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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_583_Библиотеки_им_академика_М_И_Перельмана
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Fig. 44.5 (a) Skin incision for lumbar approach. (b) Exposure of spine in extra peritoneal approach
C. Wimmer
Fig. 44.6 Preparation of disc space
Fig. 44.7 Opening of cortex with a short sharp awl, followed by a long
ing the discectomies, and it becomes more exible and more
easily correctable. Sometimes more exibility is needed to
blunt awl, which is pushed through the contralateral cortex. Penetrating
awl can be felt with the index nger
make osteotomy of the rib cabs in thoracic spine.
Anatomy dictates whether you can use a single or double
44.5.1.5 Anterior Instrumentation
After exposure of the spine and removal of the disc, insert
monoaxial bone screw (Expedium DePuy Synthes) into each
vertebral body. The Expedium screws are available in 5mm
and 6mm diameter. If possible, use a larger screw due to better pull-out strength.
rod construct. Instrument the apical vertebra rst. Insert a
staple and use an awl to create a hole in the side of the verte-
bral body through the hole of the staple. Direct the hole paral-
lel to the endplates and slightly in a posterior to anterior
direction (Fig.44.7). Impact the awl in the hole. This is the
starting hole of the vertebral body screw. It is not necessary to
44 Anterior Correction ofScoliosis
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Fig. 44.8 Insertion of bone screw parallel to endplate and in slightly
posterior anterior direction
drill or tap a vertebral body. The screws are self-tapping. With
the slotted screwdriver, insert a bone screw of appropriate
length through the staple. Direct the screw parallel to the endplate and to a point on the vertebral body on the other side
palpable by the ngertip. Use a ngertip to guide the screw
through the vertebral body. The screw should pass completely
through the opposite cortex, and the nger should be able to
feel one or two threads on the opposite cortex (Fig.44.8). The
screw length is based on the accurate measurement of the
width of the vertebral body with a depth gauge. The screws
should be placed in a relatively straight line, cephalad to caudal. Cut your rod to the length and contour it to maintain normal lumbar lordosis or thoracic kyphosis. Place the rod into
the head of the screws on the caudal end of your instrumentation. Then seat it successively in each more proximal screw
(Fig.44.9). Tighten the insert screw enough to hold the rod in
place but still allow rotation of the rod. Rotate the rod 90°;
after rotation, the disc space opens up. Now place bone graft
from the rib or from the bone bank in the anterior aspect of
the disc space [14, 17–21]. This helps to prevent any kyphosing effect of the instrumentation. Fill the remainder of the
disc space with smaller pieces of bone graft.
Obtain further correction of the curve by compressing
towards the apical screw. This also helps to lock the bone
graft into place. First, tighten the apical screw and then use a
compressing device to compress the screws towards the apex
Fig. 44.9 Principles of the anterior correction with compression in a
lumbar scoliosis
Fig. 44.10 Compression device in a segmental correction of the spine
both proximally and distally (Fig.44.10). Tighten the insert
screws completely to prevent any further rotation. Place
remaining bone strips into the disc interspaces and along the
area of the periosteal stripping (Figs.44.11, 44.12a–d, and
44.13a, b).
Suture the pleura over the upper end of the rod. Insert a
chest tube in case the thoracic cavity has been entered. Close
the chest wall muscle layers in a routine manner.
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Fig. 44.11 Intraoperative view of corrected deformity with a double-
rod construction of thoracolumbar scoliosis
ab
C. Wimmer
44.6 After Treatment
The chest tube usually is left in place for 48–72 h. It is
removed when the drainage decreases to less than 50ml for
two consecutive 8h periods. The patient is to be kept on bed
rest until the chest tube is removed. Afterwards the patient is
allowed to stand up without brace given that the bone quality
is good and the bone screw has a high t, if not a TLSO
should be used for three up to six months.
A Foley catheter is necessary to monitor urine output
because urinary retention is common. An ileus is expected
after anterior surgery which usually lasts 2 or 3days.
Fig. 44.12 (a) Preoperative x-ray in ap view of lumbar curve of 47° in
an 18-year-old patient. (b) Preoperative x-ray in lateral view in an
18-year-old patient. (c) Postoperative x-ray in ap view of a lumbar
curve after correction of 10° in an 18-year-old patient. (d) Postoperative
x-ray in lateral view in an 18-year-old patient
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a b
Fig. 44.13 (a) Preoperative x-ray in ap view of a thoracolumbar curve
of 49° in a 15-year-old patient. (b) Postoperative x-ray in ap view of a
thoracolumbar curve of 3° in a 15-year-old patient
References
1. Dwyer AF, Newton NC, Sherwood AA. An anterior approach
to scoliosis. A preliminary report. Clin Orthop Relat Res.
1996;62:192–202.
2. Zielke K.Ventral derotation spondylodesis. Results of treatment of
cases of idiopathic lumbar scoliosis (author’s translation). Z Orthop
Ihre Grenzgeb. 1982;120(3):320–9.
3. Bullmann V, Halm HF, Niemeyer T.Dual-rod correction and instrumentation of idiopathic scoliosis with the Halm-Zielke instrumentation. Spine. 2003;28:1306–13.
4. Burton DC, Asher MA, Lai SM.Patient-based outcomes analysis of
patients with single torsion thoracolumbar-lumbar scoliosis treated
with anterior or posterior instrumentation: an average 5- to 9-year
follow-up study. Spine. 2002;7:2363–7.
5. Halm H, Liljenqvist U, Niemeyer T.Halm-Zielke instrumentation
(Münster anterior double rod system) as an improvement over Zielke- VDS. Surgical method and preliminary results. Z Orthop Ihre
Grenzgeb. 1997;135:403–11. In German
6. Halm HF, Liljenqvist U, Niemeyer T. Halm-Zielke instrumentation for primary stable anterior scoliosis surgery: operative technique and 2-year results in ten consecutive adolescent idiopathic
scoliosis patients within a prospective clinical trial. Eur Spine J.
1998;7:429–34.
7. Hopf CG, Eysel P, Dubousset J. Operative treatment of scoliosis
with Cotrel-Dubousset-Hopf instrumentation. New anterior spinal
device. Spine. 1997;22:618–27.
8. Kaneda K, Shono Y, Satoh S.New anterior instrumentation for the
man-agement of thoracolumbar and lumbar scoliosis. Application
of the Kaneda two-rod system. Spine. 1996;21:1250–61.
9. Kaneda K, Shono Y, Satoh S.Anterior correction of thoracic scoliosis with Kaneda anterior spinal system. A preliminary report. Spine.
1997;22:1358–68.
10. Lenke LG, Betz RR, Haher TR.Multisurgeon assessment of surgical decision-making in adolescent idiopathic scoliosis: curve
classication, operative approach, and fusion levels. Spine.
2001;26:2347–53.
11. Lenke LG, Betz RR, Harms J. Adolescent idiopathic scoliosis: a
new classi-cation to determine extent of spinal arthrodesis. J Bone
Joint Surg Am. 2001;83:1169–81.
12. Richter A, Quante M, Macherei A, Halm H. Die modizierte
primärstabile ventral Derotationsspondylodese mit dem Halm
Zielke Instrumentarium (HZI) zur Behandlung der idiopathischen
Skoliose. OOT. 2010;2:164–76.
13. Canale ST.Campbell `s operative orthopaedics; 2003. p.1818–25.
14. Saraph VJ, Krismer M, Wimmer C.Operative treatment of scoliosis
with Kaneda anterior spine system. Spine. 2005;30:1616–20.
15. Turi M, Johnston CE, Richards BS.Anterior correction of idiopathic
scoliosis using TSRH instrumentation. Spine. 1993;18:417–22.
16. Vavruch L, Brink RC, Malmqvist M, etal. H surgical outcomes of
anterior versus posterior fusion in Lenke type 1 adolescent idiopathic scoliosis. Spine. 2019;2019:14.
17. Rajpal S, Resnick DK. Rod cantilever techniques. Neurosurgery.
2008;63:157–62.
18. Betz RR, Harms J, Clements DH III.Comparison of anterior and
posterior instrumentation for correction of adolescent thoracic idiopathic scoliosis. Spine. 1999;24:225–39.
19. Cotrel Y, Dubousset J, Guillaumat M.New universal instrumentation in spinal surgery. Clin Orthop Relat Res. 1988;227:10–23.
20. Giehl JP, Zielke K, Hack HP.Die ventrale Derotationsspondylodese
nach Zielke. Orthopedic. 1989;18:101–17.
21. Kim YJ, Lenke LG, Bridwell KH. Prospective pulmonary function compari-son of anterior spinal fusion in adolescent idiopathic
scoliosis: thoracotomy versus thoracoabdominal approach. Spine.
2008;33:1055–60.
Dynamic Scoliosis Correction:
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AMotion- Preserving Surgical Technique
forScoliosis
PerTrobisch
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45.1 Introduction and Core Messages
The standard treatment for idiopathic scoliosis exceeding more than 40° at skeletal maturity is spinal fusion.
However, motion-preserving surgical techniques are
emerging. A decade ago, Randy Betz and colleagues
published a series of papers sharing their experience
with Vertebral Body Stapling (VBS) [1–3]. Although,
short-term results were very promising, only few
selected patients were considered good candidates.
These were skeletally very immature patients with
Risser stage 2 or less, as well as patients with moderate
curves that do not exceed 35° in the thoracic spine or
40° in the lumbar spine [3, 4]. Implant strength was
considered being responsible for failures, and in 2011,
Nitinol staples that were used for VBS were replaced
with stronger implants—a specic anterior screw-cord
construct (Fig.45.1). In accordance to VBS, the new
technique has been popularized as Vertebral Body
Tethering (VBT) [4, 5]. Since 2011, approximately
2.000 patients have received this surgical treatment
worldwide. While the indication window was kept
very narrow in the rst few years, it is not continuously
widening. Today, even more rigid and severe curves
that exceed 60° and do not bend down to less than 30°
or patients that are closer to skeletal maturity (Risser 3
and 4) can be operated. In some cases, disk releases
may be required to facilitate curve correction. Disk
releases can be considered as de-tethering technique.
Therefore, some surgeons in the United States prefer
the term Anterior Scoliosis Correction (ASC) over
P. Trobisch (*)
Eifelklinik St. Brigida, Department of Spine Surgery,
Simmerath, Germany
e-mail: per.trobisch@artemed.de
VBT. In Germany, anterior scoliosis correction can
easily be confused with the very popular Ventral
Derotation Spondylodesis. Therefore, we have used
the term Dynamic Scoliosis Correction (DSC) in
Germany since its introduction. Motion-preserving
surgery mainly uses two ways for curve correction following the Hueter–Volkmann principle—growth modulation and osseous remodeling. Growth plates that are
compressed decrease growth, whereas distracted
growth plates accelerate growth [4]. DSC therefore
reverses the effect that scoliosis has on the natural
history.
45.2 Indication
VBT is a growth modifying technique; therefore, it should be
performed before skeletal maturity. The ideal candidate still
has to be dened. In the early phases, VBT was mainly indicated for patients with signicant remaining growth. Some
surgeons recommended VBT only for patients with open triradiate cartilage. Patients with curve magnitudes between
40° and 60° who had good exibility were considered to be
most suitable. Additionally, structural lumbar curves represented a contraindication because of the unknown effect that
VBT may have had on the sagittal prole, potentially reducing lumbar lordosis [4]. However, with increasing experience, as well as improved surgical techniques, including the
introduction of disk releases and derotation techniques, surgeons are now widening their indication criteria and also
changed the term VBT to ASC (in the US) or DSC (in
Germany). Nowadays, even double major curves, as well as
rigid curves and curves with more than 60° are still being
indicated for surgery (Fig.45.2). If the severity of a curve
allows to be monitored, we recommend DSC at Risser stage
2 or 3 as long as the curve has not exceeded 60°. In these
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_45
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P. Trobisch
Fig. 45.1 Model of a thoracic spine that is “tethered” with an anterior screw-cord combination. Left: neutral position, Middle: exed position,
Right: right-bent position
cases, overcorrection can be eliminated as potential compli-
45.3 Surgical Technique
cation, disk releases are usually not yet required and correction of scoliosis to less than 30° at skeletal maturity is very
45.3.1 Set-up andPositioning
likely. We also recommend DSC for lumbar curves (Lenke
type 5) that exceed 40° or secondary curves that can be classied as Lenke lumbar-C modier. In our opinion, these
patients benet even more from non-fusion surgery to prevent spinal fusion ending in the lumbar spine. With the compressive force being lateral, we have not seen a kyphosing
effect in our patients (Fig.45.3).
So far, we have not faced any absolute contraindications
for DSC except maybe signicant pulmonary restrictions.
Double-lumen intubation as well as intraoperative electrophysiologic neuromonitoring is recommended. Patients are
positioned in a strict lateral position with the convex side
facing up. We use soft bolsters under the axilla and the pelvis. The patient is xed to table with tapes. Pre-operative
X-rays are supposed to conrm correct lateral positioning
and to provide an estimation of curve correction that is
achieved with positioning.
While patients with left-sided thoracic curves and right-sided
lumbar curves have been considered as being contraindicated during our early phase, we have now found that surgi-
45.3.2 Approach
cal treatment is not much more complicated as the aorta
usually falls anterior and the liver can be manually retracted
(Fig. 45.4). At this point, we do not recommend DSC for
congenital or neuromuscular scoliosis but consider these
patients as potential candidates in the future.
We prefer a mini-open approach to the spine. Thoracic curves
often require instrumentation from T5 to T12. For these
cases, we use one 5cm long mini-open approach above T11
and another one above T7. Usually three vertebrae can be
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Fig. 45.2 Pre- and
postoperative radiograph after
single-stage double-sided
DSC for a double major curve
in a 13-year-old girl with
Risser stage 0
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instrumented through one approach (e.g. T6-T12).
Additionally, we use one to three thoracoscopic portals to
improve visualization and retraction of the lung and the diaphragm, as well as instrumentation of T5 (Fig.45.5). Lumbar
curves often required instrumentation from T10 to L3. For
these cases, we recommend a mini-open retroperitoneal
approach for instrumentation of L2 to L3 (L4 when required).
The psoas is temporarily retracted posterior. Transpsoas
instrumentation is not recommended. Instrumentation of L1
and higher is performed through a mini-open intercostal
approach, usually above T11 or T12. A diaphragm split will
help with instrumentation of L1.
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Fig. 45.3 Lateral radiograph
pre- and 1year postoperatively of a 13-year-old
patient (Risser 3) with DSC
from T10 to L3.
Instrumentation into the
lumbar spine has not shown to
have a kyphosing effect
P. Trobisch
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Fig. 45.4 Pre- and
postoperative radiograph of a
12-year-old girl (Risser 0)
after left-sided DSC from T7
to L1
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P. Trobisch
Fig. 45.5 Left: 6months after instrumentation from T6 to L2 using three mini-open incisions of 5cm length each plus one thoracoscopic portal;
right: 6weeks after instrumentation from T5 to T12 using two mini-open incisions plus two thoracoscopic portals
45.3.3 Instrumentation
ligament to the pedicle. The window is supposed to close
after segmental compression. The cord is cut with a knife or
A staple is required to decrease proximal screw windshield-
a cord-cutter approximately 1cm caudal of the lowest screw.
ing. The screw canal is prepared with a probe under uoroscopic guidance. Markers on the probe will dene screw
lengths. Meticulous screw length measurement is required in
45.3.4 Instrumented Levels
the mid thoracic spine due to the vicinity of the thoracic
Aorta on the left that is not visualized during right-sided surgery. However, bicortical screw purchase is required
(Fig. 45.6). Screw entry point is the center of a vertebral
body except for apical levels where the entry point is more
posterior with the screw aiming anterior. The cord is locked
into the screw from cranial to caudal with segmental compression and derotation of the apical levels. The goal is to
have a level disk between each screw. For very rigid curves,
one or more disk releases may be required. A small window
is cut into the lateral annulus from the anterior longitudinal
The upper instrumented vertebra (UIV) equals the upper end
vertebrae—usually T5 or T6 for thoracic curves and T10 or
T11 for lumbar curves. The lower instrumented vertebra
(LIV) equals the touching vertebra—the vertebra that is just
touching the central sacral vertical line. LIV for thoracic
curves usually is at T11 or T12 but can be as low as L2in
patients with severe trunk shift. LIV for lumbar curves usu-
ally is L3 and sometimes L4. For patients with bilateral
curves that need to be instrumented, double-sided instrumen-
tation of the transitional level is required (Fig.45.2).
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