Data on demographics, primary diagnosis, associated co morbidities, details of surgical procedure, training level of the operating surgeon, details of the incidental durotomy, the treatment, complications and the postoperative stay were recorded.
Results: Of patients, patients were included in the study. The incidence of incidental durotomy was 3. We found a very high incidence of Of 49 durotomies, complication were 5 cases of intracranial hypotension, 5 postoperative neurological deficits, 2 deep wound infection, 2 pseudomeningocele and 1 meningitis. Conclusions: The risk of incidental durotomy in thoracolumbar surgeries is high in revision surgeries and when performed by fellows in training.
Intraoperative identification and primary repair with suturing or sealant reduces postoperative complications. Zeidman SM. Intraoperative dural laceration, postoperative cerebrospinal fluid fistula and postoperative pseudomeningocele. In: Vaccaro R, ed. Complications of Pediatric and Adult Spinal Surgery. New York: Marcel Dekker; Evaluation and treatment of dural tears in lumbar spine surgery: a review. Clin Orthop Relat Res.
Incidental durotomy in lumbar spine surgery: incidence and management. Eur Spine J. Dural tears secondary to operations on the lumbar spine. Management and results after a two-year-minimum follow-up of eighty-eight patients. J Bone Joint Surg Am. Incidental durotomy during spine surgery: incidence, management and complications. A retrospective review. Incidental durotomy in spine surgery. The long-term clinical sequelae of incidental durotomy in lumbar disc surgery.
Predictive factors for dural tear and cerebrospinal fluid leakage in patients undergoing lumbar surgery. J Neurosurg Spine. Intra- and postoperative complications in lumbar disc surgery. Mayfield FH, Kurokawa K. Watertight closure of spinal dura mater. Technical note. J Neurosurg. A case report. Long-term results of lumbar spine surgery complicated by unintended incidental durotomy. Epstein NE.
The frequency and etiology of intraoperative dural tears in predominantly geriatric patients undergoing multilevel laminectomy with noninstrumented fusions. J Spinal Disord Tech. Treatment of dural tears associated with spinal surgery. Black P. The vertebral body resection begins by gaining access to the cancellous bone of the vertebral body through a lateral pedicle-body entrance. Next, curetting of the cancellous bone of the body is performed saving the bone for later bone graft. We have noted that bleeding occurring with a vertebral corpectomy is significantly less in the thoracic spine then when performing similar procedures in the lumbar spine.
Thus, in scoliosis and kyphoscoliosis deformities, the majority of the vertebral body will be removed from the convexity of the deformity since that is where the vertebral body is located. We prefer to perform the concave resection of the pedicle prior to the convex removal so there is no bleeding into this dependent concave region. This also allows the concave spinal cord to drift somewhat more medial and remove tension prior to going to the convexity for completion of the corpectomy.
The entire body is removed except for the anterior shell, as we like to keep a thin rim of bone intact on the anterior longitudinal ligament ALL for fusion purposes.
However, if this bone is cortical then it must be thinned to allow easy closure of the resection area. Next, discectomies both above and below are performed using curettes as needed. It is important not to violate the endplates of the superior and inferoadjacent regions as placement of a structural intracorporeal cage may be required. The last part of the vertebral resection will be the posterior vertebral body wall or floor of the spinal canal. The dural sac must be circumferentially freed and exposed and then separated from the epidural venous complex as well as the posterior longitudinal ligament PLL.
It is imperative that the ventral spinal cord is completely free of any bony prominences to avoid impingement during closure. This is especially true at the disc levels, especially above but also below, as there tends to be osteophytic lipping in that region which can cause ventral compression if not removed. At this point, the resection is complete and closure of the resected area with compression forces is performed. The spinal column is always shortened, not lengthened, with convex compression performed as the main correcting technique. This is performed either with individual pedicle screws in primary cases where a good bony grip of the vertebrae is found, or in a construct-to-construct closure mechanism utilizing dominoes at the apex of the resected area.
In this method, closing from a construct rod above to a construct rod below to distribute the forces of correction over several levels is performed. Typically, the spinal column will be shortened by 1 to 1. Once closure has been fully performed, a permanent contralateral rod is placed with appropriate correction maneuvers performed. Then the temporary closing rod is removed and a permanent, final rod is placed on the contralateral side as well. Appropriate compression and distraction forces, in situ contouring, and other correction techniques may be performed always being mindful of any resultant affect on the resected area with respect to subluxation or dural impingement.
Next, adequate alignment is confirmed by intraoperative radiographs. Decortication and bone grafting follow with copious amounts of local graft obtained from the resection procedure. The laminectomy defect is covered with the previously harvested ribs for the costotransversectomy approach. These ribs are split in half longitudinally with the cancellous surface placed along the entire laminectomy defect from the lamina above to the lamina below. The rib is held in place with sutures or a crosslink if there is room and no prominence.
To confirm the absence of impingement, final implant security is documented as well as a final circumferential check of the exposed dura. Postoperative Treatment All patients were rigidly stabilized to allow upright posture immediately after surgery. Most patients sat and dangled on the side of the bed on postoperative day 1, and were out of bed and to a chair by postoperative day 2.
A few pediatric patients having soft bone, or those with cervicothoracic constructs were braced for 3 to 4 months after surgery. None of the adult patients were braced after surgery. Figure 1. Figure 1A-C. Figure 1A. Figure 1B. Figure 1C. Her pre and postoperative clinical photographs show the excellent restoration of more normal trunk contours following her single-level VCR without any thoracoplasty procedure performed.
Unplanned Reoperation within 30 Days of Fusion Surgery for Spinal Deformity
No patient thus far has required revision surgery for instrumentation, or fusion complications. Figure 2. Figure 2A-D. Figure 2A.
Figure 2B. Preoperatively, she was placed in halo-gravity traction for four weeks to stretch out her spinal column and to improve her nutritional and respiratory statuses. Figure 2C. Figure 2D.
Pre and postoperative clinic photos show marked correction of her trunk with a concomitant seven-rib thoracoplasty performed in order to gain full access of her posterior spinal column because of her severe deformity. Five of the seven patients had some type of spinal column subluxation occur during the vertebrectomy site closure. In five of the patients, subluxation occurred with actual closure of the vertebrectomy site with the most common impingement being the ventral aspect of the proximal level of the spinal cord. In one patient GK NMEP data were lost with closure, and returned with reopening the osteotomy site and closure over a cage.
Figure 3 In another patient AK , over-shortening of the spinal cord occurred with closure over a small cage. When a larger cage was inserted with compression, the data remained normal.
All seven of these patients had NMEP data return to baseline promptly following the surgical correction of subluxation or placement of a larger anterior cage. Figure 3A-H. Figure 3A. Figure 3B. Her preoperative MRI showed ventral dural compression along the entire posterior edge of her global kyphosis deformity as well as fused posterior apical facet joint. She also exhibited exertional myelopathy. Statically she had normal neurology, but after walking for longer than 15 minutes, her legs became heavy, numb, and she exhibited bilateral clonus and up-going toes.
Treatment for Children with Spinal Deformities & Scoliosis
Further complicating the matter was her weight at pounds preop clinical photos. Figure 3D. She underwent a single-level posterior vertebral column resection VCR with anterior cage placement, following closure of her deformity over the cage;. Figures 3E. NMEP data was lost bilaterally, with return of data following release of her correction, and placement of a larger cage. Figure 3F. She eventually had her final construct with intact NMEP data with rib bridge strut grafts placed over the laminectomy defect for the definitive posterior instrumentation and fusion.
Figure 3G. It was thought that the deficit was most likely due to inadvertent unilateral spinal cord compression from a cottonoid placed to control copious epidural bleeding on the convex side. Following removal of the cottonoid, the SCM data returned to baseline. Following wound closure, the patient awoke with completely normal neurologic function in both lower extremities.
She remained neurologically intact and her surgery was completed one week later without neurologic sequelae. Intraoperative NMEP data was unobtainable in three patients in this series. All three of these patients had prior surgery, while two out of three had prior intradural surgery. One of these patients failed a wake-up test following closure of the vertebrectomy defect. However, function returned following re-opening of the defect, placement of an anterior cage, then recompressing posteriorly. Two patients had nerve root palsies after surgery.
One patient who underwent a revision L2 and L3 VCR had a unilateral quadriceps deficit that was noted immediately after surgery.
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The patient was returned prone on the operating table where the left-sided L2 and L3 nerve roots were re-explored and further decompression was performed. The deficit resolved spontaneously six months postoperative. No patient thus far has had revision surgery for any neurologic complication. Figure 4. Figure 4A-D. Figure 4A. Figure 4B. His preoperative MRI showed a kyphotic T dislocation with severe compression of the spinal cord at the level. He was initially placed in gradual halo traction which was locked with his chin out of his chest to allow for fiberoptic intubation with access to his neck if required.
Figure 4C. Figure 4D. A one-year postoperative CT scan shows a solid anterior fusion noted with the use of BMP-2 anteriorly. He already had a wide laminectomy defect posteriorly which would not allow for any posterior fusion. His neurologic function improved to normal by 6 weeks postoperative. Non-neurologic No patient required a chest tube for a pleural air leak, but a staged patient required bilateral chest tubes for pleural effusions postoperative.
All patients required intermittent positive pressure breathing IPPB during the early portion of their postoperative hospital course for preventing atelectasis. Several patients required up to three days of postoperative ventilation, and one patient was re-intubated approximately five days postoperative for upper airway breathing difficulties following a cervicothoracic reconstruction. One patient had a DVT two weeks postoperative treated with Lovenox. Another patient had a partial bilateral brachial plexus palsy postoperative that was somewhat predicted by degraded upper somatosensory potentials intraoperatively.
All patients received perioperative TPN through a central venous line catheter that was placed perioperatively. No patient has had any wound related complications thus far. Results : Clinical Of the 43 patients, 38 were treated in a single-stage, while 5 were treated in a two-staged fashion. The interval between stages ranged from five to seven days. The average EBL for all patients was cc, ranging from to cc. No patient became coagulopathic intraoperatively, and no patient received platelets or fresh frozen plasma.
The average operative time was 9 hours 23 minutes, ranging from 4h 52m to13h 40m for all the procedures. Discussion The surgical treatment of severe spinal deformity is challenging. Traditionally, a circumferential approach with anterior releases via discectomies, followed by posterior instrumentation and fusion has been the standard of care. The use of a vertebrectomy procedure has been around for quite some time as well, with the first description in by MacLennan8 who described a posterior apical resection followed by postoperative casting for the treatment of severe scoliosis.
Following that, several authors recorded their experiences with vertebrectomies, most commonly for the surgical treatment of congenital scoliosis. His report consisted of 13 patients who underwent a 1 to 7 level average 3 levels vertebrectomy. The average estimated blood loss was cc, and the average operative time was Bradford and Tribus 18 later reported on 24 patients with rigid coronal decompensation who underwent a circumferential vertebral column resection VCR.
However, there was an average operative time of over 12 hours, an average blood loss of mL, and 31 overall complications. Suk was the first investigator to promote a posterior-only VCR. He believed that there was a reduction in the total operating time, amount of blood loss through this one-stage posterior-only procedure. In , he presented a series of 16 patients average age 29 years who underwent a posterior VCR having a minimum 2-year follow-up.
There was an average of 1. However, complications were encountered in four patients, including one with complete permanent paralysis. He recommended this as an effective alternative for severe rigid scoliosis but cautioned that it was a highly technical procedure and should only be performed by an experienced surgical team. It is important to note, he did not utilize any form of motor tract monitoring during the surgeries, only SSEP monitoring.
Our current series of 43 consecutive patients undergoing posterior-only VCR for severe pediatric and adult spinal deformity is both complimentary and additive to these prior reports. This is the largest reported series on posterior VCRs thus far, and the first from a North American center.