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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6020_Библиотеки_им_академика_М_И_Перельмана.pdf
10 Hemivertebra Osteotomy
Fig. 10.43 Resect the central part of vertebral body with a shovel
osteotome
147
Fig. 10.45 Rapid reduction of the posterior margin of the vertebral
body with a push-down knife
Fig. 10.44 The posterior margin of the vertebral body was preserved
temporarily
10.4.8 Conclusion
Early preventive osteotomy for congenital hemivertebrae
prevents the progression of spinal curvature. The treatment
will be more difcult upon progression. Extra-pedicle screw
and wiring simplies the operation process and improves the
biomechanical effect of scoliosis correction.
10.5 Posterior Hemivertebral Osteotomy
The formation of the congenital posterior hemivertebrae may
be related to the forward extension of the bilateral pedicle
ossication centers which fuse with the posterior part of the
vertebral ossication center and related to the developmental
disorder of the ossication center of the vertebral anterior
part. The spinal deformity caused by the congenital posterior
hemivertebral body is angular kyphosis, which should be distinguished from spinal tuberculosis in X-ray diagnosis. There
is no paravertebral abscess on coronal X-ray, and there is no
narrowing of the intervertebral space on the lateral view, no
vertebral bone destruction and the presence of dead bone, and
its angular kyphosis are generally less than 90° Cobb angle.
On the lateral view, the posterior hemivertebrae usually looks
round, and the anterior edge of the upper and lower vertebrae
is often present sh-mouth signs (Fig. 10.50). The type of
surgery that treats congenital posterior hemivertebral deformity is to retain the upper and lower bilateral endplate, and
resect through the waist of the vertebra or whole hemivertebra. With additional internal xation, the result is usually satisfying. As the kyphosis angle caused by congenital posterior
hemivertebrae is smaller than that caused by tuberculous
kyphosis, there are fewer adhesions in the epidural space, and
the bleeding during operation is relatively limited. Thus, the
posterior hemivertebra is the absolute indication for vertebral
column resection through the posterior route.
10.5.1 How thePosterior Hemivertebra
Is Formed
Clinically, the congenital posterior hemivertebrae is less
common than the congenital lateral hemivertebrae. According
to the author, the formation of the posterior hemivertebrae
may be associated with embryonic development. Each vertebra consists of three primary ossication centers: primary
148
ab
Fig. 10.46 Palpate the presence of bone fragments in the osteotomy space. (a) Palpitation for bone fragments in the osteotomy gap. (b) Check
bone fragments with palpitation instead of visual inspection
H. Tian et al.
a b
Fig. 10.47 Extra-pedicle screw with wiring. (a) After osteotomy, (b) after compression with wiring
10 Hemivertebra Osteotomy
149
a
b
Fig. 10.48 Extra-pedicle screw with titanium cable xation. (a) Titanium cable applied. (b) Titanium cable tensioned
vertebral body ossication center; left and right primary vertebral arch and pedicle ossication center. When the posterior part of the vertebral body ossication center develops
vigorously with the vertebral arch and the pedicle ossication center, the two form one body. While the anterior part of
(Fig.10.51a–c), and whether there are symptoms and signs
of spinal cord compression. If necessary, spinal angiography,
MRI examination, and CT examination should be performed
to illustrate the relationship between kyphosis and spinal
canal.
the vertebral body ossication center develops with dysplasia or absence, the posterior hemivertebra and an extra vertebral arch form. With the development of posterior
10.5.3 Osteotomy andInstrumentation
hemivertebrae and an extra vertebral arch, angled kyphotic
deformity will be aggravated year by year. By the age of
15–18, kyphosis of 60–90 Cobb degree is often seen.
It is the most effective technique to remove the extra verte-
bral arch and posterior hemivertebrae with a thin-blade sharp
osteotome. As the vertebral arch and vertebral body of chil-
dren are mostly composed of cartilage tissue and bone tissue,
10.5.2 Examination Method
its texture is similar to hard rubber. It is very suitable for
cutting with a thin-blade osteotome. Tian’s set of osteotome
Anterioposterior and lateral X-ray lm of the spine is performed to determine the segment of the posterior hemivertebral deformity and the extent of angular scoliosis
is used to remove the pedicle and posterior half of the verte-
brae, which can easily solve the problems. Total posterior
hemivertebral resection or subtotal excision can be per-
150
Fig. 10.49 Preventive hemivertebra osteotomy with extra-pedicle screw and wiring xation. (a) Scope of hemivertebra osteotomy; (b) For
younger patients, after hemivertebra osteotomy, compression wiring xation is adequate to correct the deformity, ideally over-correction by 5–10°
H. Tian et al.
formed according to the angle dimension that needs to be
corrected. After the removal of the vertebral arch and the
posterior hemivertebrae, the osteotomy gap needs to be
closed by the method that uses the pedicle screws which are
inserted into the upper and below pedicles and compressed
with rods. When the gap is closed, the epidural tube is shortened and expanded to compress the epidural venous plexus.
Bleeding from epidural venous plexus will stop. For younger
patients, in order not to avoid restricting growth and development, proximal compression can be used to close the osteotomy gap, and using a growth rod to maintain straightness
of the spine can make the growth of the spine unrestricted.
This method can also replace the surgical method of internal
xation of the posterior screw–rod system.
To children younger than 8 years old with light kyphosis
deformity, we can use pedicle screws and wire to compress
and xate the vertebra without opening the distal end after
posterior hemivertebral excision (Fig.10.52a, b), and use a
plaster vest to immobilize the patient postoperatively. To the
children over 8 years old with obvious kyphosis deformity,
we should distract the distal end and compress near the end
to xate the vertebra after posterior hemivertebral resection
(Fig. 10.53a, b), and use a plaster vest to immobilize
postoperatively.
10.5.4 Surgical Procedure
1. Preoperative instrument preparation (Fig. 10.54):
Measure the osteotomy angle and the kyphosis correction
that you want to reach on the lm, and prepare surgical
instruments for osteotomy and internal xation type and
internal instruments.
2. Anesthesia: Endotracheal intubation general anesthesia
3. Body Position: The patient takes the prone position, lying
on the Hall–Relton frame, make the abdomen unsupported to reduce abdominal pressure and venous bleeding. The upper arm and elbow should be carefully padded
and the shoulder abduction should not exceed 90°. The
upper two points of the 4 point bracket hold the chest, not
the armpit. The lower two points should support the anterior superior iliac spines, do not hold in the abdomen
4. Operation procedure:
Step 1: Patient takes prone position. After disinfecting
and draping, the incisions are made in the midline along
the spinous processes, exposing the bilateral lamina,
articular processes, and transverse processes. Identify the
bilateral transverse processes of posterior hemivertebrae.
And remove the transverse process. Perform subperiosteum elevation along the lateral edge of pedicles to the
10 Hemivertebra Osteotomy
ab
151
Fig. 10.50 Differential diagnosis for congenital posterior hemivertebra and TB angular kyphosis: (a) Congenital posterior hemivertebra
deformity, roundish hemivertebra, protruding to the posterior, shmouth relation between the upper and lower vertebra. No bony fusion
hemivertebra and anterior-lateral edge of vertebral bodies
up and down. Insert lever retractor bilaterally to expose
the vertebral body (Fig.10.55).
Step 2: Remove the entire lamina of the hemivertebrae
with an osteotome or rongeurs. And expose the dorsal
side of the bilateral pedicle, epidural tube, and spinal
roots (Fig.10.56a, b).
Step 3: To identify the upper and lower edges of the
hemivertebra from its bilateral sides. Using an osteotome
to mark a scope of osteotomy, that is, a wedge with its
base toward the posterior. Its wedge tip reaches the anterior longitudinal ligament, its base reaches the posterior
longitudinal ligament, and its bilateral wedge-shaped
osteotomy lines align with each other (Fig.10.57).
in the disc space. The kyphotic angle is less than 90°. (b) The angle of
TB angular kyphosis is usually more than 90°, with 3–4 vertebra
involved in the apex. Interbody bony fusion commonly exists
Step 4: Resect layer by layer with an osteotome from
the lateral edge of the pedicle and vertebrae, to the medial
edge of the pedicle, and after excision of the medial edge
of the pedicle, expose the lateral of epidural tube
(Fig.10.58).
Step 5: Before the vertebrae is fully resected, the pedicle screws are placed in the upper and lower pedicle rst
to avoid spinal cord injury caused by instability after vertebral body truncation (Fig.10.59).
Step 6: Before resecting the posterior edge of the vertebrae, use a wire or rod for temporary xation to prevent
spinal cord injury caused by instability (Fig. 10.60).
Excision of the posterior edge of the hemivertebrae
requires a posterior longitudinal ligament elevator, push
152
a
b
c
ab
ab
H. Tian et al.
Fig. 10.51 Congenital posterior hemivertebra: (a) Male, 1-year-old, congenital posterior hemivertebra, kyphotic angle 36°, no treatment. (b)
Same patient, 7-year-old kyphotic angle 97°. (c) Appearance of 7-year-old
Fig. 10.52 (a) Congenital posterior hemivertebra, round shape, sh-
mouth sign of anterior vertebral bodies up and down. (b) After posterior
hemivertebra resection for children below 8, deformity is corrected
with compression only
Fig. 10.53 (a) Congenital posterior hemivertebra, Cobb angle 60–90°.
(b) After posterior hemivertebra resection for children above 8, distal
distraction and proximal compression is preferred
10 Hemivertebra Osteotomy
153
Fig. 10.54 A set of Tian’s osteotomes with various angles
154
H. Tian et al.
the posterior longitudinal ligament and epidural venous
plexus, then push the thin layer bone at the posterior edge
of the vertebral body with a push-down osteotome. The
fragments are removed with medullary forceps
(Fig.10.61a, b). Until after bilateral osteotomy is completed, the ngers can touch each other in the front of the
epidural tube and palpate for the presence of any residual
bone fragments within the osteotomy space (Fig.10.62).
Step 7: After complete excision of the pedicle and posterior hemivertebrae, then perform reduction and internal
xation (Fig.10.63a, b). The bleeding can be controlled
due to the epidural tube is shorten and expansion so that
compress the epidural venous plexus.
5. Postoperative management:
Younger patients without cranial pelvic ring traction lie on
atbed after returning to the ward and the negative pressure
drainage tube is removed after 24–48 h. Plaster-of- Paris
jacket external xation should be used for 6–10 months
Fig. 10.55 Bilateral exposure of posterior hemivertebra
after taking out the suture (Fig.10.64a, b), and come to the
hospital regularly for re-examination of X-ray lms.
10.5.5 Key Points forPrevention
ofComplications
1. Clarify the diagnosis that whether congenital posterior
hemivertebrae or tuberculous kyphosis before the operation. Because the congenital posterior hemivertebrae is
the absolute indication of this operation, its operation is
not difcult. And it is more difcult to perform total spinal osteotomy with tuberculous angular posterior convexity. If not prepared enough, to treat tuberculous kyphosis
as a congenital posterior hemivertebrae is likely to
encounter difculties.
2. You should be careful to determine the hemivertebrae
lamina during the operation, and must not recognize the
wrong one. Only resect one hemivertebrae lamina is sufcient. If necessary, you can determine the position of the
hemivertebra with C-arm.
3. The posterior edge of the vertebral body should be
retained when excising vertebra, so as not to cause difculty in operation by the turbulent bleeding of the epidural venous plexus.
4. When the adhesion between the posterior edge of the ver-
tebral body and the dural sac is too close, it can be treated
with the method of thin bone fragment oating, but there
is no difculty in congenital patients.
5. Protective measures for temporary internal xation of
pedicle screws and wire or rod should be done rst before
vertebral column resection is done to prevent the instability of the spine.
ab
Fig. 10.56 (a) Posterior view, arch is removed. (b) Axial view, arch is removed
10 Hemivertebra Osteotomy
Fig. 10.57 Scope of wedge osteotomy
155
Fig. 10.60 Temporary rod inserted and ready to remove the posterior
bone sheet
10.6 Posterolateral Hemivertebral Osteotomy
The operation procedures of congenital posterolateral hemivertebral osteotomy and congenital lateral hemivertebral
osteotomy are similar. It is also through the posterior
approach, dissecting and exposing from one side to the anterior. Wedge osteotomy is performed on the posterolateral
vertebra, and the tip of the wedge osteotomy should reach
the contralateral side of the vertebra; otherwise, it will bring
difculties to close the osteotomy gap and correct deformity
if hemivertebra is the only structure to be resected. As the
base of the wedge gap faces on the posterolateral side of the
spine, so it is suitable to use unilateral pedicle screws for
internal xation (Fig.10.65a–e). This is different with paralateral hemivertebra about the method that using extra-pedicle screws for internal xation. The rest of the procedure is
close to lateral hemivertebra osteotomy.
Fig. 10.58 Resect the arch by layers with straight osteotome, resect
the pedicle and vertebral body until the lateral edge of the dural sac
Fig. 10.59 Pedicle screws inserted before truncating the spine
10.6.1 Surgical Procedure
1. Preoperative preparation: Preoperative imaging to locate
the anatomical position of the hemivertebra, whether the
wedge base of the hemivertebra is toward the posterolateral side, and analysis of the direction of the osteotomy.
Determine xation techniques such as pedicle screw or
extra-pedicle screw. As the operation is a preventive operation, the family should be interviewed in detail to obtain
the consent and signature of the family.
2. Anesthesia: According to the cooperativeness of the kid,
choose the appropriate anesthesia such as endotracheal
intubation general anesthesia or local inltration
anesthesia.
3. Position: Prone position is general used.
4. Operation procedure:
156
ab
a
Fig. 10.61 (a) Push down the posterior bone sheet with push-down osteotome. (b) Remove bone debris with forceps
H. Tian et al.
b
Fig. 10.62 Explore the osteotomy gap with ngers for any residue
bone debris
Fig. 10.63 Internal xation. (a) The method of internal xation with a
screw–rod system. (b) Internal xation with proximal compression and
distal distraction
Step 1: After disinfecting and draping, make a longitudinal incision along spinous processes to expose the bilateral lamina and transverse process. Release contralateral
soft tissue rst, and then expose the lamina, articular processes, and transverse processes of one side of the hemivertebrae. (Please refer to the operation procedure of
lateral hemivertebral osteotomy.)
Step 2: (Please refer to the operation procedure of lat-
eral hemivertebral osteotomy.)
Step 3: (Please refer to the operation procedure of lat-
eral hemivertebral osteotomy.)
Step 4: (Please refer to the operation procedure of lat-
eral hemivertebral osteotomy.)
Step 5: (Please refer to the operation procedure of lat-
eral hemivertebral osteotomy.)
Step 6: (Please refer to the operation procedure of lat-
eral hemivertebral osteotomy.)
Step 7: Unilateral pedicle screws and wire xation (see
Fig.10.65).
5. Postoperative management: Same as the postoperation
procedure of lateral hemivertebral osteotomy.