Neonatal kyphectomy in the patient with myelomeningocele

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 in myelomeningocele revisited: risk factors for failure

PURPOSE

Lumbar kyphosis occurs in approximately 8-20% of patients with myelomeningocele (MMC). The purpose of this article is to analyze the risks and benefits of vertebrectomy and spinal stabilization in MMC children with severe lumbar kyphosis and to establish treatment guidelines.

METHODS

This is an IRB-approved retrospective analysis of 59 patients with MMC who underwent kyphectomy and posterior instrumentation in three centers. Average age at surgery was 7.9 years (2 weeks-17 years). Sitting trunk position, skin status, kyphosis angle, and thoracic lordosis were analyzed preoperatively, postoperatively, and at an average follow-up of 8.2 years (range 2.5-16). The correction was maintained by applying a short posterior instrumentation in 6 patients, and extending to the pelvis in 53 cases. Pelvic fixation was achieved using the Warner and Fackler technique in 24 patients, the Dunn-McCarthy in 8, Luque-Galveston in 8, sacral screws in 2, and ilio-sacral screws in 11.

RESULTS

Sitting position improved postoperatively in 47 of the 53 patients who underwent pelvic fixation and only in one patient with short instrumentation. All 6 patients with long instrumentation and poor postoperative sitting balance were in the Dunn-McCarthy fixation group. Skin sores at the apex of the deformity disappeared postoperatively in all patients but recurred in two patients with short instrumentations. Kyphosis angle improved from 109° (45°-170°) preoperatively to 10° (0°-45°) postoperatively and 21° (0°-55°) at last follow-up. The best results were seen in cases where a cross-k-wire fixation of the kyphectomy site was used, augmented with a long thoraco-pelvic instrumentation consisting of Luque sublaminar wires in the thoracic region and a Warner-Fackler type of pelvic fixation. Good results were also found with the bipolar technique and ilio-sacral screw fixation. Six over 24 patients with the Warner and Fackler technique showed gradual dislodgment or hardware failure, with subsequent nonunion of the kyphectomy site in four. Infection, with or without wound dehiscence and/or hardware exposure, occurred in 17 cases, necessitating hardware removal in 9 patients.

CONCLUSION

Lumbar kyphosis in MMC children is best managed by resection of enough vertebrae from the apex to produce a flat lumbar spine, with perfect bone-to-bone contact and long thoraco-pelvic instrumentation using the Warner and Fackler technique through the S1 foramina or the bipolar technique with ilio-sacral screw fixation. Additional local fixation of the osteotomy site using cross-wires with or without cerclage increases the stability of the construct. The majority of complications occurred in patients with short instrumentations or where residual kyphosis persisted postoperatively regardless of the type of pelvic fixation or hardware density. The Dunn-McCarthy technique for pelvic fixation following kyphectomy in MMC was less successful in producing stable pelvic fixation and should not be considered in this patient category.

Myelomeningocele: the evolution of care over the last 50 years

PURPOSE

Myelomeningocele (MMC) is one of the representative anomalies in the field of pediatric neurosurgery. During the 50 years of ISPN history, MMC had a tremendous changes in its incidence, clinical management and outcome with advanced understanding of its pathogenesis. We reviewed the changes in MMC during the period.

METHODS

We reviewed the literature review and collected our experiences.

RESULTS

During the 50 years, major changes happened in many aspects of MMC including incidence, pathoembryogenesis, folate deficiency, prevention, prenatal diagnosis, mode of delivery, treatment policy with ethical considerations, clinical treatment including fetal surgery, latex allergy, retethering, management outcome, multidisciplinary team approach, and socioeconomic and family issues.

CONCLUSIONS

There was a great advance in the management and research of MMC during the 50 years. It is a monumental achievement of pediatric neurosurgeons and colleagues of the related fields.

Orthopedic management of myelomeningocele with a multidisciplinary approach: a systematic review of the literature

Background

Myelomeningocele (MMC) is the most common and severe form of spina bifida and imposes a significant burden on patients and the healthcare system. Recently, the multidisciplinary management of MMC has become popular. Herein, we aimed to review the orthopedic management, outcomes, and complications of the of patients with MMC eyeing a multidisciplinary approach.

Methods

We searched PubMed and EMBASE to find relevant studies published before August 2020. All studies that included clinical management of MMC patients and published earlier than 2000 were considered for review on the condition that they reported at least one orthopedic intervention and the rate of complications. We excluded review articles, case reports, case series, letters, commentaries, editorials, and conference abstracts. The primary and secondary goals of our review were to report the outcomes and complication rates of multidisciplinary management for MMC patients.

Results

Twenty-six studies included data for the management of 229,791 patients with MMC and were selected. Sixteen studies reported multidisciplinary management in addition to orthopedic management. From those, 11 (42.31%) included urologic management, 13 (50%) neurosurgical management, 11 (42.31%) neurologic management, and 5 (19.23%) gastrointestinal management. All studies included postnatal operations and related management. No randomized clinical trial was found in our search.

Conclusion

Orthopedic approaches play a key role in MMC management by alleviating spinal deformities, particularly scoliosis, and hip, foot, and ankle complications. However, the most appropriate management, whether surgical or non-surgical, may vary for different patients, given disease severity and the age of patients.

Graphical abstract

Using the keystone design perforator island flap in large myelomeningocele closure

OBJECTIVE

Many repair techniques have been proposed to treat large myelomeningocele (MMC), and although effective in many cases, some of these techniques can be complex and time consuming, with complications such as cerebrospinal fluid (CSF) leakage, flap loss, tip necrosis, and wound dehiscence. The purpose of this study was to analyze cases of large skin defects and the methods applied and to report the outcomes of the keystone design perforator island flap (KDPIF) technique for large MMC closure.

METHODS

The authors performed a retrospective review of all neonatal patients who had undergone KDPIF for MMC closure in the period from 2013 to 2018. All patients had a diagnosis of lumbosacral MMC based on obstetric ultrasound. The neurosurgeons and plastic surgeons had selected the cases after concluding that primary closure would be unlikely. The design of the flap is based on the randomly located vascular perforators, creating two identical opposing flaps to fashion a double keystone flap. During wound closure, V-Y advancement of each end of the double flap in the longitudinal axis creates redundancy in the central portion of the flap and reduces the horizontal tension. After discharge, both the neurosurgery and plastic surgery teams followed up all patients, tracking the results with photography.

RESULTS

No skin flap dehiscence or necrosis, infection, or CSF leakage was detected, proving the reliability of the flap. One of the patients required further surgery for the large skin defects after insufficient intrauterine closure of the MMC and successfully underwent KDPIF treatment. Another patient (14.3%) had severe neonatal sepsis, which ultimately led to death. A ventriculoperitoneal shunt was required after the skin defect repair in 5 (83.3%) of the 6 surviving patients. Exceptional aesthetic results were achieved for all patients during the follow-up.

CONCLUSIONS

The KDPIF technique is based on well-known vascular perforators of the intercostal, lumbar, and gluteal regions. Wound tension is widely distributed by the flap and, as a consequence, relevant tissue bulk, reliable vascularity, and important geometrical versatility are provided. In addition, most of the muscles and fascia are preserved, which is another advantage in terms of minimizing secondary morbidity to local tissue rearrangement. The use of KDPIF closure was successfully shown to be a viable alternative for more complex MMCs that present with large skin defects.

Orthopedic guidelines for the care of people with spina bifida

Orthopedic or musculoskeletal problems are common in individuals with spina bifida. They can affect function and mobility and, in the case of spinal deformity, affect pulmonary function. We discuss the current treatment guidelines developed through collaboration with the Spina Bifida Association and the Orthopedics and Mobility working group using a specific methodology previously reported [1,2]. General considerations are discussed followed by evaluation and treatment guidelines for specific age ranges. References are provided where applicable, but where data is lacking treatment guidelines fall under the umbrella of clinical consensus. This leaves "research gaps" where areas of possible future study could be considered.

Acellular Dermal Matrix as a Definitive Reconstructive Option for Management of a Large Myelomeningocele Defect in the Setting of Severe Lumbar Kyphosis

BACKGROUND

Severe kyphosis is infrequently seen in neonates with myelomeningoceles. Spinal skeletal dysmorphology complicates repair, as local tissue may be insufficient to cover the dural repair. Although neonatal kyphectomy has been proposed as a potential solution to this problem, it carries significant potential risks that may not be acceptable to families.

CASE DESCRIPTION

A neonate presented with a large myelomeningocele defect with associated severe lumbar kyphosis. Kyphectomy was both declined by the family owing to the potential surgical risks and deemed not appropriate by the surgeons based on the challenging anatomic considerations. Soft tissue closure was not possible with local tissue rearrangement. Acellular dermal matrix was used as a definitive soft tissue coverage option, with complete epithelialization noted at 8 weeks postoperatively.

CONCLUSIONS

Acellular dermal matrix is a potentially useful adjunct for definitive reconstruction of complex neonatal soft tissue defects where local tissue is not available.

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.

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.

Treatment of spinal deformity associated with myelomeningocele in young children with the use of the four-rib construct

Surgery for myelomeningocele spinal deformity is accompanied by a high rate of complications. These include infection, pathological skin breakage, instrumentation failure, and neurological deterioration. The four-rib construct associated with the percutaneous technique in immature children with myelomeningocele and spinal deformity is introduced. The four-rib construct serves to correct for deformity and to allow for growth, with minimal complications. The study was small and retrospective, a level four case series. The results of four patients who underwent the four-rib construct surgery in 2008 and 2009 was revised. All four were nonambulatory, skeletally immature children, not previously corrected by bracing, with the progressive spinal deformity associated with myelomeningocele affecting their sitting position. Furthermore, the research protocol was approved by our institutional review board. Three patients were females and one was male. Two cases of kyphoscoliosis, one of kyphosis, and one of scoliosis. Age at the time of the initial procedure ranged between 64 and 82 months, with a mean age of 70 months. Follow-up time after surgery ranged from 24 to 39 months, with a mean of 31 months. Preoperatively, deformity angles were severe, averaging 55° for thoracic scoliosis, 67° for thoracolumbar scoliosis, and 85° for thoracolumbar kyphosis. Surgery mitigated the deformities markedly. Postoperative angles measured were 42° for thoracic scoliosis, 21° for thoracolumbar scoliosis, and 45° for thoracolumbar kyphosis. These observations indicate significant reductions in spinal deformity, by 24, 69, and 48%, respectively. In total, 14 procedures were performed: four initial implants and 10 lengthening and exchange procedures. There were no intraoperative complications. The postoperative complications that did arise consisted of two instances of skin breakage, one distal iliac screw dislodgement, and one shunt displacement. Significantly, no proximal fixation dislodgement, deep-seated infection, or damage in the pathological skin were detected. The four-rib construct technique can be considered as a potential surgical option in (powered by Editorial Manager and Preprint Manager; Aries Systems Corporation) treating spinal deformity associated with myelomeningocele, but still more patients with long term follow-up are needed to prove the efficacy of this procedure. The four-rib construct is simple, minimally invasive, and does not exclude alternative treatment. Moreover, the incidence of complications associated with the four-rib construct compares favorably with other growth techniques.

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.

Kyphectomy for severe kyphosis with pyogenic spondylitis associated with myelomeningocele: a case report

A 32-year-old woman was referred to our hospital for a refractory ulcer on her back. She had a history of myelomeningocele with spina bifida that was treated surgically at birth. The ulcer was located at the apex of the kyphosis. An X-ray film revealed a kyphosis of 154° between L1 and 3 and a scoliosis of 60° between T11 and L5. Computed tomography, magnetic resonance imaging and laboratory data indicated the presence of a pyogenic spondylitis at L2/3. To correct the kyphosis and remove the infected vertebrae together with the skin ulcer, kyphectomy was performed. Pedicle screws were inserted from T8 to T12 and from L4 to S1. The dural sac was transected and ligated at L2, followed by total kyphectomy of the L1-L3 vertebrae. The spinal column was reconstructed by approximating the ventral wall of the T12 vertebral body and the cranial endplate of the L4 vertebra. Postoperatively, the kyphosis was corrected to 61° and the scoliosis was corrected to 22°. In the present case, we treated the skin ulcer and pyogenic spondylitis successfully by kyphectomy, thereby, preventing recurrence of the ulcer and infection, and simultaneously obtaining sufficient correction of the spinal deformity.

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.

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.