt revision within 6 weeks of surgery. We attribute this to alteration of CSF dynamics resulting from loss of CSF absorption and flow-buffering capacity below the level of the spinal cord transection.

Posterior vertebral column resection for VATER/VACTERL associated spinal deformity: a case report

The VATER/VACTERL association is a syndrome notable for congenital vertebral malformations, anal atresia, cardiovascular anomalies, tracheoesophageal fistula, esophageal atresia, and renal or limb malformations. Vertebral malformations may include the entire spectrum of congenital spinal deformities, including kyphosis, as was seen in this case. A 14-year-old girl presented to our institution with severe rigid sagittal deformity in the thoracolumbar spine that had recurred following three prior spinal fusion surgeries: the first posterior only, the second anterior and posterior, and the third a posterior only proximal extension. These surgeries were performed to control progressive kyphosis from a complex failure of segmentation that resulted in a 66 degrees kyphosis from T11 to L3 by the time she was 9 years old. Our evaluation revealed solid arthrodesis from the most recent procedures with resultant sagittal imbalance, and surgical options to restore balance included anterior and posterior revision spinal fusion with osteotomies, multiple posterior extension osteotomies with circumferential spine fusion, and posterior vertebral column resection with circumferential spine fusion. She was advised that multiple posterior extension osteotomies would likely be insufficient to restore sagittal balance in the setting of solid arthrodesis from anterior and posterior surgery, and that the posterior-only vertebral column resection would provide results equivalent to revision anterior and posterior surgery, without the morbidity of the anterior approach. She successfully underwent posterior vertebrectomy and circumferential spinal fusion with instrumentation and is doing well 2 years postoperatively. Severe rigid sagittal deformity can be effectively managed with a posterior-only surgical approach, vertebrectomy, and circumferential spinal fusion with instrumentation.

Short segment posterior locking cervical plate fixation after kyphectomy for myelomeningocoele-associated kyphosis

We report the use of posterior cervical locking plate fixation after apical vertebral excision for congenital lumbar kyphosis in a 3-year-old male myelomeningocoele patient. At 4-year follow-up the fixation was secure and the correction was well preserved.

Congenital and developmental deformities of the spine in children with myelomeningocele

The treatment of spinal deformities in children with myelomeningocele poses a formidable task. Multiple medical comorbidities, such as insensate skin and chronic urinary tract infection, make care of the spine difficult. A thorough understanding of the natural history of these deformities is mandatory for appropriate treatment to be rendered. A team approach that includes physicians from multiple specialties provides the best care for these patients. The two most challenging problems are paralytic scoliosis and rigid lumbar kyphosis. The precise indications for surgical intervention are multifactorial, and the proposed benefits must be weighed against the potential risks. Newer spinal constructs now allow for fixation of the spine in areas previously difficult to instrument. Complications appear to be decreasing with improved understanding of the pathophysiology associated with myelomeningocele.

Kyphectomy in myelomeningocele with a modified Dunn-McCarthy technique followed by an anterior inlayed strut graft

Rigid congenital kyphosis in myelomeningocele is associated with an important morbidity with skin breakdown, recurrent infection, and decreased function. Kyphectomy is the classic treatment to restore spinal alignment; however, surgery is associated with an important morbidity and long-term correction is uncertain. The authors retrospectively reviewed 9 patients with a mean age of 8.8 years who underwent a two stage surgical procedure: first a posterior kyphectomy with a modified Dunn-McCarthy fixation consisting of lumbar pedicle screws and long S-shape rods buttressing the anterior sacrum. Then a second stage done several weeks later consisting of a thoraco-abdominal approach to the spine with an inlay strut graft classically from T10-S1. The mean follow-up was 34 months (range 1-5 years). The kyphosis was corrected from a mean of 110 degrees of Cobb angle (range 70-130 degrees) to 15 degrees after surgery (45-0 degrees). There was no instrumentation failure, no loss of correction and no pseudarthrosis. Complications consisted of one intra-operative cardiac arrest fortunately reversible, a wound necrosis, one deep venous thrombosis and one late aseptic bursitis on the posterior hardware. Congenital kyphosis in myelomeningocele can be treated successfully with an initial posterior approach correction and instrumentation followed by an anterior approach allowing for anterior inlay impacted structural graft. The authors believe that this technique improves biomechanical and biological fusion mass anteriorly and will prevent late instrumentation failure and loss of correction.

Kyphectomy in children with myelomeningocele: a long-term outcome study

Twenty-four children with myelomeningocele and a kyphotic deformity treated by surgical correction between 1980 and 1994 were reviewed. Different techniques of instrumentation and spinal fusion were used. The mean age at surgery was 9.5 years. The mean kyphotic angle was 121 degrees preoperatively, 50 degrees postoperatively, and 57 degrees at final follow-up. The postoperative complication rate was high. Delayed wound healing and late skin breakdown with exposure of instrumentation were common problems. Further surgery to remove protruding hardware was necessary in 18 patients. Long posterior instrumentation with fixation to the pelvis had significantly better stability on follow-up than other methods. Despite the prolonged postoperative morbidity in the majority of the study group, the long-term clinical and radiologic outcome at a mean follow-up of 10 years was excellent.

Caring for a child with spina bifida: understanding the child and carer

Spina bifida is a common congenital abnormality, which causes significant physical and psychological morbidity in affected children and which also affects their carers. This small-scale study looked at the health problems of a child with a myelomeningocoele. It also addresses the psychosocial problems that his mother, his main carer, faced and the social networks involved in his care. The evidence supporting various aspects of spina bifida prevention and management is explored. Furthermore, a literature review is included, with regards to physical and psychological issues for child and carer. This study aims to raise awareness of the problems faced by children with myelomeningocoele and their families. In particular, we aim to educate health care professionals on the importance of perceived stress by carers of such children, and suggest ways to reduce psychosocial morbidity.

Neonatal kyphectomy in the patient with myelomeningocele

STUDY DESIGN

A retrospective cohort study was used to investigate a group of neonates with myelomeningocele who had a kyphectomy performed in conjunction with dural sac closure during the first few days of life.

OBJECTIVES

To assess the effectiveness of operative intervention in the neonatal period to correct the kyphotic deformity in the patient with myelomeningocele and to monitor its long-term results.

SUMMARY OF BACKGROUND DATA

Orthopedic management originally focused on the immediate treatment of the kyphotic deformity in the infant with myelomeningocele. However, there has been a movement toward postponing surgical treatment of the kyphos until a later age. This study included the longest follow-up of the largest group of neonates that a single surgeon has managed surgically since the treatment of this condition was originally described.

METHODS

The radiographic and clinical results for all neonates treated with a kyphectomy at the time of myelomeningocele closure between 1980 and 2000 were analyzed.

RESULTS

Neonatal kyphectomy was performed on nine males and two females. The average preoperative kyphotic angle measured 67 degrees. The average initial correction was 77 degrees, and the average loss of correction at follow-up assessment was 55 degrees. There were no serious complications, and wound closure was successful in all patients. One patient required a repeat kyphectomy and posterior spinal fusion at the age of 9 years and 2 months. The average follow-up period was 7 years and 4 months (range 44-174 months).

CONCLUSIONS

Kyphectomy performed at the time of dural sac closure in the neonate is a safe procedure with excellent initial correction. Eventual recurrence is expected despite the procedure. However, it occurs in the form of a longer, more rounded deformity that is less technically demanding.

A kyphectomy technique with reduced perioperative morbidity for myelomeningocele kyphosis

STUDY DESIGN

The lumbar sacropelvis in 11 patients with myelomeningocele and kyphosis was treated with a subtraction kyphectomy technique and posterior instrumentation. The results of this procedure in the 11 patients were evaluated and compared with previous results.

OBJECTIVE

To examine critically their experience using the subtraction (decancellation) vertebrectomy technique combined with posterior instrumentation for myelomeningocele kyphosis, the authors reviewed the charts of 18 myelomeningocele patients who underwent surgery for lumbar kyphosis between 1994 and 1998.

SUMMARY OF BACKGROUND

The benefits of restoring sagittal spinal alignment in myelomeningocele patients with severe lumbar kyphosis deformity to achieve postural stability and improved sitting balance generally are accepted. The optimal method of deformity correction, the extent of instrumentation, and the role of limited arthrodesis remain undefined.

METHODS

Of the 18 patients considered, 11 met the inclusion criteria of having undergone reconstruction using a subtraction (decancellation) vertebrectomy technique, preservation of the thecal sac, limited arthrodesis with posterior transpedicular lumbosacral instrumentation, and a minimum follow-up evaluation of 2 years. The study considered the age of the patient, number of levels fused, estimated blood loss, preoperative deformity, immediate postoperative correction, magnitude of correction, and maintenance of correction at latest follow-up assessment.

RESULTS

The average age at the time of the index procedure was 6 years (range, 3-12 years). The average preoperative kyphosis was 88 degrees (range, 50-149 degrees ). Immediately after surgery, the average curve measurement was 3 degrees lordosis (range, 50 degrees to 50 degrees ). The average magnitude of postoperative sagittal plane deformity correction was 91 degrees (range, 43-126 degrees ). Finally, the magnitude of correction maintained at the final follow-up assessment averaged 66 degrees (range, 22-114 degrees ). This represented an average loss of correction at 2 years of 24 degrees (range, 0-84 degrees ). There were no deaths, episodes of acute-onset hydrocephalus, vascular complications, or chronic deep wound infections.

CONCLUSIONS

The subtraction (decancellation) vertebrectomy technique with preservation of the dural sac is a safe and efficacious technique for correction and stabilization of myelomeningocele kyphosis in young patients. Morbidity is reduced, as compared with that of excision techniques. Restoration of sagittal alignment at the time of initial correction and stabilization to achieve a balanced spine led to acceptable results.

Kyphosis deformity in myelomeningocele

Management of the child with myelomeningocele and kyphosis is an extreme challenge to the orthopedic surgeon and spine surgeon on many fronts. Delayed or observation treatment may result in loss of functional independence and self-esteem. Early surgical correction may result in loss of truncal height, intra-abdominal upward volume effect on the diaphragm, and loss of pulmonary capacity. Late surgical reconstruction may be associated with significant morbidity and mortality. Early surgical intervention with preservation of growth may prove safer and result in improved function and independence.

Modified luque instrumentation after myelomeningocele kyphectomy

STUDY DESIGN

Treatment of congenital kyphosis in myelomeningocele is a difficult problem. Current thinking supports kyphectomy and postoperative internal fixation.

OBJECTIVES

Since 1989, vertebral resection with modified Luque fixation has been the procedure of choice for correction of myelomeningocele kyphotic deformity at the author's institution. The study objective was to evaluate long-term results with this technique.

SUMMARY OF BACKGROUND DATA

Most investigators agree that kyphotic deformity in myelomeningocele should be treated with vertebral resection. There is less uniform consensus about postoperative fixation. Reports in the literature support fixation with modified segmental instrumentation.

METHODS

Sixteen patients, observed for an average of 57.2 months (range, 36-94 months), underwent vertebral resection from the proximal aspect of the apical vertebra cephalad into the compensatory lordotic curve. Fixation was segmental instrumentation wired to the thoracic spine and anterior to the sacrum.

RESULTS

The average blood loss was 1121 mL (range, 450-2580 mL). Kyphotic deformity averaged 111 degrees before surgery (range, 75-157 degrees), 15 degrees after surgery (range, -18-36 degrees) and 20 degrees at latest follow-up (range, -17-83 degrees). Loss of correction was 6 degrees (range, 0-27 degrees). Postoperative immobilization was with a thoracolumbosacral orthosis for 18 months. Complications occurring in 8 of the 16 patients were transient headache, superficial wound breakdown, supracondylar femur fractures, and one late infection secondary to skin breakdown that necessitated early rod removal, resulting in some loss of correction.

CONCLUSIONS

Kyphectomy is an excellent method of correcting rigid kyphotic deformity in the patient with myelodysplasia. Segmental spinal instrumentation provided three distinct advantages: rigidity of the construct, greater correction of the deformity and low-profile instrumentation.

Spinal deformity in myelodysplasia. Correction with posterior pedicle screw instrumentation

STUDY DESIGN

A retrospective review of transpedicular instrumentation used in a series of 24 patients with myelodysplastic spinal deformities and deficient posterior elements.

OBJECTIVE

To describe the usefulness and efficacy of these instruments in the treatment of complicated myelodysplastic spinal deformity.

METHODS

The mean preoperative scoliosis was 75.7 degrees (range, 39-130 degrees) in the 22 patients with scoliotic deformities; 4 patients with thoracic hyperkyphoses averaged 70.5 degrees (range, 46-90 degrees) and 10 patients with lumbar kyphoses averaged 80.5 degrees (range, 42-120 degrees). The instrumentation extended to the sacrum in 4 patients and the pelvis in 9; 10 patients also underwent anterior release and fusion and 7 underwent concomitant spinal cord detethering. At an average follow-up of 4.0 years (2.0-7.7 years; one patient died at 8 months), all patients have fused (with the exception of two lumbosacral pseudarthroses).

RESULTS

At last follow-up, deformity measured 32.1 degrees scoliosis (range, 6-85 degrees), 30.8 degrees thoracic kyphosis (range, 24-35 degrees), and 0.0 degree lumbar kyphosis (range, 35 degrees kyphosis to 29 degrees lordosis). Three patients lost some neurologic function after surgery; two recovered within 6 months and one has incomplete recovery. No ambulatory patient lost the ability to walk. Five patients required additional surgical procedures; in three cases, there was instrumentation breakage associated with pseudarthrosis or unfused spinal segments.

CONCLUSIONS

Pedicle screw instrumentation is uniquely suited to the deficient myelodysplastic spine. Compared with historical control subjects, these devices have proven capable of significant correction of both scoliotic and kyphotic deformities. This instrumentation appears particularly useful in preserving lumbar lordosis in all patients and may preserve more lumbar motion in ambulatory myelodysplasia patients.

Surgery of the spine in myelodysplasia. An overview

Significant spinal deformity is particularly common in nonambulatory patients with myelodysplasia. Progressive deformity may be caused by congenital anomalies, paralytic collapse, hip contractures, or spinal cord tethering. Existing or projected functional impairment should be the principle indication for treatment. Surgical treatment is complicated by poor soft tissue coverage, associated contractures, lack of sensation, weak bone, and absence of posterior elements. Successful fusion can be achieved by circumferential (anterior and posterior) fusion and current rigid segmental instrumentation. The unique deformities and bony anatomy require individualized techniques to achieve fixation.