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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6030_Библиотеки_им_академика_М_И_Перельмана.pdf
Rib excision
thoracotomy
C7
T1
Skin
incision
T5
Reflect
parietal
pleura
Ligated
segmental
vessels
T12
Figure 35–1
Rib excision thoracotomy through the second rib rostral to the apical
vertebra of the curve. Spine exposed, preserving osteoperiosteal flap.
Rib 5
T6
T7
T5
T8
Eo.
Pleura
Cut edge
of pleura
Maintain
posterior
third of
vertebral body
and far side
annulus
Step
2
Figure 35–2
Apical four to six vertebrae subtotal resection removing convex cortices,
cancellous bone, and intervening discs. Concave and posterior cortical
bone preserved.
1
Step
1
Keep
post one
third
Far side
annulus
Lung
Aorta
■
170
Esophagus
SECTION II THE THORACIC SPINE
Eurostile
Bone graft
Rib 5
Surgicel
Periosteum
Figure 35–3
Resected bed grafted with morselized resected portion of vertebrae and rib cut
into long slats.
Strut
Bone
chips
Periosteum
Lung
4
4
Surgicel
Figure 35–4
Grafted portion of spine covered with osteoperiosteal flap and Surgicel.
Figure 35–5
Second staged posterior segmental spinal instrumentation and fusion.
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35 THE ACCORDION PROCEDURE FOR RIGID THORACIC SCOLIOSIS
171
5
■
Figure 35–6
Preoperative photograph of a patient treated with the accordion procedure.
Figure 35–7
Postoperative photograph of a patient treated with the accordion procedure.
Figure 35–8
Preoperative x-ray of a patient treated with the accordion procedure.
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172
SECTION II THE THORACIC SPINE
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Figure 35–9
Two-year-postoperative x-rays of a patient treated with the accordion procedure.
36
Correction of Neuromuscular Pelvic Obliquity
The Domino Technique
Baron S. Lonner
Goals of Surgical Treatment
To balance, correct, and stabilize the spine and pelvis.
Diagnosis
Neuromuscular pelvic obliquity is defined as a tilt of the pelvis in the frontal plane usually as a result of severe scoliosis and/or asymmetric hip deformity, contractures, or dislocations in patients with neuromuscular disorders such as cerebral palsy or myelomeningocele (Fig. 36–1). The diagnosis is made by physical examination (waistline asymmetry, elevation of
one iliac crest, scoliosis, kyphosis) and seated, upright anteroposterior
(AP) and lateral radiographs of the spine and pelvis.
Indications for Surgery
1. Progressive pelvic obliquity
2. Pelvic obliquity associated with large, progressive scoliosis
3. Pelvic obliquity resulting in recurrent decubitus ulcers
Contraindications
1. Limited life expectancy
2. Unhealed decubitus ulcers and marginal soft tissue coverage (myelomeningocele patients)
3. Concurrent infection (e.g., pneumonia, urinary tract infection)
4. Limited mentation and interaction with caregivers (controversial)
Advantages
1. More powerful corrective forces
2. Ease of deformity correction
Disadvantage
Relative weak spot of the construct at the domino junctions.
Procedure
Fusion Levels
Neuromuscular deformity dictates that the fusion be long including the
high thoracic spine (T1 or T2) and extending down to the sacropelvic axis.
A modification of the Galveston technique into the pelvis is utilized. Ante-
rior release and fusion may be indicated for large, rigid curves (쏜 70
degrees) and for myelodysplastic patients with insufficient posterior bone
stock. Allograft bone is the preferred fusion material in these patients in
whom preservation of the ilium for fixation is essential.
Incision
A standard midline posterior incision is made from the high thoracic spine
to the sacrum. The distal extent of the incision must be sufficient to allow
for lateral exposure of the posterior superior iliac spine (PSIS) of the ilium.
In patients with myelodysplasia, the lumbar incision may need to be made
in a curvilinear fashion depending on the location and status of local
musculocutaneous flaps. Consultation with a plastic surgeon is wise as
part of the preoperative planning of the procedure.
Exposure Secrets
1. In skeletally immature patients, dissection is aided by splitting the
spinous process apophyses and following a subperiosteal plane out to
the tips of the transverse processes at each level. This limits the blood
loss for the procedure.
2. In patients with myelodysplasia, dissection of the sac is accomplished
by first finding normal bony anatomy proximal to the area of deficient
posterior elements and then following along laterally where the posterior elements are everted around the sac.
3. Exposure of the insertion site in the pelvis; that is, the PSIS is per-
formed through a separate fascial incision from the midline. The PSIS
is rongeured down so that it becomes level with the sacrum. This allows for concomitant instrumentation of the first sacral pedicles and
reduces hardware prominence. A subperiosteal tunnel is created between the pelvic insertion site and the midline-exposed spine.
4. Anchor sites for instrumentation include the lamina, transverse
processes, pedicles, and ilium. Pedicles offer optimal fixation and are
generally utilized in the lumbar spines and sacrum. In myelodysplastics, pedicles are easily instrumented if they are of sufficient diameter.
Systems that utilize slotted connectors for pedicle screws are best
suited for these complex deformities.
Instrumentation
1. The domino technique relies on the creation of two instrumentation
foundations, one proximally and one distally. The cephalad construct
is created by contouring the desired kyphosis into two rods and anchoring the rods to the thoracic spine, usually with a combination of
sublaminar wires and proximal hook claws. The rods are tied together
with a transverse connector.
2. The caudal construct is created by anchoring two rods (contoured in
lordosis) to the lumbar spine, sacrum, and pelvis. Rods may be contoured to be inserted into the pelvis via the Galveston technique, or a
modification in which screws are inserted into the ilium and then attached to the rods may be performed. Again, a transverse connector is
applied across the two rods.
3. Once two stable foundations have been created, deformity correction
may be achieved. The two sets of rods will be parallel and directed past
one another. Domino connectors are placed on two adjacent rods. The
corrective maneuver requires two surgeons. The two sets of rods are
gradually and gently brought toward one another. When the corresponding rods line up, the dominoes are slid onto the adjacent rod and
provisional tightening is achieved. Final compression and distraction
of aligning rods may be performed for further correction.
4. One-quarter-inch rods should ideally be used to provide for adequate
support and to avoid rod breakage (Fig. 36–2).
Pitfalls
1. Skin integrity may be a problem in neuromuscular patients. This is
particularly a problem for myelodysplastics with insensate skin. Preoperative evaluation by a plastic surgeon is helpful. Preoperative
tissue expanders or flap revision may be beneficial. Rod contouring to
minimize hardware prominence is also important.
2. Limit the risk of postoperative infection by ensuring adequate skin integrity prior to surgery. The risk of aspiration and secondary pneumonia must be assessed preoperatively with a pH probe or swallowing
study. Preoperative gastrostomy may be indicated. All patients should
be evaluated for urinary tract infections.
3. In myelodysplastic patients who self-catheterize, it is important to put
the patient in slightly positive sagittal balance. If the patient is
balanced posteriorly, self-catheterization may no longer be possible.
4. All patients with myelomeningocele must be considered to be allergic
to latex with potential for anaphylaxis. Precautions must be taken perioperatively to eliminate exposure to latex products.
Complications
Hardware pullout, breakage, or loosening. Large forces are exerted along
this lengthy construct, particularly at the lumbosacral junction. This may
manifest in hardware failure and loss of correction. So-called windshield
wiping of the rods or screws in the pelvis may be an indication of lumbosacral pseudarthrosis.
Postoperative Care
1. Patients are mobilized in a wheelchair on postoperative day 1 or 2.
2. Soft spinal orthoses are utilized at the discretion of the surgeon depending on bone quality and adequacy of fixation.
3. Skin integrity must be carefully monitored both at the incision site and
in weight-bearing areas.
4. Air mattresses are useful for patients with insensate skin.
Suggested Readings
Allen BL Jr, Ferguson RL. The operative treatment of myelomeningocele
spinal deformity. Orthop Clin North Am 1979;10:845–862.
Allen BL Jr, Ferguson RL. The Galveston technique of pelvic fixation with
L-rod instrumentation of the spine. Spine 1984;9:388–394.
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36 CORRECTION OF NEUROMUSCULAR PELVIC OBLIQUITY
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A
Figure 36–1
Preoperative seated upright anteroposterior (AP) (A) and lateral (B) views of the spine.
B
■
174
A
Figure 36–2
Postoperative seated AP (A) and lateral (B) views of the spine.
SECTION II THE THORACIC SPINE
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B
37
Thoracic Vertebrectomy for Congenital Deformity
James W. Ogilvie
Goals of Surgical Treatment
Removal of the segmented hemivertebra and its superior and inferior discs,
improvement of the deformity through compression internal fixation, and
arthrodesis to the adjacent vertebrae are the goals of this procedure.
Diagnosis
Congenital malformation of the spinal elements is frequently made on
routine neonatal roentgenograms. Thoracic asymmetry with forward bending or other signs of spinal deformity can lead to the diagnosis in early
childhood. When the diagnosis is suspected, in addition to a general and
specific neurologic examination of the lower extremities, standing 2 m x-
rays of the entire spine in the posteroanterior and lateral projections
should be made. Magnetic resonance imaging (MRI) of the spine with
coronal images of the area under consideration will both rule out other
neuraxis
abnormalities and clearly define the vertebral anomaly. Thin-section computed tomography (CT) scans may be helpful, but the sagittal reconstructions can be misleading by implying a congenital bar or other failure of
segmentation that is not actually present.
Indications for Surgery
There are two general indications for resection of congenital hemivertebra:
1. If there is a fully segmented hemi-element that has a viable growth
plate on each side, progression of the scoliosis should be anticipated.
Scoliosis progression can be 5 to 10 degrees per year or more, particularly if there is a contralateral unsegmented bar.
2. If the hemivertebra has already caused an unacceptable deformity, ex-
cision of the element and correction of the deformity is the only definitive treatment.
Timing of the surgery is variable. If there is a clear diagnosis and documented progression of the deformity, surgery should not be delayed unless
other medical factors intervene.
Contraindications
1. Congenital scoliosis is often accompanied by other malformations of
the cardiorespiratory and gastrointestinal systems. Right heart failure,
poor nutrition, or other systemic factors precluding surgery should be
considered.
2. Excision of an isolated wedge or congenital hemivertebra can usually
achieve a maximum correction of 25 to 30 degrees. When more correction than this is needed, a multiple-level staged anterior vertebrectomy
followed by posterior fusion is usually required.
Advantages
1. Excision of the hemivertebra and compression instrumentation is
definitive treatment for this disorder.
2. The use of compression internal fixation allows removal of the post-
operative orthosis under controlled conditions rather than depending
on a cast for correction of the scoliosis.
3. There is no distraction applied to achieve the correction, thereby
adding an additional element of safety when compared to lengthening
procedures.
4. Decreasing the congenital scoliosis lessens the likelihood that second-
ary curves will require treatment.
5. Selectively limiting the fusion to adjacent vertebrae preserves as much
axial growth as possible. In theory, excising a hemivertebra and fusion
is the final treatment that is needed for congenital scoliosis.
Disadvantages
1. Thoracic hemivertebrectomy is a more difficult technically than in situ
posterior fusion or anteroposterior hemiepiphysiodesis for congenital
scoliosis.
2. When there is a mild, but progressive curve due to congenital
hemivertebra, that is, 쏝 25 degrees, the other two fusion options are
usually appropriate.
Procedure: Left T11 Anteroposterior Hemivertebrectomy
with Sublaminar Fixation
The patient is placed in the right lateral decubitus position with the thoracolumbar junction centered over the hinge in the operating table. Moderate
flexion is created in the table after securing the patient to the table.
A spinal needle is placed over the left 11th rib and an anteroposterior xray is obtained to localize the incision (Fig. 37–1A). A 4-cm incision is
made over the 11th rib beginning approximately 2.5 cm lateral to the midline and extending lateral. Subperiosteal dissection is used to expose the
rib, which is then divided with a bone cutter 5 to 6 cm lateral to the midline. The parietal pleura is bluntly moved away from the proximal rib until
the costovertebral joint is visualized. Removal of the proximal rib fragment
is undertaken (Fig. 37–1B). Care is used to identify the segmental vessel
over the hemivertebra, although this vessel is often absent. Further blunt
dissection across the midline, proximal and distal from T11, allows the
placement of a Chandler retractor to protect the great vessels. Before removing disc or vertebra, a localizing x-ray should be taken if there is any
doubt concerning the exact level of the hemivertebra to be excised.
The disc proximal and distal to the hemivertebra is excised by elevating
it off of the adjacent bony end plates and using sharp curets to “melon ball”
the disc material. Avoid removing bone during this maneuver to minimize
bleeding. After as much disc has been removed as possible, the vertebral
body is removed with a rongeur.If brisk bleeding is encountered at a particular site, Gelfoam is placed over the bone much as one would utilize bone
wax while attention is turned to another area of bone. The undersurface of
the transverse process and pedicle are visible and can be removed until the
inner cortex is recognized. Medial to the pedicle and posterior to the body
of the hemivertebra there are epidural veins and dura. Bipolar electrocautery may be used as needed.
As the dissection continues, the canal is entered and small back-angled
curets are used to push bone away from the dura. Fortunately, the dura is
naturally displaced toward the concave side of the curve, affording additional safety. If any bone is removed with each pass of the curet, it should
be considered progress (Fig. 37–2A). Patience is of the utmost importance.
When the hemivertebra is completely removed, it is possible to visualize
the single disc on the concave side. Removal of this allows additional collapse and correction of the deformity (Fig. 37–2B). If is kyphotic deformity
is present, it is possible to place an appropriately sized segment of the excised rib in an anterior-concave position.
When the anterior excision is complete, the wound is closed in an anatomic fashion. If a plural tear has occurred, closed chest suction is performed with a small-diameter tube that is left in for 24 to 48 hours.
The patient is then placed in the prone position and the back is again
prepared and draped. A midline incision is made and the posterior elements are identified before taking an anteroposterior x-ray to confirm the
level of dissection. The lamina corresponding to the excised hemivertebra
may be free floating and easily identified or it may be confluent with an adjacent lamina. Spina bifida occulta or other congenital malformations of
adjacent lamina are common. After excision of the lamina of the
hemivertebra, a decision is made regarding appropriate internal compression fixation. If the adjacent pedicles are large enough, convex pedicle
screws may be used. If the spinal elements are smaller, a low-profile laminar compression clamp may be used. Sublaminar suture of 5-mm mersilene tape or double-filament nonabsorbable No. 1 suture may be used depending on geometric constraints.
A large clamp (Kocher) is then used on the transverse process above and
below,along with manual convex pressure, to close the wedge under direct
vision of the underlying dura (Fig. 37−3). Compression immobilization of
the closing wedge can be achieved in several ways, depending on the size
and configuration of the local anatomy. For larger patients, pedicle fixation
is excellent. When this is not advisable, a low profile laminar compression
clamp construct, such as used in the cervical spine, can maintain the closing wedge in its reduced position. For the very young, 5-mm mersilene
tape or doubled nonabsorbable sublaminar sutures provide adequate compression.
After wound closure, a body cast is applied. A wake-up test is performed at a convenient time and before the sterile field of the back table has
been broken. Alternately, motor evoked potentials can be done during the
Eurostile
37 THORACIC VERTEBRECTOMY FOR CONGENITAL DEFORMITY
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Costotransverse joint
Costovertebral joint
Removal of entire proximal rib
Lateral
decubitus
(First incision)
4 cm
incision
over rib 11
Rib 11
Rib 12
Posterior
incision
(patient in
prone
position)
Costovertebral
joint
Release
costotransverse
ligaments
Rib 11
A B
Figure 37–1
(A) The patient is positioned in the lateral decubitus position. The incision is
made along the associated rib of the hemivertebra. (B) The rib is exposed and removed. The great vessels are protected and the hemivertebra is exposed.
Hemivertebra
removed in
fragments
Remove discs with curets
Intercostal
vessels
and
nerve
T10
T11
Transverse
process
of
hemivertebra
T12
B
A
Figure 37–2
(A) The disc is removed with curets, further exposing the hemivertebra. (B) The
hemivertebra is delineated and removed.
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SECTION II THE THORACIC SPINE
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Figure 37–3
The hemivertebra is removed and the spine is realigned using a suture clamp.
Eurostile
37 THORACIC VERTEBRECTOMY FOR CONGENITAL DEFORMITY
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posterior portion of the procedure. If the excised level is lower lumbar, a
single pantaloon spica cast is applied. If the excised level is in the upper
thoracic area, a Minerva collar is added to the cast.
Pitfalls and Complications
The most dreaded complication is the production of a spinal cord injury. In
theory, because the spine is shortened through hemivertebrectomy, this
should be a rare occurrence. Direct trauma to the cord in either the anterior
or posterior portion of the procedure is a more likely cause.
During the extrapleural anterior portion of the procedure, possible
problems can arise through direct trauma to the great vessels or tearing the
pleura, thus necessitating the use of a chest tube. The surgeon should be
prepared both temporally and psychologically to perform an open thoracotomy should the need arise. Complete excision of the cartilaginous end
plate will lessen the likelihood of a pseudarthrosis or reformation of the
previously excised element. Excising the apex of the hemi-element and the
ipsilateral disc requires special attention and is assisted by the use of
reverse-angled curets.
On the posterior portion of the procedure the choice of internal fixation
is dictated by local anatomy. If the convex pedicles are not large enough to
accept pedicle screws, sublaminar sutures or laminar compression hook
assemblies are the choice. Occasionally spina bifida occulta or other congenital laminar anomalies preclude the use of internal fixation.
Postoperative Care
A chest x-ray is taken following the procedure and before the patient is recovered from anesthesia so that, if indicated, closed suction drainage can
be inserted in the operating room while the patient is still anesthetized.
Postoperative ileus may make it necessary to split the cast. Monovalving
the cast from in front and placing a spacer in the cleft makes repair of the
cast easier when normal gastrointestinal function returns without necessitating a complete cast change.
If the internal fixation is satisfactory and the cast is intact, progressive
ambulation is allowed. At 6 weeks postoperatively a removable TLSO is
fitted. This is done by bivalving the cast, molding the TLSO, and reapplying the cast. When the TLSO is fabricated and applied, an in-brace x-ray of
the sine is obtained. The TLSO, which can be removed under supervision
for personal hygiene, is worn for 6 months following surgery. If healing is
satisfactory, the patient is followed brace free with routine x-ray at 6month intervals for 2 years after surgery and then yearly.
Suggested Readings
Bradford DS, Boachie-Adejei O. One-stage anterior and posterior
hemivertebrectomy resection and fusion for congenital scoliosis. J
Bone Joint Surg Am 1990;72:536–540.
Callahan BC, Georopoulos G, Eilert RE. Hemivertebrectomy excision of
congenital scoliosis. J Pediatr Orthop 1997;17:96–99.
Compere EL. Excision of hemivertebrae for correction of congenital scolio-
sis: report of two cases. J Bone Joint Surg 1932;14:555–562.
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38
Prevention and Treatment of the Crankshaft Phenomenon
John P. Lubicky
Goals of Surgical Intervention
1. To prevent the crankshaft process by eliminating anterior column
growth at the time of spinal fusion for scoliosis
2. To eliminate further crankshafting and/or correct the effects of it on a
previously performed spinal fusion
Diagnosis
The crankshaft phenomenon (CP) is the consequence of continued anterior
column growth in the presence of a posterior spinal fusion (PSF). (This
must be differentiated from “adding on” and pseudarthrosis.) Because the
PSF prevents longitudinal growth of the spine, intercalary vertebral
growth in the residual curve causes these vertebrae to rotate toward its con-
vexity, giving the appearance of progression of the previously corrected
curve. This process is seen only in skeletally immature individuals. The
CP can be recognized by radiographic features: increase in the Cobb angle,
increased rotation of the apical vertebrae, changes in the relationship of the
spine to the chest wall, trunk shift, and change in the alignment of the posterior instrumentation. Clinically, it is manifested by increasing deformity,
especially the rib hump and trunk shift as well as new prominence of the
hardware. Prevention of initial and continuing CP is accomplished by
growth arrest of the vertebral body growth plates, most commonly via ante-
rior spinal fusion (ASF) (Fig. 38–1).
Prevention of the Crankshaft Phenomenon
Indications
1. Growing children (쏝 10 years old, premenarchal, open triradiate car-
tilages, Risser 0 to 1, PGA 쏝 0) with residual curve expected to be 쏜 30
degrees
2. For definitive spinal correction and fusion
3. For “growing rod” constructs
correction, not closed like a book. This cannot happen unless the disc
spaces are filled with bone graft (Fig. 38–4 and 38–5).
Standard anterior instrumentation: see Chapter 25.
Nonstandard anterior instrumentation: The vertebral bodies in small
children may not be large enough to accept standard size implants. The situation can be handled by using heavy sutures around the lateral aspects of
the bodies, cervical spine implants, or small-fragment reconstruction
plates and screws.
Pitfalls
1. Confirm the segment of the spine with an intraoperative radiograph.
Identifying the appropriate level may be difficult especially in congenital cases.
2. An ASF across the wrong segment will not adequately prevent the CP.
Complications
1. Pseudarthrosis of the ASF
2. Usual complications of ASF and PSF
3. CP despite ASF because incorrect levels were fused
Postoperative Care
1. Usual care algorithm for ASF and PSF
2. Early mobilization
3. Orthosis at the discretion of the surgeon
Treatment of the Crankshaft Phenomenon (That Has Already
Occurred)
Indications
Moderate to severe deformity after PSF due to the CP in both skeletally mature and immature patients.
Contraindications
1. Inability to tolerate an anterior procedure (poor lung function, scarring
from prior surgery, etc.)
2. Signs of skeletal maturity (쏜10 years old, post menarchal, closed
triradiate cartilages, Risser 쏜 1, PGA 쏜 O) with residual curve expected to be 쏝 30 degrees
Procedure
Vertebral body growth arrest via ASF: This is most commonly done in association with PSF (with or without instrumentation). The ASF can be done
by open techniques using standard thoracotomy or lumbotomy or by minimally invasive techniques such as thoracoscopy or laparoscopy. An alternative in appropriately selected patients involves an ASF with instrumentation only. ASF can be used in cases of definitive correction and fusion as
well as an adjunct in “growing rod” constructs (Figs. 38–2 and 38–3).
Surgical Points
Approach: Whether done open or though the scope, adequate visualization
of the spinal region to be operated must be obtained. For the open cases,
the main incision should be placed so as to reach all levels necessary. For
the scope cases, portal site selection and number must allow access to all
levels by the scope and the tools.
Levels to be fused anteriorly: When doing an ASF with a concomitant
PSF, the ASF must span at least the structural segment of the curve as demonstrated on side-bending films. If an ASF with instrumentation is the
only strategy to be used, the instrumentation and ASF must involve the entire measured curve.
Segmental vessels: An ASF without instrumentation does not require
sacrifice of the vessels, which may be especially worrisome in congenital
kyphoscoliosis cases. Vessel ligation when using instrumentation, though
debatable, has some advantages and may be safer (in terms of avoiding inadvertent or unrecognized vessel injury).
Discectomy: Whether done open or through the scope, the discs need to
be thoroughly excised back to at least the posterior annulus, if not the post-
erior longitudinal ligament, and completely across to the opposite side.
Bone grafting: An adequate amount of auto- and/or allograft is necessary to fill the disc spaces. Disc spaces need to be “leveled” during curve
Contraindications
Minimal deformity in skeletally mature patients.
Procedure
1. For minimal but increasing deformity in a growing child: ASF across
residual curve.
2. For moderate to severe deformity in a growing child: ASF across residual curve and revise PSF, with or without instrumentation, with or
without osteotomy.
3. For moderate to severe deformity in a skeletally mature patient: Revise
PSF and instrumentation, with or without osteotomy.
Surgical Points
See above.
1. Posterior osteotomies should be done so as not to cause impingement
on the dura and nerve roots when closed down.
2. Posterior instrumentation strategies during revision should restore
trunk and spinal balance in both the coronal and sagittal planes, as
well as curve control rather than absolute correction in the coronal
plane.
Pitfalls, Complications, and Postoperative Care
See above.
Suggested Readings
Dohin B, Dubousset JF. Prevention of the crankshaft phenomenon with
anterior spinal epiphyseodesis in surgical treatment of severe scoliosis
of the younger patient. Eur Spine J 1994;3:165–168.
Dubousset JF, Herring JA, Shufflebarger H. The crankshaft phenomenon. J
Pediatr Orthop 1989;9:541–550.
Sanders JO, Little DG, Richards BS. Prediction of the crankshaft phenome-
non by the peak growth age. Presented at the Scoliosis Research
Society annual meeting, Ottawa, Ontario, Canada, September 1996.
Terek RM, Wehner J, Lubicky JP. Crankshaft phenomenon in congenital
scoliosis: a preliminary report. J Pediatr Orthop 1991;11:527–532.
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38 PREVENTION AND TREATMENT OF THE CRANKSHAFT PHENOMENON
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