Evaluation of Vertebral Anomalies and Vertebral Osteotomy in Congenital Spinal Deformity Noriaki Kawakami, Taichi Tsuji, Kazuyoshi Miyasaka, Tetsuya Ohara, Yasunori Tatara, Kei Ando, Ayato Nohara Dept. of Orthopedics & Spine Surgery Meijo Hospital, Nagoya, Japan　

Three-Dimensional Evaluation of Congenital Vertebral Anomalies Congenital Vertebral Anomalies (Closed defect) Solitary Simple Multiple Simple Multiple Complex Segmentation Failure Unison anomaly Discordant anomaly We analyzed three-dimensional morphology of congenital vertebral anomaly and reported two types of anomaly, such as discordant and unison anomaly, from the view point of the relationship between anterior and posterior structure Nakajima, Kawakami, et al. SPINE 2007 Kawakami, et al. presented at pre-course, SRS, 2007

Surgical Treatment of Congenital Spinal Deformity Hemvertebrectomy 41 1 Combined Ant & Post Vertebrectomy VS. Posterior only vertebrectomy When we talk about the operation of hemivertebrectomy, many doctors reported good outcome and its safety of that through posterior approach. And this posterior hemivertebrectomy has been getting popular in spite of its technically demanding.

Purpose To assess the type of congenital vertebral anomaly three-dimensionally for determining which types should be treated using a combined anterior and posterior procedure. Cases Vertebrectomy 60 pts. 1993-2006 Congenital spinal deformity Surgical treatment Sex M 31、F 29 Age 13.2（2+4〜68+9） 61 ops. (One patient underwent two ops for discrete vertebral anomalies separately) The purpose of this study was to assess the type of congenital vertebral anomaly three-disensionally for determining which types should be treated using a combined anterior and posterior procedures. During the last 14 years, we operated 123 patients with congenital spinal deformity. Of this, 60 patients were performed vertebrectomy. One of them underwent two vertebrectomies separately. And total 61 operations were retrospectively analyzed in this study. 123 pts. Retrospectively analyzed

Approach & Stage of Operations Two-staged 　　　　　　　7 Posterior 36 Ant + Post 25 One-staged　54 Two-staged operation Ant. Strut bone graft 5 Ant. Fusion 1 Correction of upper curve 1 This slid shows operative approach and stage. 36 operations were through posterior only and the other 25 were through anterior and posterior combined approach. Only 7 operations were planned two staged, and for 6 of them anterior bone graft were added on the gap in the anterior column. The number of fused vertebrae and operative time in posterior approach was significantly smaller than combined anterior and posterior.

Types of Vertebral Anomaly Solitary Simple (SS) 16 Multiple Simple (MS) 24 Multiple Complex (MC) 16 Without rib anomalies 12 with rib anomalies 4 Spina bifida + Hemidefect 1 Failure of Segmentation 4 Failure of Formation 52 Mixed type 4 Failure of Segmentation 4 The reasons of Ant & Post Ops. Multiple vertebral anomalies in the curve 11 Ostotomy and multiple segment release 9 Osteotomy more than two segments 2 To Prevent Crankshaft 8 Learning curve 7 Big gap in the anterior vertebral column 6 Atypical vert. anomalies 1 Types of vertebral anomaly were shown in this slide. Solitary simple was 16, multiple simple 24, multipe comples 16, and segmentation failure 4. The reasons why anterior and posterior combined approach was chosen were as follows. 11 operations were chosen because of existence of multiple vertebral anomalies in the curve. In this series included 7 operations as learning curve. 6 operations were as additional operations for the gap in the anterior vertebral column.

Comparison of Vertebral Anomaly with Surgical Approach (1) Solitary & Multiple Ant.＋Post. Post. (If operate again) Ant.＋Post. Solitary malformation type (SS) Post. Ant.＋Post. When we compare the vertebral anomalies with their surgical approach, more than 80% of solitary malformation was operated from posterior appriach only, and about half of multiple was from the combined approach. If I could operate the same series now, I would have chosen posterior approach for all solitary malformation. Multiple malformation type (MS+MC) Post.

Comparison of Vertebral Anomaly with Surgical Approach (2) Simple (Unison) & Complex (Discordant) (If operate again) As for the comparison of surgical approach between unison and discordant anomalies, about 70 % of operations of unison anomaly was chosen posterior approach. This indicated that the more simple the vertebral anomaly, the more operations were chosen from posterior approach only.

Correction of Spinal Deformity Kyphosis Scoliosis Cobb angle Cobb angle Correction rate　62.2 ±21.2％ In all operations, scoliosis was corrected from 52.7 degrees to 31.56 degrees with ave, correction rate 62.2%. Correction of scoliosis demonstrated significance between two groups. 52.7±28.0 21.5±18.4 51.9±25.4 22.3±15.6 24.8±16.7 Ant. & Post.　72.6±25.1　33.1±17.8 Post. Only　 43.2±24.2　16.1±16.2 No statistical significance Both two groups of posterior and combined significantly demonstrated good correction of scoliosis.

Scoliosis Correction in Each type of Vertebral Anomalies Multiple simple (MS) Multiple complex (MC) Cobb angle Cobb angle Solitary (SS) Cobb angle This graphs demonstrated correction of scoliosis in three types of congenital anomaly. The correction rate of Solitary simple, Multiple simple and multiple complex were 76 %, 43%, and 51.1%, respectively. Pre Post Pre Post Pre Post 76.2±23.0％ 63.2±16.6％ 51.1±19.0％ P=0.044 P=0.059 P=0.005 The more complicated the deformity, the less correction rate.

Surgical Complications 27/61（44.3%) Posterior Approach Ant. & Post. Approach Inst. related　 Pedicle cut-out 4 Screw displacement 1 Neurological　 Radiculopathy 4 Paraparesis(transient) 2 Dural tear 1 Respiratory Pneumothorax 1 Pneumonia 1 Inst. related　 Screw displacement 2 Junctional kyphosis 4 Neurological　 Radiculopathy 4 Dural tear 2 Paraparesis(transient) 1 Respiratory Atelectasis 1 Lung injury 1 Halo traction related 3 Neurological complication rate between two groups was not statistically significant although posterior approach seemed to have more neurological risk. 4/36(11.1%) 7/25(28.0%) Preop. Scoliosis magnitude Ant. & Post.　72.6±25.1° Post. Only　 43.2±24.2° <<

Case 9+2 Female Congenital scoliosis with fused ribs Multiple malformation complex (MC) 46 14 -37 One-stage anterior (T10-L2) & posterior (T2-L2) combined hemivertebrerctomy and fusion 30 88 -40

Case 10y/o Female Contralateral hemivertebrae (Hemimetamelic Shift) -44 28 Multipe malformation group Simple type 21 -48 48 18 41 -24

Surgical Treatment of Congenital Spine Deformity (CSD) Multiple anomalies with rib union Multiple anomalies in the curve Solitary anomaly in the curve Expansion thoracoplasty Fusion (including hemiepiphysiodesis) Correction with Osteotomy Posterior VS. Combined ant & post Correction w/o osteotomy Good correction Unsatisfied outcome Op. complications In discussion. The strategy of surgical treatment depends on the operator’s skill and experience. It is definitely necessary to obtain good correction of congenital spinal deformity to perform osteotomy including vertebrectomy through either posterior only or combined anterior and posterior approach. Because posterior approach has been widely getting accepted, this study was conducted to evaluate the clinical significance of anterior procedure in the combined anterior and posterior procedure. It is necessary for obtaining good correction of CSD to perform osteotomy through either posterior only or combined anterior and posterior approach. This study was conducted to investigate clinical significance of an anterior procedure.

In Summary Solitary type, and mild curve of multiple type of congenital spinal deformity could be managed by a posterior procedure only. Many severe deformities due to more complicated anomalies necessitated combined ant and post procedures. More severe curves and multiple complicated anomaly may be factors that necessitate the combined anterior and posterior operations. 多椎の奇形椎でも変形の程度が重度でなければ前方後方一致奇形の単純型は後方のみで対応できる症例が多かった。前後合併手術は多発奇形椎の症例で、変形の高度な症例に選択されていた。 Solitary type, and mild curve of multiple type of congenital spinal deformity can be managed by performing posterior procedure only. Many severe deformities due to more complicated anomalies necessitated combined ant and post procedure to obtain maximum correction. More severe curves and multiple congenital vertebral anomaly, such as discordant anomaly, may be factors that necessitate the combined anterior and posterior operation even though posterior vertebrectomy has been gradually accepted as a standard operation.

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