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45 Dynamic Scoliosis Correction: AMotion-Preserving Surgical Technique forScoliosis
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45.3.5 Postoperative Care
Patients are monitored in the intensive care unit as long as a
chest tube is required. Chest tubes are removed when the
output decreases to less than 200cc in 24h, which is achieved
in most patients on the rst or second postoperative day
(POD). We recommend early mobilization; most patients
walk on POD 1, with walking on stairs on POD 3 to 5. We
initially use patient-controlled analgesia but switch to oral
analgesics after 2 or 3 days. Patients are discharged between
POD 4 and 7. We do not give restrictions for weight bearing
or spinal motion.
References
1. Betz RR, Kim J, D’Andrea L.An innovative technique of vertebral body stapling for the treatment of patients with adolescent
idiopathic scoliosis: a feasibility, safety, and utility study. Spine.
2003;28:255–65.
2. Betz RR, Ranade A, Samdani AF.Vertebral body stapling. A fusionless treatment option for a growing child with moderate idiopathic
scoliosis. Spine. 2010;35:169–76.
3. Trobisch PD, Samdani A, Cahill P, Betz RR. Vertebral body stapling as an alternative in the treatment of idiopathic scoliosis. Oper
Orthop Traumatol. 2011;23:227–31.
4. Jain V, Lykissas M, Trobisch P, et al. Surgical aspects of spinal growth modulation in scoliosis correction. Instr Course Lect.
2014;63:335–44.
Fig. 45.6 Intraoperative radiograph: (1) Staple, (2) Staple with probe
for canal preparation, (3) Staple and screw with bicortical purchase, (4)
Retractor for lung and diaphragm protection
5. Baroncini A, Trobisch P. Wachstumsmodelierende und nichtversteifende Skoliosechirurgie. Medizinisch-Orthopädische Technik.
2017;2:7–10.
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Vertical Expandable Prosthetic
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Titanium Rib (VEPTR)
CorneliusWimmer andUweVieweg
46
46.1 Introduction and Core Messages
VEPTR stands for Vertical Expandable Prosthetic
Titanium Rib. The purpose of implantation of a VEPTR
is to correct deformities of the thorax and the spine in
children. The VEPTR is a special form of the devices
known as growing rods. In 1993, Campbell published
an overview of the use of the VEPTR in the treatment
of thoracic insufciency syndrome (TIS). The device
consists of a curved expandable prosthetic titanium rib
with several holes in a row that allows it to be xed at
the desired length. In general, 6 months after initial
implantation, intervention is necessary to extend the
device. It is xed in place between two ribs (rib-to-
rib), a rib and the lumbar spine (rib-to-lumbar lamina)
or between a rib and the ilium (rib-to-ilium). The correction of scoliosis is not achieved by means of direct
effects on the individual vertebrae requiring correction
but rather the device achieves the desired outcome by
means of acting on the rib thorax [1]. In very young
children, a VEPTR device can be used for growthcorrecting treatment of congenital scoliosis [1–3].
Typically, there are three different forms of xation. In
cases of distortion of the thorax, thoracotomy on the
concave side is used for osteotomy of rib synostosis
C. Wimmer
Department of Spine Surgery, Trauma Center, Trostberg, Germany
Department of Orthopaedic Surgery, University of Innsbruck,
Innsbruck, Austria
e-mail: ProfWimmer@t-online.de
U. Vieweg (*)
Department of Conservative and Surgical Spine Therapy with
Interdisciplinary Spinal Deformities Centre and Rummelsberg
Sectional Center, Hospital Rummelsberg, Schwarzenbruck,
Germany
e-mail: uwe.vieweg@sana.de
and opening of the ribs with the help of a rib spreader.
The device is then introduced as a rib-to-rib implant. In
cases of thoracic lumbar distortion, a laminar hook is
used to introduce the device as a rib-to-lumbar spine
implant. In addition, it is also possible to x the device
to the pelvis.
46.2 Indications andContraindications
46.2.1 Indications
Use of the device is indicated in [1, 4, 5]:
1. Primary thoracic insufciency syndrome (TIS) due to a
three-dimensional deformity of the thorax.
– Thoracic congenital scoliosis with concave-fused ribs.
– Progressive congenital scoliosis of the thorax with
concave-fused ribs or ail chest as a result of missing
ribs.
– Progressive congenital neurogenic or idiopathic scoli-
osis of the thorax without rib anomalies.
– Hypoplastic thorax syndrome.
– Acquired posterolateral chest wall defects.
2. Secondary thoracic insufciency due to lumbar kyphosis
(non-gibbus).
3. Early onset scoliosis (EOS).
46.2.2 Contraindications
Contraindications are [1]:
• Absent diaphragmatic function.
• Completed bone growth.
• Severe kyphosis >70° per Cobb.
• Children over the age of 10years.
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_46
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• Children aged under 6months.
• Known allergy to any of the materials of the implant.
• Infections at the site of surgery.
• Inadequate soft tissue for coverage of the VEPTR.
• Inadequate strength of bone for attachment of the VEPTR.
• Absence of proximal and distal ribs for attachment of the
VEPTR.
46.3 Technical Prerequisites
46.3.1 Implant
C. Wimmer and U. Vieweg
VEPTR II device: vertical expandable prosthetic titanium rib
II (see Fig.46.1: rib-to-rib, Fig.46.2 rib-to-lumbar spine).
46.3.2 Diagnosis
Required for diagnosis and surgical planning are x-rays of
the entire spinal column, CT and MRT images of the spinal
column, cardiological examination including an electrocardiogram and pulmonary function test.
46.3.3 Intraoperative Set-up
Required instruments are a C-arm, double lumen tube, a neuromonitoring system, a Bülau drain catheter, a sucker device
with thin lead, a bipolar coagulator, special spreader and
compression forceps for the introduction and expansion of
the implant.
46.4 Technique
46.4.1 Patient Positioning
Fig. 46.1 Rib to rib. The VEPRT is attached to a superior rib and to an
inferior rib: (1) Rib hook cap, (2) Closure for extension Bar, (3) Rib
hook, (4) Proximal extension, and (5) Distal extension
Place the patient in a lateral decubitus position similar to that
required for a standard thoracotomy. To protect against brachial plexus injury, do not extend the shoulder more than
90°. If a hybrid construct is being implanted, it is also possible to place the patient in the prone position for better
mobilisation of the intercostal muscles.
46.4.2 Implantation Procedure
• Make a J-shaped thoracotomy incision without disrupting
the periosteum overlying the ribs.
Fig. 46.2 Rib-to-lumbar lamina. The VEPRT is attached to a rib and
the lumbar spine: (1) Rib hook cap, (2) Closure for extension, (3) Rib
hook, (4) Proximal extension, and (5) Distal extension
46 Vertical Expandable Prosthetic Titanium Rib (VEPTR)
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323
• Retract the skin aps. Continue the incision and elevate
the paraspinal muscles medially only to the tips of the
transverse processes. Gently elevate the scapula to expose
the middle and posterior scalene muscle.
46.5 Rib-to-Rib (see Fig. 46.1)
• First insert the cranial implant. Identify the cranial rib that
is to serve as the cranial attachment point. Mark the position and verify by means of radiographic imaging. Note:
Because of the risk of brachial plexus impingement, do not
choose the rst rib as the superior point of attachment.
• Make a 1 cm incision into the intercostal muscles both
above and below the position for the planned attachment
to the cranial rib. Use a periosteal elevator to carefully
elevate the periosteum of the rib next to the lung. Take
care not to damage the soft tissue surrounding the rib so
as to preserve rib vascularity and the neurovascular bundle. Use a trial rib hook to prepare the rib for the rib hook.
Note: In the case of smaller patients, in whom a small rib
hook is to be used employ the small trial rib hook for
preparation.
• Select a rib hook in the size determined by the trial rib
hook. Using the rib hook holder, position the underside of
the rib hook in the space between periosteum and rib and
turn the hook until it sits correctly.
• Select a rib hook cap appropriate to the anatomy of the
patient.
• With the help of holding forceps, insert the rib hook cap
into the intercostal space above the rib, rotate the cap distally until it slots into the rib hook. Ensure hook and cap
are correctly aligned.
• Put a closure for the extension bar into the lock impactor.
To lock the rib hook/rib cap combination together, precisely align the holes of the rib cap and rib hook. Use a
hammer to rmly strike the impactor to x the closure in
place.
• Attach the 2ft. for the rib distractor to the retractor. Using
this assembly, distract the ribs as necessary. Alternatively,
use a bone spreader to carefully distract the chest wall at
the site of the opening wedge thoracostomy.
• If distraction proves difcult, additional resection of
medially fused ribs may be necessary. Only resect visible
bone directly next to the spine.
• Measure the distance between the expandable portion of
the construct to determine the required proximal extension. Note: Measure the expandable portion over the dis-
tracted thorax between the cranial rib and the
thoraco-lumbar attachment point (rib-to-lamina/ilium) or
between cranial and caudal rib (rib-to-rib).
• Cut and contour the rod to the size of the required proximal extension.
• Retain at least 11mm of the straight rod to ensure that this
section of the proximal extension will sit correctly in the
rib hook. Use the measuring instrument to verify that the
rod section is long enough to be seated securely in the rib
hook. Any remaining rod can be cut and/or contoured to
t the anatomy of the patient. Select a distal extension
that corresponds to the size of the proximal extension.
• Use the trial rod to determine the contour of the rod section of the distal extension. Do not bend the T-shaped end
of the distal extension that connects with the proximal
extension. Bend only the rod section of the distal extension using the rod bender. Alternatively, the bending irons
and the rod benders can be used to contour the frontal
section. Cut the rod section to the required length using
the rod cutter. Note: If implanting a rib-to-rib construct,
the rod sections of the proximal and distal extensions
must have a length of at least 11mm to ensure that they
will sit correctly in the rib hook.
• Before introducing the distal extension, insert it in the
proximal extension so that the caudal hole of the proximal
extension is directly above the hole in the furthest caudal
position of the distal extension.
• Using the offset impactor, put a closure for the extension
bar in place in the hole. Gently tap the impactor with a
hammer to seat the closure in place. Ensure the closure is
correctly seated.
46.5.1 Rib-to-lamina or IIium (see Fig. 46.2)
• Make a 4 cm paraspinal incision on the concave side of
the curve of the lumbar interspace selected
preoperatively.
• Use the lamina feeler to separate the ligamentum avum
unilaterally from the underside of the lamina to provide
for good anchorage of the lamina hook on the bone; make
sure the interspinal ligament remains intact. Resect the
ligamentum avum to provide passage for the hook.
Select an appropriate lamina hook.
• Attach the hook pointing downwards with the adjustment
screw in the most lateral position. Use the lamina hook
holding forceps to position the hook in the required site
on the lumbar lamina.
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C. Wimmer and U. Vieweg
• If necessary, the hook can be additionally secured using
heavy, non-absorbable suture thread wrapped around the
posterior spinous process. Make a 4cm longitudinal incision slightly laterally to the posterior superior iliac spine.
Identify the posterior third and middle third of the iliac
crest. Make a 1 cm transverse incision in the mid substance of the apophysis so that there are equal cartilage
layers above and below the incision. Pass the periosteal
elevator through the incision in the apophysis and widen
it to form a tunnel and then pass the elevator along the
medial cortical surface of the iliac crest until the tip of the
elevator is just lateral to the sacroiliac joint. Select an
appropriate ala-hook or S-rod. If using an S-rod, cut the
rod to the appropriate length and contour as necessary.
Use the small hexagonal screwdriver to attach an extension connector or a parallel connector to the ala-hook or
S-rod.
• With the help of the rod holder, position the ala-hook or
S-hook on the iliac crest medial to the wing of the ilium.
Attaching to the lamina hook (rib-to-lumbar lamina)/alahook or S-rod (rib-to-ilium).
• From the proximal incision, create a tunnel through the
paraspinal muscles to just above the caudal attachment
point. Insert the end of the distal extension in the tip of a
no. 20 thoracic catheter and carefully pass this proximal
to distal to the caudal attachment point.
• If attaching to a lamina hook (rib-to-lumbar lamina construct), guide the distal extension into the lamina hook.
• If attaching to an ala-hook or S-hook (rib-to-ilium construct), insert the distal extension into the extension connector or parallel connector. Use the small hexagonal
screwdriver to tighten the screws of the extension connector or parallel connector.
46.7 Complications
Unfortunately, the initial enthusiasm with which this technique of spine-sparing deformity correction was welcomed
has progressively subsided with the increasing number of
reports on complications, including the detection of extraspinal ossications along the implants and across ribs [5]
(Figs.46.3, 46.4, and 46.5).
Fig. 46.3 Frontal radiograph of the spine of a 5-year-old boy with a
progressive neuromuscular scoliosis
46.6 Postoperative Care
Patients with an implanted VEPTR device should not be
braced. Patients may require additional wound protection to
prevent inadvertent rubbing or bumping of the wound.
Fig. 46.4 Frontal radiograph 12 months after initial implantation of a
rib-to lamina construct (VEPTR)
46 Vertical Expandable Prosthetic Titanium Rib (VEPTR)
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325
ab
References
1. Wimmer C, Wallnoefer P, Pfandlsteiner T. Operative treatment of
scolioses with the VEPTR instrumentation. Oper Orthop Traumatol.
2010;22(2):123–36. in German
2. Campbell RM Jr, Smith MD, Mayes TC, etal. The characteristics
of thoracic insufciency syndrome associated with fused ribs and
congenital scoliosis. J Bone Joint Surg A. 2003;85–A(3):399–408.
3. Campbell RM Jr. VEPTR: past experience and the future of VEPTR
principles. Eur Spine J. 2013;22(Suppl 2):106–17.
4. Drebor RS, Katsarov A.Poland syndrome: use of vertical expandable prosthetic titanium rib system before walking age-a case
report. Surg J. 2016;2:e91–5.
5. Studler D, Haßler C. Long term outcome of vertical expandable
prosthetic titanium rib treatment in children with early onset scoliosis. Ann Transl Med. 2020;8(25):1–7.
Fig. 46.5
Part VI
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Posterior Thoracic Spine
Overview ofSurgical Techniques
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andImplants
PauloTadeuMaiaCavali
47
47.1 Introduction and Core Messages
Currently, the instrumentation of thoracic spine is a
rigid construction. There is no dynamic instrumentation system for the thoracic spine, except for early
onset scoliosis, where growing systems can be applied.
This means that achieving an arthrodesis is the goal of
an ideal spine stabilization, and the use of implants
does not substitute the procedure of bone grafting.
Many factors are involved in selecting the type of system (screws, hooks, wires, plates, rods, etc.) and function (tension band, bridge xation, buttressing,
derotation, compression, etc.) to be employed. The
surgeon has to always understand the following factors: surgeon familiarity with techniques, host bone
quality, mechanism of injury, direction of instability,
degree of instability, expected level of patient loading,
graft bone quality, availability of implants, necessity of
postoperative immobilization, and time of tissue healing. Harrington in the 1960s developed the rst generation of spinal instrumentation using a hook-based
distraction, Luque in the 1970s and 1980s developed
the second generation of instrumentation, using a segment xation technique with sublaminar wires, and
Cotrel and Dubousset in the 1980s rst brought up
rigid segmental hook-based xation which gave rise to
all types of implants using screws and hooks with
enormous biomechanical versatility [1]. The objectives of this chapter are to discuss the different implants
and different techniques for the treatment of scoliosis,
kyphosis, and fracture.
47.2 Implants
The implants employed in the posterior thoracic spine constructs are wires, hooks, and pedicle screw systems from different companies (see Fig.47.1a, b).
47.2.1 Wiring Systems
Although the sublaminar wiring techniques are no longer
common in the thoracic spine, a number of wire-rod techniques continue to be routinely employed. The Luque
technique is the most common and employs sublaminar
wires in each vertebra as additional anchors. These wires
are then wrapped around rods of nonrigid segmental spine
constructs. Indications commonly include the neuromuscular scoliosis (see Fig. 47.2a, b), scoliosis including a
thoracic lordosis and some cases of osteoporotic spine,
where they are used as a hybrid construct with pedicle
screw. Wiring techniques do not provide axial stability,
and they are a poor choice for stabilization of pathologic
processes including anterior column insufciency such as
tumors and fractures. Another limitation of these techniques is the lacking rotation correction of scoliosis. In
addition, these methods have a high risk of iatrogenic neurologic injury with the sublaminar wires passage being in
the spinal canal and moving there during the xation and
reduction maneuvers. The contraindications to wiring system are patients with kyphosis or canal stenosis and those
related to biomechanic insufciencies.
P. T. M. Cavali (*)
Department of Scoliosis os Hospital AACD-Sao Paulo,
Sao Paulo, Brazil
e-mail: paulo.escolioseaacd@uol.com.br
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_47
47.2.2 Hooks
There are a variety of hooks with different characteristics.
Basically, three types of hooks can be used: pedicle hooks,
laminar hooks, and transverse process hooks (see
Fig. 47.3). Pedicle hooks, resting on the lamina of the
instrumented vertebrae and the superior articular process
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P. T. M. Cavali
Fig. 47.1 (a) Sublaminar
wires. The Luque
instrumentation. (b) Types of
pedicles screws and hooks.
Implants of S4 System by
Aesculap
a
b
of next distal vertebrae, are the strongest hooks. They are
always directed cephalad so that their “u” shaped tip
embraces the pedicle and provides maximal stability concerning rotation and translation maneuvers. These implants
can be placed from T1 to T10. Some of these hooks have
additional features such as the possibility of being locked
to the pedicle. Laminar hooks are available in a variety of
designs. Variations in the blade width and style allow for
an optimized hook–bone interface. These hooks may be
placed in supralaminar or infralaminar positions dependent upon the required distraction or compression forces.
Transverse process hooks have less risk of iatrogenic cord
injury because they are out of the spinal canal. Usually,
these implants are combined with a pedicle hook or a pedicle screw. This claw is the strongest hook construct, and it
is very helpful in hyperkyphosis correction and can be
added to transpedicular constructs to protect the screws
from pullout.
ab
47 Overview ofSurgical Techniques andImplants
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331
Fig. 47.2 (a) Preoperative image of neuromuscular scoliosis. (b) Surgical treatment of neuromuscular scoliosis with sublaminar wires
technique
Fig. 47.3 Three types of hooks: pedicle, transverse process, and laminar hooks. Implants of S4 System by Aesculap
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