Closing–opening wedge osteotomy for severe, rigid, thoracolumbar post-tubercular kyphosis

[摘要] OpenimageinnewwindowChildhoodspinaltuberculosis,especiallywhenassociatedwithseverevertebraldestructionofmorethantwovertebralbodiescanendupinseveredeformity.Thesechildrenshowprogressivedeformitythroughouttheperiodofgrowthandcandevelopseverekyphosisof>100°.Suchkyphosisisseverelydisablingwithsignificantriskofneurologicaldeficitandrespiratorycompromise.Surgicalcorrectionofthesedeformitiesbybothanteriorandposteriorapproacheshasbeendescribedbuteachhaveseriouslimitationsofapproach,correctabilityandsafety.Wedescribehereatechniqueofposteriorclosing–anterioropeningosteotomy,whichallowedustocorrectarigidpost-tuberculardeformityof118°ina13-year-oldboywithneglectedspinaltuberculosis.Thepatientwasa13-year-oldboy,whohadcontractedspinaltuberculosisattheageof6 years.Althoughthediseasewascuredbyanti-tubercularchemotherapy,hecontinuedtodeteriorateindeformityandpresentedtouswithseverethoracolumbarkyphosis(118°).Hewasneurologicallyintactbutwasbeginningtoshowshortnessofbreathonexertion.Patientalsohadforeshorteningofthetrunkwithimpingementoftheribcageontheiliaccrest.RadiographsrevealedcompletedestructionofT12,L1andL2vertebralbodieswiththeT11vertebrafusingwithL3anteriorly.CTscansandMRIrevealedseverecollapseofthevertebralcolumnandthespinalcordbeingstretchedoverthe‘internalgibbus’,whichwasformedbytheremnantsofthedestroyedvertebrae.Asinglestageclosing–openingosteotomywasdonebyamidlineposteriorapproachwithcontinuousintraoperativespinalcordmonitoring.TheprocedureinvolvedextensivelaminectomyofT11–L2,pediclescrewfixationofthreelevelsaboveandthreelevelsbelowtheapex,awedgeosteotomyattheapexofthedeformityfrombothsides,anteriorcolumnreconstructionbyappropriate-sizedtitaniumcageandgradualcorrectionofdeformitybyclosingtheposteriorcolumnusingthecageasafulcrum.Thisallowedustoachieveacorrectionto38°(68%correction).Therewasnointraoperativeorperioperativeadverseeventandpatienthadgoodfunctionalandradiologicaloutcomeat1-yearfollow-up.InthisGrandRoundscasepresentation,wehavealsodiscussedtheaetiologyandevolutionofseverepost-tubercularkyphosis,whichisthemostcommoncauseofspinaldeformityinthedevelopingworld.Earlyidentificationofchildrenatriskforseveredeformity,thetimeandidealmethodsofpreventionofsuchdeformitiesarediscussed.Theprosandconsoftheavailableoptionsofsurgicalcorrectionofestablisheddeformityandthemeritsofoursurgicaltechniquearediscussed...

[学科分类] 骨科学

[关键词] Post-tubercular ;Kyphosis ;Closing–opening wedge ;Osteotomy