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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 with respect to this group of patients.
Performed a retrospective analysis of the medical records and radiographs of patients consecutively operated in 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.
Six patients were included in the study. The lumbar kyphosis measuring 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. 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.
El objetivo de este estudio es resumir los resultados y complicaciones obtenidos por el equipo en , con respecto a este grupo de pacientes. Se incluyeron 6 pacientes en el estudio. Lumbar kyphosis in patients with myelomeningocele represents a complex deformity of the spine whose correction to maintain vertebral alignment generally depends on surgical treatment. Progressive kyphosis is a result of several factors: incomplete formation of the posterior elements of the spine; imbalance of the paraspinal muscles inserted anterior to the axis vertebra; action without opposition of the psoas muscle and the neurological deficit caused by dysraphism.
Figure 1. Since the first kyphectomy published by Sharrard, 6 the surgical technique has undergone constant changes. In , McCarthy et al. Even with some modifications, the most popular series published recently used this technique. Patients operated consecutively at the institution in the year were selected for inclusion. The study was approved by the Institutional Review Board, under protocol number A retrospective analysis of the medical records was conducted to collect data relative to surgical indication, spinal tilt and length of hospital stay following the procedure.
The information referring to surgery included surgical time, necessary transfusions, number of vertebrae removed and reduction obtained in the postoperative period. The complications relative to postoperative infection and loosening of the synthesis material were also recorded.
All the patients underwent a stringent preoperative assessment. The ventriculoperitoneal valve must be permeable and hydrocephaly compensated. Urinary complications were taken into account, with urine culture testing and the treatment of any infections with at least three days of antibiotic therapy directed by antibiogram. Potential respiratory complications are minimized by means of spirometry in selected patients. The surgical technique used consists of the modification of the technique described by McCarthy et al 7 in which we used fixation with pedicle screws instead of sublaminar ligatures in the thoracic spine.
The patient is positioned in prone position on cushions, and the surgeon must avoid compression of the ventriculoperitoneal valve against the ribs or clavicle. The posterior longitudinal incision can pass through the apex of the kyphosis where the skin is more fragile as after the kyphectomy this skin will be redundant and can even be resected. Subperiosteal exposure is then initiated from the normal spinous processes above the deformity. At the apex of the kyphosis, the dissection should be restricted to the region of the transversal processes as there is no lamina protecting the dural sac at this site.
Inadvertent injury of the sac should be avoided. The thecal sac is then connected above the level of the planned osteotomy with double sutures, followed by the Valsalva maneuver to check whether there is any CSF leakage. The next stage is the vertebrectomy at the apex of the kyphosis, removing the necessary vertebrae to achieve good apposition of the preserved vertebral bodies.
At this point an attempt is made to preserve at least L4 and L5 to allow a sufficient area of bone support and arthrodesis beyond the sacrum. Osteosynthesis is then performed following the principles described by McCarthy et al. The short arms of the rods are passed rhombically through the S1 foramina where they are located anterior to the sacrum. When the rods are positioned horizontally a lever is formed that ends up reducing the lumbar kyphosis and restoring the sacrum to its original position.
Figure 2. The upper portion of the rods is then fixed to the thoracic spine using pedicle screws. The resected body provides a good amount of bone graft. Suturing by planes is then performed leaving a subfascial drain.
It is not necessary to use immobilization in the postoperative period. The results obtained are summarized in Table 1. The mean angle of kyphosis in the preoperative period was In other words, there was a mean reduction of kyphosis of An average of 1. None of the patients managed to lie in the supine position in the preoperative period. After the procedure, all the patients managed to lie down on their own and to sit without support. Of the six patients operated, four evolved with postoperative infection, requiring re-hospitalization and surgical cleaning in follow-up.
One of these patients had to have the synthesis material removed to control the infection. Another patient had to have the synthesis material removed after one year due to loosening of the rod in the sacrum. There were no complications relative to increased intracranial pressure after dural sac ligature.
The surgical technique for correction of lumbar kyphosis in patients with myelomeningocele has evolved considerably since the first kyphectomy published by Sharrard. In , Heydermann and Gillespie 11 proposed anterior lumbopelvic fixation, enabling the faster functional recovery of these patients without the need for immobilization with a jacket.
In McCarthy et al. In Warner and Fackler 12 refined this technique, fixing the rods to the first S1 foramen, and demonstrated that it produced a much lower level of complications in comparison to the use of Harrington rods.
Fixation to the spine, however, was achieved using sublaminar ligatures. The use of pedicle screws made it possible to improve correction with minimal morbidity in patients with idiopathic scoliosis.
The mean reduction from The improvement in the deformity also influences the fact that these patients no longer need wheelchairs with an adapted headrest, and can also sit on normal chairs after the surgery. We attribute the relatively high average age of the operated patients 11y and 7m to the fact that further correction of the curve was not possible, although this has not implied functional loss.
Four patients of the six operated in this series Of these patients, one only had the infection controlled after the removal of the synthesis material in the 7 th postoperative month. The thin, poor quality skin that ends up covering the operated area can contribute to continually high rates of infection. Some studies advocate the performance of the surgery without myelotomy, stating that this reduces the chance of complications related to increased intracranial pressure, CSF leaks and meningitis.
Significant rates of pseudarthrosis and loosing of the synthesis material have been reported in the literature. Although pedicle screws offer better pull-out resistance and better results in idiopathic scoliosis, 15 16 22 it is still not known whether their use in cases of kyphectomy will reduce the rate of failure of the material. The association of the Dunn-McCarthy technique with pedicle screw fixation in the thoracic spine allows excellent functional results after kyphectomy in patients with myelomeningocele.
Larger series with a longer follow-up time are necessary to verify whether the rates of complications will be better than those reported in the literature up to that point. Congenital kyphosis in myelomeningocele: results following operative and nonoperative treatment. J Pediatr Orthop. Drennan JC. The role of muscles in the development of human lumbar kyphosis. Dev Med Child Neurol Suppl. Hoppenfeld S. Congenital kyphosis in myelomeningocele. J Bone Joint Surg Br.
Surgical management of paralytic scoliosis in myelomeningocele. J Pediatr Orthop B. Vertebral excision for kyphosis in children with myelomeningocele.
J Bone Joint Surg Am. Sharrard WJ. Spinal osteotomy for congenital kyphosis in myelomeningocele. Luque fixation to the sacral ala using the Dunn-McCarthy modification. Spine Phila Pa Kyphectomy in the treatment of patients with myelomeningocele.
Spine J. Combination of luque instrumentation with polyaxial screws in the treatment of myelomeningocele kyphosis. J Spinal Disord Tech. Kyphectomy in children with myelomeningocele: a long-term outcome study. Heydemann JS, Gillespie R.
Management of myelomeningocele kyphosis in the older child by kyphectomy and segmental spinal instrumentation. Comparison of two instrumentation techniques in treatment of lumbar kyphosis in myelodysplasia. Comparative analysis of pedicle screw versus hook instrumentation in posterior spinal fusion of adolescent idiopathic scoliosis.
Coronal and sagittal plane correction in adolescent idiopathic scoliosis: a comparison between all pedicle screw versus hybrid thoracic hook lumbar screw constructs. Selective thoracic fusion with segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis: more than 5-year follow-up.
2017, Number 2
PubMed Central. De ellos, De los 70 casos, tres 4. La mortalidad general y postoperatoria fue de 7. Potencial eficacia del metotrexato. Diagnostico prenatal no siempre es correcto. Suturamos la plaqueta.
Key words:. Rev Mex Med Phis Rehab. Myelomeningocele: surgical trends and predictors of outcome in the United States, J Neurosurg Pediatr. Adzick NS. Fetal surgery for spina bifida: past, present, future. Semin Pediatr Surg.