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Kyphectomy in myelomeningocele revisited: risk factors for failure

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Abstract

Purpose

Lumbar kyphosis occurs in approximately 8–20% of patients with myelomeningocele (MMC). The purpose of this article is to analyze the risks and benefits of vertebrectomy and spinal stabilization in MMC children with severe lumbar kyphosis and to establish treatment guidelines.

Methods

This is an IRB-approved retrospective analysis of 59 patients with MMC who underwent kyphectomy and posterior instrumentation in three centers. Average age at surgery was 7.9 years (2 weeks–17 years). Sitting trunk position, skin status, kyphosis angle, and thoracic lordosis were analyzed preoperatively, postoperatively, and at an average follow-up of 8.2 years (range 2.5–16). The correction was maintained by applying a short posterior instrumentation in 6 patients, and extending to the pelvis in 53 cases. Pelvic fixation was achieved using the Warner and Fackler technique in 24 patients, the Dunn–McCarthy in 8, Luque–Galveston in 8, sacral screws in 2, and ilio-sacral screws in 11.

Results

Sitting position improved postoperatively in 47 of the 53 patients who underwent pelvic fixation and only in one patient with short instrumentation. All 6 patients with long instrumentation and poor postoperative sitting balance were in the Dunn–McCarthy fixation group. Skin sores at the apex of the deformity disappeared postoperatively in all patients but recurred in two patients with short instrumentations. Kyphosis angle improved from 109° (45°–170°) preoperatively to 10° (0°–45°) postoperatively and 21° (0°–55°) at last follow-up. The best results were seen in cases where a cross-k-wire fixation of the kyphectomy site was used, augmented with a long thoraco-pelvic instrumentation consisting of Luque sublaminar wires in the thoracic region and a Warner–Fackler type of pelvic fixation. Good results were also found with the bipolar technique and ilio-sacral screw fixation. Six over 24 patients with the Warner and Fackler technique showed gradual dislodgment or hardware failure, with subsequent nonunion of the kyphectomy site in four. Infection, with or without wound dehiscence and/or hardware exposure, occurred in 17 cases, necessitating hardware removal in 9 patients.

Conclusion

Lumbar kyphosis in MMC children is best managed by resection of enough vertebrae from the apex to produce a flat lumbar spine, with perfect bone-to-bone contact and long thoraco-pelvic instrumentation using the Warner and Fackler technique through the S1 foramina or the bipolar technique with ilio-sacral screw fixation. Additional local fixation of the osteotomy site using cross-wires with or without cerclage increases the stability of the construct. The majority of complications occurred in patients with short instrumentations or where residual kyphosis persisted postoperatively regardless of the type of pelvic fixation or hardware density. The Dunn–McCarthy technique for pelvic fixation following kyphectomy in MMC was less successful in producing stable pelvic fixation and should not be considered in this patient category.

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References

  1. de Amoreira GR, Quiroga MRS, Gomes CR, de Araújo HJ (2013) Kyphectomy in meningomyelocele children: surgical technique, risk analysis, and improvement of kyphosis. Childs Nerv Syst 29:1137–1141. https://doi.org/10.1007/s00381-013-2035-6

    Article  Google Scholar 

  2. Vibert B, Turati M, Rabattu P-Y, Bigoni M, Eid A, Courvoisier A (2018) Congenital lumbar kyphosis with skin ulceration and osteomyelitis in a myelomeningocele child: a case report. Childs Nerv Syst 34:771–775. https://doi.org/10.1007/s00381-017-3598-4

    Article  PubMed  Google Scholar 

  3. Warner WC, Fackler CD (1993) Comparison of two instrumentation techniques in treatment of lumbar kyphosis in myelodysplasia. J Pediatr Orthop 13:704–708

    Article  PubMed  Google Scholar 

  4. Dunn RN, Bomela LN (2016) Kyphectomy in children with severe myelomeningocele-related kyphosis. Spine Deform 4:230–236. https://doi.org/10.1016/j.jspd.2015.11.006

    Article  CAS  PubMed  Google Scholar 

  5. Yoshioka K, Watanabe K, Toyama Y, Chiba K, Matsumoto M (2011) Kyphectomy for severe kyphosis with pyogenic spondylitis associated with myelomeningocele: a case report. Scoliosis 6:5. https://doi.org/10.1186/1748-7161-6-5

    Article  PubMed  PubMed Central  Google Scholar 

  6. Fürderer S, Eysel P, Hopf C, Heine J (1999) Sagittal static imbalance in myelomeningocele patients: improvement in sitting ability by partial and total gibbus resection. Eur Spine J 8:451–457. https://doi.org/10.1007/s005860050204

    Article  PubMed  PubMed Central  Google Scholar 

  7. Sharrard WJ (1968) Spinal osteotomy for congenital kyphosis in myelomeningocele. J Bone Joint Surg Br 50:466–471

    Article  CAS  PubMed  Google Scholar 

  8. Özdemir N, Özdemir SA, Özer EA (2019) Kyphectomy in neonates with meningomyelocele. Childs Nerv Syst 35:673–681. https://doi.org/10.1007/s00381-018-4006-4

    Article  PubMed  Google Scholar 

  9. Ryabykh SO, Pavlova OM, Savin DM, Burtsev AV, Gubin AV (2018) Surgical management of myelomeningocele-related spinal deformities. World Neurosurg 112:e431–e441. https://doi.org/10.1016/j.wneu.2018.01.058

    Article  PubMed  Google Scholar 

  10. Garg S, Oetgen M, Rathjen K, Richards BS (2011) Kyphectomy improves sitting and skin problems in patients with myelomeningocele. Clin Orthop Relat Res 469:1279–1285. https://doi.org/10.1007/s11999-010-1650-8

    Article  PubMed  Google Scholar 

  11. Petersen PA, Marcon RM, Letaif OB, Mello Santos MA, Oliveira RG, de Barros P, Filho TE et al (2020) Does kyphectomy improve the quality of life of patients with myelomeningocele? Clin Orthop Relat Res 478:104–111

    Article  PubMed  Google Scholar 

  12. Comstock SA, Cook PC, Leahey JL, El-Hawary R, Hyndman JC (2011) Posterior kyphectomy for myelomeningocele with anterior placement of fixation: a retrospective review. Clin Orthop Relat Res 469:1265–1271. https://doi.org/10.1007/s11999-010-1611-2

    Article  PubMed  Google Scholar 

  13. McCarthy RE, Dunn H, McCullough FL (1989) Luque fixation to the sacral ala using the Dunn-McCarthy modification. Spine (Phila Pa 1976) 14:281–283. https://doi.org/10.1097/00007632-198903000-00007

    Article  CAS  PubMed  Google Scholar 

  14. Fromm B, Carstens C, Graf J (2008) Aortographic findings in children with myelomeningocele and lumbar kyphosis. Z Orthop Ihre Grenzgeb 132:56–61. https://doi.org/10.1055/s-2008-1039820

    Article  Google Scholar 

  15. Wui S-H, Hyun S-J, Kim K-J, Jahng T-A, Kim HJ (2019) Kyphectomy and interbody fixation using lag screws in a child with myelomeningocele kyphosis: a technical case report. Childs Nerv Syst 35:1407–1410. https://doi.org/10.1007/s00381-019-04217-w

    Article  PubMed  Google Scholar 

  16. Sarifakioglu N, Bingül F, Terzioglu A, Ates L, Aslan G (2003) Bilateral split latissimus dorsi V-Y flaps for closure of large thoracolumbar meningomyelocele defects. Br J Plast Surg 56:303–306. https://doi.org/10.1016/s0007-1226(03)00115-2

    Article  PubMed  Google Scholar 

  17. Gómez Chavarría J, Cardoso Monterrubio A, Garavito Salazar E (2008) Use of expanders in surgical treatment of kyphosis in patients with myelomeningocele. Acta Ortop Mex 22:162–168

    PubMed  Google Scholar 

  18. Crawford AH, Strub WM, Lewis R, Gabriel KR, Billmire DA, Berger T et al (2003) Neonatal kyphectomy in the patient with myelomeningocele. Spine (Phila Pa 1976) 28:260–266. https://doi.org/10.1097/01.BRS.0000042234.98512.BE

    Article  PubMed  Google Scholar 

  19. Duddy JC, Caird J, Connolly P (2013) Repair of a large thoracolumbar myelomeningocele with associated lumbar kyphosis. Acta Neurochir (Wien) 155:1965–1968. https://doi.org/10.1007/s00701-013-1805-y

    Article  PubMed  Google Scholar 

  20. Kaplan SÇ, Ekşi MŞ, Bayri Y, Toktaş ZO, Konya D (2015) Kyphectomy and pedicular screw fixation with posterior-only approach in pediatric patients with myelomeningocele. Pediatr Neurosurg 50:133–144. https://doi.org/10.1159/000430467

    Article  PubMed  Google Scholar 

  21. Kiepe F, Hermann EJ, Heissler HE, Henseler H, Vogt PM, Krauss JK (2019) Multisegmental lumbar corporectomy and transcorporal fixation for correction of extreme thoracolumbar kyphosis in myelomeningocele with chronic decubitus. Pediatr Neurosurg 54:116–120. https://doi.org/10.1159/000494564

    Article  PubMed  Google Scholar 

  22. Kocaoğlu B, Erol B, Akgülle H, Gasimov E, Yalçin S (2008) Combination of luque instrumentation with polyaxial screws in the treatment of myelomeningocele kyphosis. J Spinal Disord Tech 21:199–204. https://doi.org/10.1097/BSD.0b013e318074e4c6

    Article  PubMed  Google Scholar 

  23. Bas CE, Preminger J, Olgun ZD, Demirkiran G, Sponseller P, Yazici M et al (2015) Safety and efficacy of apical resection following growth-friendly instrumentation in myelomeningocele patients with gibbus: growing rod versus luque trolley. J Pediatr Orthop 35:e98-103. https://doi.org/10.1097/BPO.0000000000000419

    Article  PubMed  Google Scholar 

  24. Samagh SP, Cheng I, Elzik M, Kondrashov DG, Rinsky LA (2011) Kyphectomy in the treatment of patients with myelomeningocele. Spine J 11:e5-11. https://doi.org/10.1016/j.spinee.2011.01.020

    Article  PubMed  Google Scholar 

  25. Thomsen M, Lang RD, Carstens C (2000) Results of kyphectomy with the technique of Warner and Fackler in children with myelodysplasia. J Pediatr Orthop B 9:143–147. https://doi.org/10.1097/01202412-200006000-00002

    Article  CAS  PubMed  Google Scholar 

  26. Altiok H, Finlayson C, Hassani S, Sturm P (2011) Kyphectomy in children with myelomeningocele. Clin Orthop Relat Res 469:1272–1278. https://doi.org/10.1007/s11999-010-1641-9

    Article  PubMed  Google Scholar 

  27. Smith JT (2016) Bilateral rib-based distraction to the pelvis for the management of congenital gibbus deformity in the growing child with myelodysplasia. Spine Deform 4:70–77. https://doi.org/10.1016/j.jspd.2015.07.004

    Article  PubMed  Google Scholar 

  28. Niall DM, Dowling FE, Fogarty EE, Moore DP, Goldberg C (2004) Kyphectomy in children with myelomeningocele: a long-term outcome study. J Pediatr Orthop 24:37–44. https://doi.org/10.1097/00004694-200401000-00008

    Article  CAS  PubMed  Google Scholar 

  29. Nolden MT, Sarwark JF, Vora A, Grayhack JJ (2002) A kyphectomy technique with reduced perioperative morbidity for myelomeningocele kyphosis. Spine (Phila Pa 1976) 27:1807–1813. https://doi.org/10.1097/00007632-200208150-00022

    Article  PubMed  Google Scholar 

  30. Ganjeifar B, Zabihyan S, Baharvahdat H, Baradaran A (2016) Five-level posterior total en bloc spondylectomy of severe myelomeningocele kyphosis. World Neurosurg 90:705.e1-705.e3. https://doi.org/10.1016/j.wneu.2016.03.006

    Article  PubMed  Google Scholar 

  31. Hwang SW, Thomas JG, Blumberg TJ, Whitehead WE, Curry DJ, Dauser RC et al (2011) Kyphectomy in patients with myelomeningocele treated with pedicle screw-only constructs: case reports and review. J Neurosurg Pediatr 8:63–70. https://doi.org/10.3171/2011.4.PEDS1130

    Article  PubMed  Google Scholar 

  32. Kose KC, Inanmaz ME, Uslu M, Bal E, Caliskan I (2012) Kyphectomy for congenital kyphosis due to meningomyelocele: a case treated with a modified approach to skin healing. Int Wound J 9:311–315. https://doi.org/10.1111/j.1742-481X.2011.00885.x

    Article  PubMed  Google Scholar 

  33. Alshaalan KS, Howard JJ, Alshangiti AK, Alkhalife YI, Aleissa S, Al Sayegh SO (2019) Kyphectomy in myelomeningocele for severe early-onset kyphosis using distal intravertebral fixation and thoracic growing rods. J Am Acad Orthop Surg Glob Res Rev 3:e006. https://doi.org/10.5435/JAAOSGlobal-D-19-00006

    Article  PubMed  PubMed Central  Google Scholar 

  34. Akbar M, Almatrod S, Fürstenberg CH, Hemmer S, Kretzer JP, Abel R et al (2010) Kyphectomy in myelomeningocele patients. Longterm results, complications and risk analysis. Orthopade 39:792–800. https://doi.org/10.1007/s00132-010-1615-3

    Article  CAS  PubMed  Google Scholar 

  35. Odent T, Arlet V, Ouellet J, Bitan F (2004) Kyphectomy in myelomeningocele with a modified Dunn-McCarthy technique followed by an anterior inlayed strut graft. Eur Spine J 13:206–212. https://doi.org/10.1007/s00586-003-0662-4

    Article  PubMed  PubMed Central  Google Scholar 

  36. Arnell K (2006) Primary and secondary tissue expansion gives high quality skin and subcutaneous coverage in children with a large myelomeningocele and kyphosis. Acta Neurochir Wien 148:293–297. https://doi.org/10.1007/s00701-005-0704-2

    Article  CAS  PubMed  Google Scholar 

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Funding

The authors did not receive support from any organization for the submitted work. No funding was received to assist with the preparation of this manuscript. No funding was received for conducting this study. No funds, grants, or other support were received. The authors have no relevant financial or non-financial interests to disclose.

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Authors and Affiliations

  1. Division of Orthopedics, Hotel-Dieu de France Hospital, St Joseph University, Beirut, Lebanon

    Ismat Ghanem, Ibrahim Saliba & Ayman Assi

  2. Faculty of Medicine, American University of Beirut, Beirut, Lebanon

    Diane Ghanem

  3. Saint Vincent de Paul Hospital, Université Paris Descartes, Paris, France

    Jean Dubousset & Lotfi Miladi

  4. Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA

    Saul Bernstein, Vernon Tolo & George Bassett

  5. Hopital d’Enfants Malades Necker, Paris, France

    Lotfi Miladi

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  1. Ismat Ghanem
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Correspondence to Ibrahim Saliba.

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Ghanem, I., Saliba, I., Ghanem, D. et al. Kyphectomy in myelomeningocele revisited: risk factors for failure. Eur Spine J 32, 4128–4144 (2023). https://doi.org/10.1007/s00586-023-07924-w

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  • DOI: https://doi.org/10.1007/s00586-023-07924-w

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