Evid Based Spine Care J 2011; 2(1): 17-22
DOI: 10.1055/s-0030-1267082
Original research
© Georg Thieme Verlag KG Stuttgart · New York

Long-term outcome of surgical correction of congenital kyphosis in patients with myelomeningocele (MMC) with segmental spino-pelvic fixation

Josh E. Schroeder, Yair Barzilay, Amir Hasharoni, Leon Kaplan
  • 1Spine Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Publikationsverlauf

Publikationsdatum:
10. Mai 2011 (online)

ABSTRACT

 

Study design: A retrospective case series of patients with myelomeningocele (MMC) who underwent kyphectomy and posterior segmental fixation using Luque rods and 16-gauge wires.

Objective: To assess outcomes after posterior kyphectomy and segmental fixation for kyphosis in patients with MMC.

Methods: Thirteen consecutive patients who underwent posterior kyphectomy for transforaminal fixation contiguous to „everted lamina.” Fusion rates, time to fusion, change in Cobb angle, complications, and improvement in activities of daily living using the Katz score were measured.

Results: Average age at time of surgery was 9.2 (range, 4.5–17) years. Average time to follow-up was 120 (range, 20–310) months. Solid fusion was achieved in 9 patients (69 %) with a mean time to fusion of 12 months. The mean postoperative kyphotic curve was 22° with an average correction of 90°. Five patients (38 %) experienced a postoperative complication. The mean improvement in activities of daily living score was 1.6 points and all patients achieved independent sitting balance.

Conclusion: Segmental spino-pelvic fixation is a solid alternative mode of fixation in patients with MMC with congenital kyphosis. Patient selection, proper perioperative multidisciplinary assessment, and surgeons’ expertise are significant in the success of this complex surgery.

STUDY RATIONALE Thoracolumbar kyphosis occurs in 10–20 % of patients with myelomeningocele (MMC) 1, 2, 3. Curves are congenital and rigid, larger than 80° at birth and progressing to more than 100° 4. These lead to chronic pressure sores, impaired sitting balance, collapsing spine phenomena, decreased abdominal capacity, and reduced respiratory function 4. There is no consensus regarding the proper mode of correction in patients with MMC 5. OBJECTIVE To present the long-term results of a segmental spino-pelvic fixation method for correction of congenital thoracolumbar kyphotic deformities in patients with MMC using Luque rods and neuroforaminal wires. METHODS Study design: Retrospective case series (all medical 
records of the children were reviewed). Inclusion criteria: Thoracic level MMC (T6–T12) and congenital rigid kyphotic deformity All patients referred for surgical correction at one institution A patent ventriculoperitoneal shunt Exclusion criteria: Active skin or urinary tract infection Inadequate nutritional status (albumin levels within normal age correlated levels) Patient population: Thirteen consecutive patients meeting study criteria All patients were paraplegic from MMC level down All patients had skin scarring from abrasions or lacerations on the apex of the deformity Surgical technique: Patients were placed on specialized silicon cushions and prepared for a posterior approach. A posterior longitudinal incision was executed and dissection of the soft-tissue flap was kept as thick as possible. The dural sac was released, ligated, cut, and removed at the level of the MMC. A kyphectomy was performed (Fig 1, Fig 2, Fig 3, Fig 4, Fig 5, Fig 6). Fixation started four or five segments above the beginning of the deformity down to the sacrum using the Galveston technique 1 (Fig 3). A local bone graft is added to sides of vertebrae to induce fusion. Patients were placed in a tailor-made jacket until bony fusion was evident. Further detail is provided in the web appendices. Outcomes: Standard x-rays were performed every 6 to 8 weeks to evaluate: Fusion rate—fusion defined as connecting vertebrae in the lateral view and a bony mass on the sides of the bifid vertebrae uniting the two vertebrae in the anteroposterior view Time to fusion—defined as the first x-ray with evidence of fusion Change in the Cobb angle (comparing preoperative with postoperative Cobb angles) Complication rates Functional outcomes using: Katz independence in activity of daily living (ADL) score 6. A scale of 0–6 points testing patient independence in bathing, dressing, toileting, transferring, continence, and feeding. A patient gets 1 point for each activity he/she is unable to perform. The higher the score, the lower the function. Independence in ADLs suggested as a score of 0 to 1 point Sitting position—assessed as either independent or needing hand-hold support Analysis Descriptive statistics were performed including mean ± SD for continuous measures and frequency counts for categorical variables.

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EDITORIAL STAFF PERSPECTIVE

Case series rightfully remain next to the bottom of the evidence hierarchy. However, they can have merit for exceptional conditions or as a basic fact-finding investigation, especially when conducted in truly sequential fashion with consistent care application and appropriate long-term follow-up. Despite its limitation as case series, this article received favorable reviews for being interesting and commendable with excellent long-term follow-up of wound and hardware complications with a specific technique for a difficult clinical problem. The Katz functional outcome instrument was found to be applicable, relevant, and simple to use and a welcome expansion of the outcomes armamentarium.

The following limitations, which could not be resolved due to infrastructure and study design, were noted and could conceivably have enhanced the study further:

  • Methodology of patient identifications and records review was not elucidated.

  • The following complications common to this population were not discussed either because of incredible technique or the failure to document them:

    • Urinary tract infection

    • VP shunt malfunction

    • CSF leak

    • Hydrocephalus problems

    • Neurogenic pain or symptoms

    • Pneumonia

The only complications documented were related to hardware failure, nonunion, or wound complications.

  • Were any patients excluded from this case series or did every patient with myelomeningocele and kyphosis meet the criteria?

  • An attempt at comparison to other treatment groups would have elevated the status of this study tremendously, for instance assessment of patients treated nonoperatively, or assessment of surgical technique other than neuroforaminal wires. Now the prevailing question on every surgeon’s mind after reading this article will be: how does this specific method of fixation compare to other options—pedicle screws, iliac bolts, hooks, or unit rods?

  • The comparisons with other articles are appreciated; however an attempt to consolidate the variables looked at in those articles and an attempt to align them with the variables studied in this article more comprehensively would have been a welcome addition.

In conclusion, the article of Schroeder et al advances our knowledge base on this condition and refocuses our attention on the indication for which we operate, and raises the important question of relevance of high-tech implants to achieve optimal outcomes for specific conditions.

 

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