Posterior based circumferential spinal cord decompression in paediatric patients with the vertebral column resection (VCR) technique spares the anterior approach in severe kyphosis

Abstract

Introduction: Patients with kyphosis and myelopathy have traditionally been managed by combined anterior and posterior surgery with associated morbidity and long theatre episodes. The posterior vertebral column resection (pVCR) technique allows circumferential apical decompression with instrumented correction and stabilisation through a single extra-pulmonary approach. The objective of this study was to review the use of pVCR in the paediatric population as to feasibility, safety and effectiveness.

Methods: A retrospective review of prospectively maintained database was undertaken. Twenty-six consecutive paediatric patients (18 females) were reviewed. The median age at surgery was 12.1 years (IQR 7.6–14.2, range 2.1–17.7). The underlying pathology was active tuberculosis in nine patients, healed tuberculosis in seven, congenital in seven, tumour in two and trauma in one. Myelopathy was present in 17 and two had associated syringomyelia. The median surgical duration was 3.3 hours (IQR 3–5.0, range 1.9–6.5) with a blood loss of 20.8 ml/kg (IQR 12.5–38.1, range 6.3–67.6).

Results: The median percentage sagittal correction was 65% (IQR 44–79, range 21–100). The correction was best in the thoracolumbar spine at 75%. All non-ambulatory patients improved to an ambulatory status. There was one permanent and one transient neurological deterioration. All intact patients (ASIA E) remained so. One of the two patients that had associated syringomyelia had complete resolution of the syrinx with improved neurological function. There were no related pulmonary complications. One patient developed early (in-hospital) proximal junctional failure requiring revision.

Conclusion: Posterior based circumferential decompression and corrective fusion using the pVCR technique is both feasible and effective in the paediatric population. It avoids the morbidity associated with the trans-thoracic approach and allows improvement both in neurological function and CSF dynamics when they are compromised. It remains a technically challenging procedure both for the surgical and anaesthetic team and there needs to be a clear understanding of the risk–benefit relationship when deciding on its implementation.

Level of evidence: Level 4