MANAGEMENT
POSSIBILITIES IN DIFFICULT SPINAL DEFORMITIES
John CY Leong
Professor
& Head, Dept of Orthopaedic Surgery, University of Hong Kong
SCOLIOSIS
Moderate curves (>80°) should be treated with
anterior discectomy (either open or endoscopic) before posterior
instrumentation and spinal fusion.
Severe and rigid scoliosis or kyphoscoliosis (>100° and virtually
inflexible), can only be corrected (partially) by spinal column resection (shortening) in 1 or 2 stages. The whole curve needs to be fused
with instrumentation, under intraoperative spinal cord monitoring. A thorough understanding of the
surgical anatomy of the spine, including the blood supply of the spinal
cord is mandatory.
KYPHOSIS
Moderate kyphosis (>50°) requires anterior
strut grafting to prevent deterioration. If spinal growth is still on-going, an additional
posterolateral fusion is needed.
In severe angular kyphosis (>90°) strut grafting must include the
entire extent of the proximal and distal limbs, and a posterolateral fusion.
In severe round rigid kyphosis, correction by transpedicular
decancellization osteotomy
is very effective. In
severe angular rigid kyphosis, correction requires staged anterior and
posterior spinal osteotomies, followed by gradual correction of the deformity,
and finally anterior strut grafting and posterolateral fusion, after
maximum correction has been achieved.
The site of the kyphosis may render the
procedures much more difficult, such as at the cervicodorsal and
lumbosacral junctions. A
special surgical approach will be described.
Neurological deficit can occur spontaneously in angular and
severe types of kyphosis. The
most common causes are congenital, tuberculous, and secondary to
neurofibromatosis. Anterior
decompression is mandatory, but such sites as the cervicodorsal junction,
upper dorsal spine, and the lower lumbar spine are very difficult
areas. A transpediculectomy
approach to perform an internal kyphectomy is the method of choice.