Posterior convex lamina wedge osteotomy and thoracic intervertebral disc space release through costovertebral joints for severe and rigid kyphoscoliosis in adolescents

English Keywords:Severe kyphoscoliosis  Adolescent  Convex lamina wedge osteotomy  Costovertebral joints  Thoracic intervertebral space release

English Abstract:

  【Abstract】 Objectives: To evaluate the early clinical efficacy and safety of posterior convex lamina wedge osteotomy and thoracic intervertebral disc space release through costovertebral joints for severe and rigid kyphoscoliosis in adolescents. Methods: From May 2014 to December 2016, 15 patients with severe rigid kyphoscoliosis were treated with posterior convex lamina wedge osteotomy and thoracic intervertebral space release through costovertebral joints at our hospital, and only one of them underwent halo-pelvic traction before operation. There were 6 males and 9 females, aged 13 to 18 years, with a mean age of 16.1±1.6 years. Among them, 3 patients were of congenital vertebral deformity, 11 were of neglected idiopathic scoliosis, and 1 was of type I neurofibromatosis. The mean preoperative scoliosis Cobb angle was 102.5°±17.6°(ranged 82° to 144°). The mean flexibility was (21.56±5.70)%(range, 6.4% to 28.5%). And the mean preoperative sagittal kyphosis angle was 68.1°±15.3°(ranged 50° to 95°). The coronal balance(distance between coronal C7 centroid plumb line and the central sacral vertical line) was 2.0 to 6.8cm, with a mean distance of 3.40±1.37cm. The muscle strength and sensation of extremities of all the patients were normal before operation. Results: The average number of wedge osteotomy of convex vertebral lamina was 5.20±0.56 and the release space was 5.20±0.56． The operative time ranged from 6.1 to 7.9 hours, which was averaged 7.00±0.51 hours. Intraoperative blood loss was 1050ml to 2500ml, with a mean of 1450.0±521.3ml. The mean postoperative scoliosis Cobb angle was 28.0°±6.6°(range, 18° to 40°), and the correction rate was 72.5%. The mean postoperative sagittal kyphosis angle was 27.8°±6.1°(ranged 22° to 42°), and the correction rate was 58.4%. The mean coronal balance was 0.85±0.74cm(range, 0 to 2cm), and the correction rate was 72.8%. The mean follow up period was 33.1±5.4 months(range, 25 to 41 months). At the most recent follow-up, the scoliosis Cobb angle was 30.0°±6.9°(range, 19° to 43°), and the correction rate was 70.6%. The sagittal kyphosis angle was 28.6°±6.5°(range, 22° to 42°), and the correction rate was 57.2%. The mean coronal balance was 1.10±0.72cm (range, 0.2 to 2.3cm), and the correction rate was 71.3%. No pleural rupture was recognized during surgery. There were no definite pseudarthrosis, no breakage or loosening of internal fixation. Besides, no definite loss of correction was observed at the final follow up. One patient had pelvic traction nail tract infection before operation. After 2 weeks, the infection was controlled after local wound dressing change and antibiotic application. One patient experienced superior mesenteric artery syndrome at the third day postoperatively, which was resolved after 2 weeks by nutrilization via nasogastrie tube, electrolytic balance and appropriate position． One case developed incomplete paralysis of the left lower limb 5 hours after operation and gradually aggravated. CT examination showed that the left pedicle screw of T4 invaded the spinal canal and compressed the spinal cord. The operation was repeated 8 hours after operation, which removed the left pedicle screw of T4, and the function of the left lower limb recovered completely 5 months after operation. Conclusions: Posterior convex lamina wedge osteotomy and thoracic intervertebral disc space release through the costovertebral joints for treating severe and rigid kyphoscoliosis in adolescents does not require that the parietal pleura be detached off the lateral side of the vertebra. There is less deep dissection and trauma is less. The operation not only serves to increase the flexibility of the spine, but also provides enough space for compression and closure to correct the kyphoscoliosis. It can obtain excellent three-dimensional correction of spine.