Disclosures Alternatives to VCR in major deformity • AOSpine (a, d) • Avalon Spinecare (a) correction • Medtronic (d) • NuVasive (d) • OrthoSmart (g) Kenneth Cheung Jessie Ho Professor in Spine Surgery Conflicts of Interest Key: a – grants/research support; b – consultant; c – stock/shareholder (self- managed); d – speaker honoraria ; e – advisory board or panel; f – employee, salary (commercial Head, Department of Orthopaedics & Traumatology interest); g – other financial or material support (royalties, patents, etc.) 1 2 VCR or not? Complication rates in major deformity surgeries • Kostuik and Hall 1983 – 78% • Simmonds et al. 1993 – 41% • Daubs et al. 2007 – 37% • Charovsky et al. 2012 - 39% 3 4 Prospective, Multicenter Assessment of Complications Following Complex Adult Spinal Deformity Surgery: Kenneth Cheung 1 , Mark Dekutoski 2 , Frank Schwab 3 , Oheneba Boachie-adjei 4 , Khaled Kebaish 5 , Christopher The Scoli-RISK-1 Trial Ames6, Yong Qiu 7 , Yukihiro Matsuyama 8 , Benny Dahl 9 , Hossein Mehdian 10 , Ferran Pellisé-Urquiza 11 , Leah Carreon 12 , Christopher Shaffrey 13 , Michael Fehlings 14 , Lawrence Lenke15 Affiliations: L AWRENCE G. L ENKE , MD 1 The University of Hong Kong, Hong Kong 2 The CORE Institute, Roschester, U.S.A. M ICHAEL G. F EHLINGS , MD, P H D 3 New York University, U.S.A. 4 Hospital for Special Surgery, New York, U.S.A. C HRISTOPHER I. S HAFFREY , MD 5 Johns Hopkins University, U.S.A. 6 University of California, San Francisco, U.S.A. K ENNETH MC C HEUNG , MD 7 Nanjing University Medical School, China L EAH C ARREON , MD, MS C 8 Hamamatsu University School of Medicine, Japan 9 SpineUnit, Rigshospitalet, Copenhagen, Denmark 10 University Hospital, Nottingham, U.K. 11 Hospital Universitari Vall d’Hebron, Spain 12 Norton Leatherman Spine Center, Louiseville, U.S.A. 13 University of Virginia, U.S.A. 14 University of Toronto, Canada 15 Washington University, U.S.A. 5 6
• Total with complications = 163 (60.6%) • At discharge – 25.76% • Intra-operative event = 29.4% (n=79) • Post-op complications = 49.8% (n=134) • At 6 weeks – 18.18% • Major = 21.6% (n=58) • Minor = 42.0% (n=112) • At 6 months - 6.06% • Number of patients with ≥ 1 complications = 37% (n=99) 7 8 Summary of risk factors • Age How to minimise • Obesity and medical comorbidities • Smoking status and nutrition complications? • Bone quality – evaluation, agonists (Teriparatide), fixation strategies • Magnitude of surgery o osteotomies o Length of fusion o Fusion to sacrum • Blood transfusion and excessive blood loss • Poor postop sagittal balance 9 10 Alternatives to VCR in big deformities • Accurate flexibility assessment Accurate flexibility • Implant density assessment • Correction techniques • Posterior column osteotomies • Spinal traction – external / internal • Salvage o Partial correction o In-situ fusion 11 12
Big curves are not necessarily stiff.. AIS And stiff curves are not always big! Case 1 Case 2 93 ° 62 o 34 ° 53 ° Flexibility index= 64% Flexibility index= 15% 13 15 FBCI -122% FBCI -230% JBJS-A 79 (8), August 1997 16 17 Eur Spine Journal December 2014, Volume 23, Issue 12, pp 2603–2618 JBJS-A, Jan 2010 FBCI - 100% flexible curves - 200% for stiff curves 18 19
FBCI is correlated with flexibility Flexible curves : FBCI = 100% regardless of screw strategy • Curve correction can be predicted • FBCI o 122% flexible curves o 203% for stiff curves 20 21 More screws for stiff curves FBCI is correlated with flexibility Stiff curves : FBCI >150% KVSS up to 155% CMSS and ALSS up to 200% Curve of <20 deg on the FBR 22 23 Posterior column osteotomies Alternatives to VCR in big deformities • Accurate flexibility assessment • Implant density • Correction techniques • Posterior column osteotomies • Spinal traction – external / internal • Salvage o Partial correction From AO Surgery reference o In-situ fusion From AOSpine Surgery Reference 24 25
Cantilever correction technique with concave reduction screws Spinal distraction 26 27 4 months of traction / 50% body weight 6 years old Suspected Mucopolysaccharidosis 28 29 4 months of traction / 50% body weight 4 months of traction / 50% body weight 30 31
Spinal deformities in OI Halo Gravity Traction • HKU Shenzhen Hospital 2014-2016 in • 300 OI patients treated Osteogenesis Imperfecta • 105 have scoliosis (35%) • Age 8.3 +/- 6.1 • 27% have Cobb’s angles > 10 degrees Michael To, Jason Cheung, Eric Yeung, YL Fan, DH Zhong, o Type III (11.4%) > Type IV (7.6%)/V (7.6%) > Type I (<1%) Kenneth Cheung • 5 patients had severe scoliosis – treated by halo traction prior to surgery M. To et al. 2017 : Unpublished data 32 33 Halo traction Results • 6-8 pins inserted • 3 type IV and 2 type V CT scan skull • • Traction started from 3Kg • Mean age 15.2 (12-18) Weekly increase by 0.5-1kg and XR monitoring • • 3 patients require exchange of pins during traction 34 35 Results Case 4 Subjects OI Pre- 1st month Max % Cobb Days of % Body Type traction traction traction angle traction weight Cobb Cobb angle Cobb angle correction of angle traction 1 V 140 110 110 21.4 17 40 55º 2 IV 72 68 63 12.5 75 35 74º 85º 3 IV 97 88 87 10.3 60 24.1 4 IV 85 65 55 35.3 120 45.5 5 V 110 109 106 3.6 62 42 2.5 months traction at 40% body weight 2/5 patients have Cobb angle correction above 20% With 40% of body weight 36 37
Conclusion • Pre-operative halo traction seems safe • Significant correction occurs within one month Internal halo distraction • Poor responders have more thoracic and rib deformities 38 39 97.1° 105 14yo with syrinx and severe kyphoscoliosis 40 41 40 41 45.6° Prior to Definitive Fusion 43 43 44
36° 115° 45 46 Halo traction combined with VCR • 15/F student • Neurofibromatosis • Progressive spinal deformity • Bilateral lower limb weakness (grade 0-1) • No lower limb sensation • Bladder and bowel intact 47 48 NO traction Start traction from 2017/03/17 2017/03/14 2017/04/01 2017/04/07 2017/04/14 2017/04/21 2017/04/28 2017/05/05 2017/05/12 Oct 2017 Deformity improved over 6 weeks No further improvement Hip flexion: Gd 2 Knee extension: Gd 3 Ankle and toes: Gd 0 Light touch & pinprick: return to normal Temperature sense improved: 50%. 49 50
Patient and family opted for VCR Intraop Neuromonitoring • • Preoperative planning • Detailed preop time out o Riluzole - 50 mg bd PO for 14 days preop and continue for 14 days o Blood salvage o Tranexamic acid (10mg/kg body wt loading; 1 mg/kg/hr) postop o Hypotensive during dissection o 3D printed model and pedicle screw guidance templates o Normotensive during VCR o IV steroid before VCR Use of ultrasonic bone scalpel for osteotomy • Planned 1 st stage dissection and screw insertion and 2 nd stage VCR • and correction 24 hours later. 53 54 55 56 57 58
59 60 Salvage 63 64 19yo male Achondroplasia Severe anaemia and recurrent GI bleeds from oesophageal varices 104 65 67
In–Situ Fusion 13yo severe scoliosis (Cambodia) 90 90 68 69 Alternatives to VCR in big deformities • Accurate flexibility assessment • Implant density • Correction techniques • Posterior column osteotomies • Spinal traction – external / internal • Salvage o Partial correction o In-situ fusion 70 71 Thank You!! The University of Hong Kong Queen Mary Hospital Faculty of Medicine The Duchess of Kent Children’s Hospital 72 73
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