This article is more than 5 years old. Information may no longer be current.
Researchers call for spinal cord monitoring during vertebral column resection
Click Here to Manage Email Alerts
Thirteen percent of pediatric patients had a postoperative neurologic deficit following vertebral column resection, according to results of a retrospective review.
“Fortunately, there was a high rate of recovery when corrective action was taken intraoperatively,” Suken A. Shah, MD, from the department of orthopedics at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del. said during a presentation at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons.
Vertebral column resection is a posterior-only treatment for severe pediatric spinal deformity, Shah said. The procedure is gaining popularity because it is “an extremely powerful method of correction.” There are downsides to the operation including a high risk of neurologic injury because of the nature of the surgery. “These patients have complex deformities,” Shah said. “They may have pre-existing neurologic deficits, and this is a complicated surgery that requires some experience that’s gained with more of these procedures.”
For his multicenter retrospective study, Shah and colleagues reviewed the records of 147 patients who underwent 184 procedures. There were 74 girls and 73 boys with an average age nearly 14 years. The patients had an average of 1.6 vertebrae resected.
Forty-two patients had an abnormal preoperative neurologic examination. Some were myelopathic and some had previous surgery, Shah said. Thirty-nine patients had an intraoperative neurological event. However, no patients sustained a complete or permanent paraplegia. Postoperatively, 19 patients had neurologic deterioration of their preoperative status, he said. Fifteen of these cases occurred in the spinal cord regions, and four were nerve root deficits.
“All except one were detected by intraoperative neurophysiologic monitoring or a wake-up test during surgery,” Shah said.
All deficits recovered
All of these deficits, except for one, recovered by 3.5 months.
“The critical thing was we attempted to identify some of the risk factors that perhaps would be important in counseling patients and families,” Shah said. He noted that the risk factors are common issues when correcting any spinal deformity. “Kyphosis is a bad actor, congenital deformities are particularly complex, those patients who had revision surgery, pre-existing myelopathy or unreliable monitoring were at risk as were those who had intraoperative hypotension that was sustained,” he said.
Six patients with abnormal preoperative neurologic exams improved after vertebral column resection.
“Many patients undergoing VCR (vertebral column resection) for severe deformities have pre-existing neurologic deficits, which may preclude monitoring or make it more difficult,” Shah said. “However, we still feel that monitoring during a VCR procedure is mandatory since there is a very high incidence of alerts in this patient population.”
High neurologic recovery rate
The procedure has a 13% rate of postoperative neurologic deficit, according to the study abstract. Most of the deficits are found at the thoracic cord level. Nerve root injuries are possible in lumbar-level resections. Fortunately, the neurologic recovery rate is high when the surgeon takes intraoperative corrective action to realign or decompress the vertebral canal appropriately after neurophysiologic monitoring changes, Shah noted.
“Shortening the spine is important to decrease traction on the spinal cord,” Shah said. “And this may involve placement of anterior column support with a cage and obviously, raising the blood pressure and looking for any laminar defects that may be impinging the cord or causing cord buckling.”– by Colleen Owens
Reference:
- Shah SA, Sucato DJ, Newton PO, Shufflebarger HL, Sponseller, PD, Baltimore, Lenke, LG, et al. Perioperative neurologic events in pediatric vertebral column resection: nature, frequency and outcomes. Paper #396. Presented at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons. Feb. 15-19. San Diego.
- Suken A. Shah, MD, can be reached at Nemours/Alfred I duPont Hospital for Children, 1600 Rockland Road, PO Box 269, Department of Orthopaedics, Wilmington, DE 19899; 302-651-5904; email: sshah@nemours.org.
- Disclosure: Shah receives royalties and institutional or research support from DePuy Spine; is on the speakers’ bureau and is a paid consultant for DePuy Spine; is an unpaid consultant for K-Spine Inc.; and has stock or stock options in Globus Medical.
|
|
Shah et al in this study provide useful information when counseling parents regarding the risks of neurological injury when vertebral column resection (VCR) is required to correct a major deformity. The use of neurological monitoring remains controversial, but this study supports the use of monitoring when performing corrections using the VCR technique. They report a high rate of events captured by monitoring allowing for possible corrective action. In addition, the reported improvements over the short term of new postoperative deficits should provide some comfort for surgeons and parents when faced with difficult decision making.
— Kai-Ming Fu, MD
Department of
Neurosurgery
University of Virginia Medical School
Charlottesville,
VA
Disclosure: He has no relevant financial disclosures.