The Hip: Preservation, Replacement and Revision Tracking Pixel
Duke Orthopaedics
presents
Wheeless' Textbook of Orthopaedics

Post Traumatic / Post Surgical Kyphosis



- Discussion:
    - commonly results from:
          -  frx of throracolumbar spine treated non-operatively,  esp when posterior ligamentous complex has been disrupted;
          - fractures treated by laminectomy w/o fusion (or w/ failed fusion);
          - children who have had extensive laminectomies, esp when facet excision is included;
                - prophylactic arthrodesis of the thoracic spine should be considered at the time of extensive laminectomy;
    - Post Laminectomy Kyphotic Deformity:
          - progressive deformity from prior wide laminectomy;
          - laminectomy in children is followed by high risk deformity (90%);
          - preservation of at least one half of each facet is recommended when possible;
          - if it is not possible to preserve one whole facet or one half of each facet, arthrodesis is indicated;
          - fusion using pedicle screw fixation is best for reconstruction in adult lumbar spine;

- Clinical Findings:
    - pain at the fracture site
    - occassional radiating leg pain and/or neurologic dysfunction;

- Indications for Surgery:
      - thoracolumbar kyphosis;
      - increasing kyphotic deformity;
      - pain;
      - increasing neurologic deficit;

- Surgical Planning:
      - determine whether kyphosis is flexible or rigid;
      - consider somatosensory evoked potentials;
      - use intra-opeartive traction (Gardner Wells tongs);
      - halo fixator is used for 6 weeks postoperatively;

- Surgical Options:
    - posterior decompression;
           - mentioned only to be condemned;
           - posterior decompression will not allow spinal cord migrate away from anterior compressing structures in kyphotic position;
    - anterior corpectomy and strut-grafting;
           - lateral borders of the vertebral body must  be preserved;
           - for two disc levels, iliac-crest strut graft is adequate;
           - for more than two levels, fibular strut graft is superior;
           - for defects longer than seven cm, vascularized fibular strut graft may be advantageous;
    - combined anterior and posterior approaches w/ instrumentation &, fusion and possibly combined osteotomies (for severe 
           deformities);
           - posteriorly consider use of facet fusion or facet plates;
           - kyphosis w/ spondylosis (posterior compression)
                  - combined anterior and posterior decompression are indicated;
                  - anterior corpectomy w/ fibular strut-grafting are recommended;
                  - to decompress the cord adequately, trough should be at least 16 mm;
    - w/ paralytic deformity:
           - two stage treatment is often recommended;
           - initial anterior decompression is followed by posterior stabilization;
           - decompressive laminectomy should not extend cephalad of L2 in order to avoid promoting further kyphosis;
           - facet joints must be maintained for spinal integrity;

- postoperative treatment:
      - postoperative use of halo immobilization will help prevent
            - graft dislodgment;
            - spinal malalignment;
            - pseudarthrosis;
      - w/ multilevel surgery, plan to keep patient intubated until there is no chance of excessive postoperative laryngeal swelling;
            - w/ high cervical fusions, consider tracheostomy


Anterior stabilization, instrumentation, and decompression for post-traumatic kyphosis.

Vascularised rib grafts for stabilisation of kyphosis.

Post-traumatic kyphosis. A review of forty-eight surgically treated patients.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, April 13, 2012 2:42 pm