Posterior all-pedicle screw instrumentation combined with multiple chevron and concave rib osteotomies in the treatment of adolescent congenital kyphoscoliosis

Abstract

Background context: Congenital kyphoscoliosis is a disorder that often requires surgical treatment. Although many methods of surgical treatment exist, posterior-only vertebral column resection with instrumentation and fusion seem to have become the gold standard for very severe and very rigid curves. Multiple chevron and concave rib osteotomies have been previously reported to be effective in the treatment of neglected severe idiopathic curves. We hypothesized that this method may also be used successfully in the treatment of congenital kyphoscoliosis.

Purpose: To evaluate the effectiveness and safety of multiple chevron osteotomies combined with concave rib osteotomy and posterior pedicle screw instrumentation.

Study design: Retrospective chart review in the spine service of a large university hospital.

Patient sample: Adolescent patients undergoing a specific surgical treatment for the indication of rigid congenital kyphoscoliotic deformity.

Outcome measures: Radiographic images were used for the measurement of deformity correction. The Turkish version of the Scoliosis Research Society 22 (SRS-22) Patient Questionnaire has been used as a clinical outcome measure in the patient population.

Methods: A retrospective chart review was performed. Patients admitted to Hacettepe Hospital Spine Center during the period of 2005 to 2009 were included. Criteria for inclusion were as follows: adolescent age group (10-16 years); congenital kyphoscoliosis; formation and/or segmentation defect of at least two vertebral motion segments; surgical treatment of deformity by posterior all-pedicle screw instrumentation, multiple chevron osteotomies, and multiple concave rib osteotomies; follow-up of at least 24 months; and a complete set of preoperative, postoperative, and follow-up standing posteroanterior and lateral full spinal radiographs. The patients' hospital records and X-rays were reviewed. Duration of surgery, intraoperative blood loss, postoperative transfusion requirements, postoperative stay in postanesthesia care unit (PACU), time of hospitalization, and complications were recorded. Deformity in both coronal and sagittal planes was analyzed for correction and maintenance of the correction in preoperative, postoperative, and follow-up radiographs. Patients' health-related quality of life was assessed using the SRS-22 questionnaire at the final follow-up.

Results: Eighteen patients met the inclusion criteria. Their average age was 13.6 years (range, 11-16 years). Chevron osteotomies were performed at apical segments (three to seven levels) and concave rib osteotomies at Cobb-to-Cobb (five to eight levels). No patient had preoperative cord compression because of the sharply angulated deformity or neurologic deficit. The average preoperative scoliosis was 66.0° (range, 31°-116°), 52.4° (range, 22°-85°) on flexibility X-rays, and became 24.9° (range, 12°-52°) postoperatively. The average preoperative global kyphosis (T2-T12) of 75.9° (range, 50°-106°) became 49.5° (range, 18°-66°). The average preoperative local kyphosis of 71.9° (range, 35°-114°) became 31.4° (range, -44° to 64°). The average intraoperative bleeding was 989 cc, surgical time was 292 minutes, and intraoperative transfusion was 2.3 units. The maximum PACU stay was overnight. There were no neurologic complications except one pneumothorax and one pneumonia. The average follow-up was 34.3 months. At follow-up, average scoliosis was 27.5° (range, 10°-50°), global kyphosis was 50.3° (range, 28°-73°), and local kyphosis was 36.9°(range, -36° to 58°). Performed on the last follow-up, the average scores for the five domains of SRS-22 were 4.3, 4.4, 4.2, 4.1, and 4.8 for function, pain, self-image, mental health, satisfaction, and total, respectively.

Conclusions: Multiple chevron and concave rib osteotomies with posterior instrumentation provide an acceptable rate of deformity correction and maintenance of correction at 2 years with acceptable intraoperative bleeding, surgical time, postoperative morbidity, and rate of complications. It can be considered as an alternative in the treatment of rigid congenital curves involving more than three levels or multiple curves separated by at least two segments that would otherwise require multiple vertebral resections.

Keywords: Chevron; Congenital; Kyphoscoliosis; Osteotomy; Pedicle screw instrumentation.