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Mahajan R, Kumar G. Is deformity correction essential in a "Myelopathic Cord"? - A case series. Spinal Cord Ser Cases 2024; 10:61. [PMID: 39164227 PMCID: PMC11335899 DOI: 10.1038/s41394-024-00676-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 08/11/2024] [Accepted: 08/14/2024] [Indexed: 08/22/2024] Open
Abstract
INTRODUCTION The incidence of preoperative neurological deficits in pediatric patients with complex deformities ranges from 15% to 23%. Furthermore, the likelihood of a postoperative neurological deficit can be considerably increased to 83.3% in the presence of a preoperative neurological deficit. Hence, the management of pediatric spinal deformities with neurological deficits is a challenge for every spine surgeon. Here, we describe four consecutive cases of pediatric spinal deformity with myelopathic cord, all of which were managed with decompressive surgery and stabilization without any attempts to correct the deformity. All the patients recovered well neurologically, without any progression of deformity. CASE PRESENTATION The authors obtained the informed written consent from the patient and their parents for the print and electronic publication of the case. All four patients had clinical myelopathy with a progressive, worsening neurological deficit. The pathology was in the thoracic region in all the patients. Of the four cases, two were post-tubercular deformities, and two were congenital deformities. The treatment strategy for all patients was circumferential decompression of the spinal cord with posterior pedicle screw instrumentation. Although all patients had significant neurological deficits (Nurick grade 4 or 5) preoperatively, we used intraoperative neuromonitoring to prevent the worsening of the deficit during the procedure. None of the patients experienced intraoperative signal changes. All patients had significant neurological recovery (Nurick grade 0 to 2) and showed no worsening of deformity at their latest follow-up, up to 4 years. All showed good improvement in all domains of the SRS22r questionnaire. DISCUSSION It is challenging for spine surgeons to manage complex spinal abnormalities in pediatric patients with myelopathic cords. Even a minimal manipulation of the cord during surgery might result in severe long-term morbidity. The primary objective in managing such patients should be neurological recovery rather than deformity correction-"First do no harm," and if necessary, the deformity can be corrected at a later stage under neuromonitoring.
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Affiliation(s)
- Rajat Mahajan
- Department of Spine Services, Indian Spinal Injuries Centre, Sector-C, Vasant Kunj, New Delhi, 110070, India
| | - Ganesh Kumar
- Department of Spine Services, Indian Spinal Injuries Centre, Sector-C, Vasant Kunj, New Delhi, 110070, India.
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Grabala P, Fani N, Gregorczyk J, Grabala M. Posterior-Only T11 Vertebral Column Resection for Pediatric Congenital Kyphosis Surgical Correction. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:897. [PMID: 38929517 PMCID: PMC11206005 DOI: 10.3390/medicina60060897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 06/28/2024]
Abstract
Background: Congenital kyphosis is a spinal deformity that arises from the inadequate anterior development or segmentation of the vertebrae in the sagittal plane during the initial embryonic stage. Consequently, this condition triggers atypical spinal growth, leading to the manifestation of deformity. Concurrently, other congenital abnormalities like renal or cardiac defects within the gastrointestinal tract may co-occur with spinal deformities due to their shared formation timeline. In light of the specific characteristics of the deformity, the age range of the patient, deformity sizes, and neurological conditions, surgical intervention emerges as the optimal course of action for such cases. The selection of the appropriate surgical approach is contingent upon the specific characteristics of the anomaly. Case Presentation: This investigation illustrates the utilization of a surgical posterior-only strategy for correcting pediatric congenital kyphoscoliosis through the implementation of a vertebral column resection method along with spine reconstruction employing a mesh cage. The individual in question, a 16-year-old female, exhibited symptoms such as a progressive rib hump, shoulder asymmetry, and back discomfort. Non-invasive interventions like bracing proved ineffective, leading to the progression of the spinal curvature. After the surgical procedure, diagnostic imaging displayed a marked enhancement across all three spatial dimensions. After a postoperative physical assessment, it was noted that the patient experienced significant enhancements in shoulder alignment and rib hump prominence, with no discernible neurological or other adverse effects. Conclusions: Surgical intervention is considered the optimal approach for addressing such congenital anomalies. Typically, timely surgical intervention leads to favorable results and has the potential to halt the advancement of deformity and curvature enlargement.
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Affiliation(s)
- Pawel Grabala
- Department of Pediatric Orthopedic Surgery and Traumatology, Medical University of Bialystok, University Children’s Hospital, Waszyngtona 17, 15-274 Bialystok, Poland
- Paley European Institute, Al. Rzeczypospolitej 1, 02-972 Warsaw, Poland
- Department of Neurosurgery, Medical University of Bialystok, M. Sklodowskiej-Curie 24A, 15-276 Bialystok, Poland
| | - Negin Fani
- Medical Faculty, Medical University of Warsaw, 02-091 Warsaw, Poland; (N.F.); (J.G.)
| | - Jerzy Gregorczyk
- Medical Faculty, Medical University of Warsaw, 02-091 Warsaw, Poland; (N.F.); (J.G.)
| | - Michal Grabala
- 2nd Clinical Department of General and Gastroenterogical Surgery, Medical University of Bialystok, ul. M. Skłodowskiej-Curie 24a, 15-276 Bialystok, Poland;
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Ohtsubo S, Ohashi M, Hirano T, Tashi H, Makino T, Minato K, Mitsuma Y, Deguchi H, Hoshino R, Ohashi N, Furutani K, Kawashima H, Watanabe K. Delayed paraparesis after posterior spinal fusion for congenital scoliosis: a case report. Spinal Cord Ser Cases 2024; 10:24. [PMID: 38632284 PMCID: PMC11024208 DOI: 10.1038/s41394-024-00639-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Although multimodal intraoperative neuromonitoring (IONM), which has high sensitivity and specificity, is typically performed during spinal deformity surgery, neurological status may deteriorate with delay after surgical maneuvers. Here, we report a rare case of delayed postoperative neurological deficit (DPND) that was not detected by IONM during posterior spinal fusion (PSF) for congenital scoliosis. CASE PRESENTATION A 14-year-old male presented with congenital scoliosis associated with T3 and T10 hemivertebrae. Preoperative Cobb angle of proximal thoracic (PT) and main thoracic (MT) curves were 50° and 41°, respectively. PSF (T1-L1) without hemivertebrectomy was performed, and the curves were corrected to 31° and 21° in the PT and MT curves, respectively, without any abnormal findings in IONM, blood pressure, or hemoglobin level. However, postoperative neurological examination revealed complete loss of motor function. A revision surgery, release of the curve correction by removing the rods, was immediately performed and muscle strength completely recovered on the first postoperative day. Five days postoperatively, PSF was achieved with less curve correction (36° in the PT curve and 26° in the MT curve), without postoperative neurological deficits. DISCUSSION Possible mechanisms of DPND in our patient are spinal cord ischemia due to spinal cord traction caused by scoliosis correction and spinal cord kinking by the pedicle at the concave side. Understanding the possible mechanisms of intra- and postoperative neural injury is essential for appropriate intervention in each situation. Additionally, IONM should be continued to at least skin closure to detect DPND observed in our patient.
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Affiliation(s)
- Shuhei Ohtsubo
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Masayuki Ohashi
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan.
| | - Toru Hirano
- Department of Orthopedic Surgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minamiuonuma City, Japan
| | - Hideki Tashi
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Tatsuo Makino
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Keitaro Minato
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Yusuke Mitsuma
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Hiroyuki Deguchi
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Rintaro Hoshino
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Nobuko Ohashi
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Kenta Furutani
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Hiroyuki Kawashima
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Kei Watanabe
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
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Nagata K, Dimar JR, Carreon LY, Glassman SD. Preoperative Optimization: Risk Factors for Perioperative Complications and Preoperative Modification. Neurosurg Clin N Am 2023; 34:505-517. [PMID: 37718097 DOI: 10.1016/j.nec.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Adult spinal deformity (ASD) is common and the complication rate in ASD surgery is high due to its invasiveness. There are several factors that increase the risk of complications with ASD surgery. These include age, past medical history, frailty, osteoporosis, or operative invasiveness. Risk factors for perioperative complications can be categorized as modifiable and non-modifiable. The purpose of this article is to present the current available evidence on risk factors for perioperative complications, with a focus on frailty, osteoporosis, surgical site infection prevention, and hip-spine syndrome. In addition, we present the latest evidence for patient-specific surgical risk assessment and surgical planning.
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Affiliation(s)
- Kosei Nagata
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA
| | - John R Dimar
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA
| | - Leah Y Carreon
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA.
| | - Steven D Glassman
- Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202, USA
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Hartley L, Jones C, Lui D, Bernard J, Bishop T, Herzog J, Chan D, Stokes O, Gardner A. An Examination of the Number of Adolescent Scoliotic Curves That Are Braceable at First Presentation to a Scoliosis Service. Healthcare (Basel) 2023; 11:healthcare11030445. [PMID: 36767020 PMCID: PMC9914198 DOI: 10.3390/healthcare11030445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/24/2023] [Accepted: 01/31/2023] [Indexed: 02/09/2023] Open
Abstract
Adolescent idiopathic scoliosis (AIS) affects between 0.5% and 5.2% of adolescents and is progressive in two-thirds of cases. Bracing is an effective non-operative treatment for AIS and has been shown to prevent up to 72% of curves from requiring surgery. This paper explores the presentation of AIS in the UK and identifies who would be suitable for bracing, as per guidelines published by the Scoliosis Research Society (SRS) and British Scoliosis Society (BSS), through curve severity and skeletal maturity at presentation. There were 526 patients with AIS eligible for inclusion across three tertiary referral centres in the UK. The study period was individualised to each centre, between January 2012 and December 2021. Only 10% were appropriate for bracing via either SRS or BSS criteria. The rest were either too old, skeletally mature or had a curve size too large to benefit. By the end of data collection, 38% had undergone surgery for their scoliosis. In the UK, bracing for AIS is only suitable for a small number at presentation. Future efforts to minimise delays in specialist review and intervention will increase the number of those with AIS suitable for bracing and reduce the number and burden of operative interventions for AIS in the UK.
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Affiliation(s)
- Laura Hartley
- The Royal Orthopaedic Hospital, NHS Foundation Trust, Birmingham B31 2AP, UK
| | - Conor Jones
- The Royal Devon and Exeter, NHS Foundation Trust, Exeter EX2 5DW, UK
| | - Darren Lui
- St George’s University Hospitals, NHS Foundation Trust, London SW17 0OT, UK
| | - Jason Bernard
- St George’s University Hospitals, NHS Foundation Trust, London SW17 0OT, UK
| | - Timothy Bishop
- St George’s University Hospitals, NHS Foundation Trust, London SW17 0OT, UK
| | - Jan Herzog
- St George’s University Hospitals, NHS Foundation Trust, London SW17 0OT, UK
| | - Daniel Chan
- The Royal Devon and Exeter, NHS Foundation Trust, Exeter EX2 5DW, UK
| | - Oliver Stokes
- The Royal Devon and Exeter, NHS Foundation Trust, Exeter EX2 5DW, UK
| | - Adrian Gardner
- The Royal Orthopaedic Hospital, NHS Foundation Trust, Birmingham B31 2AP, UK
- Correspondence: ; Tel.: +44-7841-638236
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Paediatric Spinal Deformity Surgery: Complications and Their Management. Healthcare (Basel) 2022; 10:healthcare10122519. [PMID: 36554043 PMCID: PMC9778654 DOI: 10.3390/healthcare10122519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/24/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022] Open
Abstract
Surgical correction of paediatric spinal deformity is associated with risks, adverse events, and complications that must be preoperatively discussed with patients and their families to inform treatment decisions, expectations, and long-term outcomes. The incidence of complications varies in relation to the underlying aetiology of spinal deformity and surgical procedure. Intraoperative complications include bleeding, neurological injury, and those related to positioning. Postoperative complications include persistent pain, surgical site infection, venous thromboembolism, pulmonary complications, superior mesenteric artery syndrome, and also pseudarthrosis and implant failure, proximal junctional kyphosis, crankshaft phenomenon, and adding-on deformity, which may necessitate revision surgery. Interventions included in enhanced recovery after surgery protocols may reduce the incidence of complications. Complications must be diagnosed, investigated and managed expeditiously to prevent further deterioration and to ensure optimal outcomes. This review summarises the complications associated with paediatric spinal deformity surgery and their management.
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