Posterior column resection effective for certain spinal injuries, deformities

When performed by experienced surgeons, 3-D corrections can be made in single approach.

Issue: Issue 2 2010

A specific technique for posterior vertebral column resection demonstrated safety and efficacy in a recently presented case series of patients, adding to the evidence that this technique is effective when performed by experienced surgeons.

“Posterior vertebral column resection is a safe and effective method for severe neglected or maltreated deformities when done by experienced surgeons … and strictly done under neurological monitoring,” Cagatay Ozturk, MD, of the Istanbul Spine Center at the Florence Nightingale Hospital in Istanbul, Turkey, said during his presentation at the North American Spine Society’s 24th Annual Meeting. “It may allow us to do 3-D corrections via a single approach, and it may be the procedure of choice, especially in those patients with pulmonary compromise.”

Consecutive-patient study

Ozturk presented case series results from 102 patients who were consecutively treated with posterior vertebral column resection at the Istanbul Spine Center from 1996 to 2007. Minimum follow-up was 2 years, and average patient age was 37.6 years. The study group included 80 women and 22 men. Twenty-five patients had osteoporotic fracture with neurologic compromise, nine had post-traumatic deformity, 12 had post-infectious severe angular kyphosis, and 56 had severe scoliosis, kyphoscoliosis or lordoscoliosis.

The procedure involved a wide laminectomy above and below the resected level to prevent impingement; pedicle screw insertion; sacrifice of the thoracic nerve roots bilaterally; gradual correction by compression and in situ bending; and temporary rod placement without any attempt at correction.

“We almost always place an anterior mesh cage to prevent shortening of the spinal column,” Ozturk said. “We also place an anterior H-shape femoral allograft to prevent hematoma formation as well as to increase the fusion rate.”

Average 9-year follow-up

In this case series, 78 patients underwent one-level resections, 15 had two-level resections, and nine had three-level resections. At an average follow-up of 9 years, a retrospective X-ray analysis revealed a 72% correction rate in the coronal plane and a 71% correction rate in the sagittal plane, Ozturk said. Two patients experienced nerve root palsy, and six patients had postoperative infections. However, with antibiotic treatment and multiple debridements, these patients have been able to avoid revision surgery, according to Ozturk.

Mean standard deviation values changed from 42 preoperatively to 52 postoperatively for pelvic incidence, from 31 to 39 for sacral slope, and from 11 to 13 for pelvic tilt. According to the study abstract, no patients showed worsening neurological status, with some improving and others remaining the same. The researchers stressed in the abstract that this technique should be performed by a highly experienced surgical team. – by Tina Dimarcantonio

Reference:

Ozturk C, Aydogan M, Tezer M, et al. Posterior vertebral column resection in severe spinal deformities: A total of 102 cases. Presented at the North American Spine Society 24th Annual Meeting. Nov. 10-14, 2009. San Francisco, U.S.A.

Cagatay Ozturk, MD, can be reached at the Istanbul Spine Center at the Florence Nightingale Hospital in Istanbul, Turkey. e-mail: cgtyztrk@yahoo.com.

Ozturk et al is a very sophisticated group managing a really complex set of problems. These are patients with severe deformity who are not going to be managed in most typical practices. Historically, this type of patient would be treated with a combined anterior surgery, where you have to go through the chest, and then posterior surgery — a two-stage procedure. Increasingly, both internationally and in the United States, an alternative single-stage posterior approach, with resection of one or more vertebral bodies for decompression or deformity correction, has been advocated.

This type of procedure is complicated and difficult; however, the study demonstrated that experienced surgeons can generate good long-term outcomes with a single-stage posterior approach for vertebral column resection and deformity correction. Previously, there were only a couple of centers in the United States that had demonstrated clear proficiency with this complex surgical approach. The fact that there are now an expanding number of centers reporting successful outcomes with this approach is additional evidence that the technique is going to be viable in broader application. Importantly, it’s only going to be a technique used by very experienced surgeons, and the authors emphasized that message.

A critical point for surgeons who are considering potentially using this technique is that these authors have developed the ability to obtain an exposure of the pathology, via a posterior approach, that is comparable to the exposure normally achieved through a standard anterior approach. The general impression is that a vertebrectomy, performed through a posterior exposure, is a smaller procedure. But you’re not really doing something smaller; you are only doing something differently. If you accept compromised exposure, because you’re not comfortable really accessing the pathology through the back of the spine, then you’re not going to be able to duplicate the quality of result that Ozturk et al have reported.

Overall, I don’t think these results will affect standard clinical practice — because these cases aren’t seen in standard clinical practice. However, this is additional evidence, in what is now a series of studies over the past several years from different centers around the world, demonstrating that in experienced hands, a posterior-only approach to really complicated pathology is viable.

– Steven D. Glassman, MD
Professor of Orthopedic Surgery, University of Louisville, Louisville, Ky.