Abstract
Study Design
Clinical case series.
Objective
To assess objective outcomes of surgical correction of post–external beam radiation therapy (ERBT) kyphosis in a series of five adults.
Summary of Background Data
EBRT is a well-established treatment for many cancers in children and adults. One complication associated with EBRT is postirradiation spine deformity. Scoliosis is the most common deformity, but kyphosis also occurs frequently. Differences in deformity patterns are likely related to the location and intensity of radiation. To our knowledge, no studies have addressed treatment of these deformities in adults, and the most recent case series (of children) was published in 2005.
Methods
We present a series of five adults who underwent surgery for postirradiation kyphosis, with a mean follow-up of 3.8 years (range, 2.5–6.2 years).
Results
Surgery improved the kyphotic deformity in all patients. Overall mean kyphotic deformity correction was 56° and was larger for cervical/cervicothoracic deformities (mean, 76°) than for lumbar deformities (mean, 42°) at midterm follow-up. Patients reported significant improvements in pain and self-image. Consistent with prior case series of children, we observed a high rate of complications (mean, 1.4 complications per patient) in adults. Three patients each underwent an unplanned surgical procedure because of a complication.
Conclusion
The surgical treatment of postirradiation kyphotic spinal deformity is challenging, with common postoperative complications such as infection, instrumentation failure, and pseudarthrosis. However, with modern surgical techniques and spinal instrumentation, excellent deformity correction can be achieved and maintained. We recommend performing a two-stage procedure for cervicothoracic deformity, with anterior release followed by posterior fusion and instrumentation. In thoracolumbar deformities, correction can be achieved through single-stage posterior fusion. Rigid spinopelvic fixation with sacral-alar-iliac screws and second-stage anterior lumbar interbody fusion at L5–S1 is recommended to reduce nonunion risk. Cement augmentation of proximal and distal anchors can help prevent junctional failure.
Level of Evidence
Level IV.
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References
Xu XG, Bednarz B, Paganetti H. A review of dosimetry studies on external-beam radiation treatment with respect to second cancer induction. Phys Med Biol 2008;53:R193–241.
Armstrong GT, Stovall M, Robison LL. Long-term effects of radiation exposure among adult survivors of childhood cancer: results from the childhood cancer survivor study. Radiat Res 2010;174:840–50.
de Jonge T, Slullitel H, Dubousset J, et al. Late-onset spinal deformities in children treated by laminectomy and radiation therapy for malignant tumours. Eur Spine J 2005;14:765–71.
Green DM. The evolution of treatment for Wilms tumor. J Pediatr Surg 2013;48:14–9.
Riseborough EJ. Irradiation induced kyphosis. Clin Orthop Relat Res 1977;128:101–6.
Heaston DK, Libshitz HI, Chan RC. Skeletal effects of megavoltage irradiation in survivors of Wilms’ tumor. AJR Am J Roentgenol 1979;133:389–95.
Oliver JH, Gluck G, Gledhill RB, et al. Musculoskeletal deformities following treatment of Wilms’ tumour. Can Med Assoc J 1978;119:459–64.
Paulino AC, Wen BC, Brown CK, et al. Late effects in children treated with radiation therapy for Wilms’ tumor. Int J Radiat Oncol Biol Phys 2000;46:1239–46.
Sasso G, Greco N, Murino P, et al. Late toxicity in Wilms tumor patients treated with radiotherapy at 15 years of median follow-up. J Pediatr Hematol Oncol 2010;32:e264–7.
Arkin AM, Pack GT, Ransohoff NS, et al. Radiation-induced scoliosis; a case report. J Bone Joint Surg Am 1950;32a:401–4.
Chen SH, Chen PQ, Huang TJ, et al. Surgical correction of postradiation spinal deformity. Chang Gung Med J 2003;26:160–9.
King J, Stowe S. Results of spinal fusion for radiation scoliosis. Spine (Phila Pa 1976) 1982;7:574–85.
O’Brien JR, Yu WD, Bhatnagar R, et al. An anatomic study of the S2 iliac technique for lumbopelvic screw placement. Spine (Phila Pa 1976) 2009;34:E439–42.
Schwab FJ, Lafage R, Liabaud B, et al. Does one size fit all? Defining spinopelvic alignment thresholds based on age. Spine J 2014;14:S120–1.
Makipernaa A, Heikkila JT, Merikanto J, et al. Spinal deformity induced by radiotherapy for solid tumours in childhood: a long-term follow up study. Eur J Pediatr 1993;152:197–200.
Lonstein JE. Post-laminectomy kyphosis. Clin Orthop Relat Res 1977;128:93–100.
Albert TJ, Vacarro A. Postlaminectomy kyphosis. Spine (Phila Pa 1976) 1998;23:2738–45.
Yasuoka S, Peterson HA, MacCarty CS. Incidence of spinal column deformity after multilevel laminectomy in children and adults. J Neurosurg 1982;57:441–5.
McAllister BD, Rebholz BJ, Wang JC. Is posterior fusion necessary with laminectomy in the cervical spine? Surg Neurol Int 2012;3:S225–31.
Papagelopoulos PJ, Peterson HA, Ebersold MJ, et al. Spinal column deformity and instability after lumbar or thoracolumbar laminectomy for intraspinal tumors in children and young adults. Spine (Phila Pa 1976) 1997;22:442–51.
Weistroffer JK, Perra JH, Lonstein JE, et al. Complications in long fusions to the sacrum for adult scoliosis: minimum five-year analysis of fifty patients. Spine (Phila Pa 1976) 2008;33:1478–83.
Crandall DG, Revella J. Transforaminal lumbar interbody fusion versus anterior lumbar interbody fusion as an adjunct to posterior instrumented correction of degenerative lumbar scoliosis: three year clinical and radiographic outcomes. Spine (Phila Pa 1976) 2009;34:2126–33.
Kebaish K, El Dafrawy MH. Sublaminar decompression technique. Available at: https://www.vumedi.com/video/sublaminar-decompression-technique/. Accessed October 24, 2016.
Kebaish KM, Martin CT, O’Brien JR, et al. Use of vertebroplasty to prevent proximal junctional fractures in adult deformity surgery: a biomechanical cadaveric study. Spine J 2013;13:1897–903.
Hyun SJ, Lenke LG, Kim YC, et al. Comparison of standard 2-rod constructs to multiple-rod constructs for fixation across 3-column spinal osteotomies. Spine (Phila Pa 1976) 2014;39:1899–904.
Jalai CM, Worley N, Poorman GW, et al. Surgical site infections following operative management of cervical spondylotic myelopathy: prevalence, predictors of occurrence, and influence on peri-operative outcomes. Eur Spine J 2016;25:1891–6.
Lai Q, Song Q, Guo R, et al. Risk factors for acute surgical site infections after lumbar surgery: a retrospective study. J Orthop Surg Res 2017;12:116.
Lee NJ, Shin JI, Kothari P, et al. Incidence, impact, and risk factors for 30-day wound complications following elective adult spinal deformity surgery. Global Spine J 2017;7:417–24.
Liu JM, Deng HL, Chen XY, et al. Risk factors for surgical site infection after posterior lumbar spinal surgery. Spine (Phila Pa 1976) 2018;43:732–7.
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Author disclosures: SLM (none), CJD (none), MHED (none), KMK (personal fees from DePuy, A Johnson & Johnson Company, Orthofix, Inc., K2 Medical Inc., and Spinecraft, outside the submitted work).
Conflict of Interest: The authors have no conflicts of interest to report.
Funding Statement: No funding was received in support of this study.
IRB Approval Statement: Institutional review board approval (IRB00145784) was received for this study.
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Mitchell, S.L., Donaldson, C.J., El Dafrawy, M.H. et al. Difficulties in Treating Postirradiation Kyphosis in Adults: A Series of Five Cases. Spine Deform 7, 937–944 (2019). https://doi.org/10.1016/j.jspd.2019.01.008
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DOI: https://doi.org/10.1016/j.jspd.2019.01.008