18: Operative Management of Scheuermann Kyphosis

Published on 21/04/2015 by admin

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Last modified 21/04/2015

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Procedure 18 Operative Management of Scheuermann Kyphosis

Per D. Trobisch, Wilsa Charles, Alok D. Sharan, Thomas J. Errico

image

Indications

image Rigid curves greater than 75 degrees

image Curves that have progressed despite brace treatment

image Painful kyphotic curves that progress despite nonoperative treatment

image Neurological deficit

image Respiratory difficulty resulting from curves greater than 100 degrees

Indications Pitfalls

• A complete neurologic workup should be included if there are any upper motor signs, to rule out the presence of a cyst or thoracic disk herniation.

Indications Controversies

• Spondylolisthesis is sometimes associated with Scheuermann kyphosis.

• An asymptomatic spondylolisthesis does not require treatment.

• Neurologic dysfunction more likely results from other causes (e.g., disk herniation) rather than the kyphotic deformity itself.

Examination/Imaging

image Anteroposterior and lateral radiographs on long cassettes

image Hyperextension radiograph taken over a bolster

image Magnetic resonance imaging (MRI) of thoracic and lumbar spine to rule out a cyst or disk herniation

Treatment Options

• Posterior spinal fusion (PSF) (hooks, pedicle screws, hybrid constructs)

• Combined anterior/posterior spinal fusion

• Anterior thoracoscopic spinal fusion by video-assisted thoracoscopic surgery (VATS)

Surgical Anatomy

image T2 to T12 can be accessed by a transthoracic approach, with vertebrae below T12 by a retroperitoneal approach.

image Usually two to three disks can be approached through one portal if VATS is performed.

image Alternatively, multiple segmental posterior osteotomies (SPOs) for posterior-only approaches can be performed.

image When performing SPOs, it is important to resect the inferior and the superior facet of adjacent vertebrae.

image The supraspinous ligament at the most cephalad level(s) should be preserved to prevent proximal junctional kyphosis.

Positioning

image For the anterior approach, place the patient in the lateral decubitus position.

image Left-sided approaches are preferred, because injury to the aorta is easier to repair than injury to the vena cava.

image For the posterior approach, place the patient prone on a four-poster frame.

Positioning Pearls

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