18: Operative Management of Scheuermann Kyphosis

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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

• Placing the hips in hyperextension during the posterior approach helps to maintain lumbar lordosis.

• The knees are flexed to 30 degrees to relax the hamstrings.

• The upper pads should be placed caudal to the shoulder, to passively help correct the thoracic kyphosis.

Procedure

Step 1: Anterior Release and Fusion

image Perform an open or video-assisted thoracoscopic approach.

image Disks that do not become lordotic on hyperextension radiographs should be resected.

image A strut graft can be placed to enhance fusion and prevent loss of correction.

image Reintubate with a single-lumen tube after closure of the anterior approach, and turn the patient into the prone position.

Step 1 Pearls

• Resecting the anterior portion of the rib head allows more exposure of the posterior disk.

• A laminar spreader can be used to view the remaining disk after the initial diskectomy.

• It is critical to release the anterior longitudinal ligament, because this is part of the deforming force.

• Chest tubes are discontinued when drain output is less than 80 mL per 8-hour shift.

Step 1 Pitfalls

• Anterior approaches require deflation of the ipsilateral lung.

• The segmental vessels should be maintained, because they are critical to the stretched spinal cord.

Step 1 Instrumentation/Implantation

• Specialized thoracoscopic equipment is needed for VATS.

• Reduction screws below the apex facilitate rod placement.

Step 1 Controversies

• A thoracic surgeon may be required for anterior approaches.

• A vertebral column resection (VCR) or pedicle subtraction osteotomy (PSO) in posterior-only fusion may lead to correction equal to that of anterior release and posterior fusion.

• Performing a VCR or PSO at cord level potentially carries a higher risk of neurologic complications, especially in older patients.

• Combined procedures have a higher incidence of general complications than posterior-only surgery.

• VATS has been found to result in less morbidity than conventional thoracotomy, but it is approximately 30% more expensive.

Postoperative Care and Expected Outcomes

image Bracing is typically not necessary.

image Patients are maintained in the intensive care unit or a monitored bed overnight.

image Ambulation is encouraged on the first postoperative day.

Postoperative Pitfalls

• The risk of superior mesenteric artery syndrome is not insignificant.

• Presentation includes nausea, vomiting, and abdominal pain.

• Treatment is to maintain “nothing by mouth” status until the syndrome resolves with adequate hydration.

Step 2

image Perform a wide release, including a radical facetectomy at the apex and at the three adjacent cranial and caudal levels.

image Bilateral pedicle screws should be inserted at the apex and at least eight screws above and eight screws below the apex.

image A rod should be contoured to normal sagittal alignment.

image The rod is inserted into the proximal screws (Figure 18-2, A) and cantilevered into the remaining screws (Figure 18-2, B).

image Once the rod is seated, additional compression will close the segmental osteotomies and increase curve reduction.

image If a PSO or VCR is performed, a temporary fixation rod is required for any correction maneuvers.

image

FIGURE 18-2, A-B

Step 2 Pearls

• The distal end of the instrumentation should be the sagittal stable vertebra, which is the most proximal thoracolumbar or lumbar vertebra intersected (not bisected) by the posterior sacral vertical line.

• The proximal end of the instrumentation should be the proximal vertebra measured in the Cobb angle (Figure 18-1).

image

FIGURE 18-1

Step 2 Pitfalls

• If an apical disk herniation is seen on the MRI, an anterior diskectomy or VCR should be performed before curve correction.

• A thoracic VCR requires resection of the rib head and often sacrifices the nerve root.

• The mean arterial pressure should be increased to at least 75 mm Hg before correction.

Step 2 Instrumentation/Implantation

• A rigid rod for PSF (image-inch stainless steel) will prevent loss of correction.

Step 2 Controversies

• Posterior-only instrumentation with thoracic pedicle screws and segmental osteotomies can reduce operative time, blood loss, and complication rates compared with anterior-posterior fusion.

Evidence

Arlet V, Schlenzka D. Scheuermann’s kyphosis: surgical management. Eur Spine J. 2005;14:817-827.

This review article discusses the use of newer segmental instrumentation used to correct kyphosis. The four-rod technique as well as various compression techniques are also presented.

Boachie-Adjei O, Sarwahi V. Scheuermann’s kyphosis. In: DeWald RL, editor. Spinal Deformities: The Comprehensive Text. New York: Thieme Medical Publishers; 2003:777-786.

This chapter describes some of the surgical concepts and techniques that are used to correct kyphosis in Scheuermann disease.

Lee SS, Lenke LG, Kuklo TR, et al. Comparison of Scheuermann kyphosis correction by posterior-only thoracic pedicle screw fixation versus combined anterior/posterior fixation. Spine. 2006;31:2316-2321.

This article describes the clinical and radiographic results of 18 patients who underwent posterior-only fusion compared with 21 patients who underwent anterior/posterior fusion. With the use of segmental osteotomies and thoracic pedicle screws, posterior-only fusion seems to be superior to combined fusion when using hybrid hook/screw constructs.

Murray PM, Weinstein SL, Spratt KF. The natural history and long-term follow-up of Scheuermann kyphosis. J Bone Joint Surg Am. 1993;75:236-248.

This classical article describes the long-term follow-up of 67 patients with Scheuermann kyphosis followed for an average of 32 years compared with a control group. The patients with Scheuermann kyphosis had more intense back pain, jobs that required less activity, and less range of motion of trunk extension.

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