At the final follow-up at 3 years 11 months postoperatively, the patient had no pain, no seating intolerance, and no recurrence of the ulcer. The kyphosis was reduced from 155° preoperatively to 85° postoperatively (45% correction), with no progression of the deformity at the final follow-up. No significant pulmonary infections or other respiratory compromise occurred during the follow-up period.
Kyphectomy has become one of the more common indications for spinal correction in MMC given recent evidence suggesting that scoliosis correction in these patients does not improve quality of life and has a high risk of complications.18 Various techniques for fixation and correction following kyphectomy have been reported. In early reports, short posterior fusion procedures using staples, surgical wires, and screws resulted in significant correction loss in most cases.3,10,11 In the modern era, most surgeons perform long posterior fusion for kyphectomy correction.6,19 The most common postoperative concerns associated with kyphectomy include wound-related complications, including dehiscence and deep wound infection which have been reported to be as high as 89% in one series.13 In larger series, infection rates following the more traditional method of kyphectomy range between 4.5% and 12.5%, with wound-related complications being even more prevalent.9,20–23 Significant rates of pseudarthrosis and implant failure have also been reported.8,9,19,20
One of the advantages of the Halifax kyphectomy technique is the avoidance of the MMC scar. We believe this avoidance decreases the risk of wound-related complications and postoperative infection by operating through a tissue that is relatively healthy. Accordingly, our patient did not experience any wound dehiscence or infection. In addition, no deep wound infections were reported for either the Halifax or Australian series, both of which used the kyphectomy technique used in this report.18,24
Given the young age at which many of these patients require kyphectomy, correction techniques that preserve spinal growth and prevent TIS are desired. The technique described herein addresses issues related to both wound complications and the preservation of spinal growth by combining thoracic spine-based growing rods with anterior intravertebral rod fixation of the lumbar vertebrae without fusion. This is in contrast to more commonly performed techniques that involve posterior instrumentation and fusion from T2 to the pelvis, which could at least lead to partial cessation of spinal growth. Except for the limited fusion at the osteotomy site, the combined procedure of Halifax kyphectomy and thoracic growing rods insertion allows for continued growth of the entire spine (Figure 6).
When the initial procedure was performed, we did not have access to magnetically controlled growing rods. Therefore, multiple open growing rod lengthening procedures were performed for the first few years following the index procedure, in a standard fashion via a small midline incision made over the tandem connectors.17 At the time of revision, these implants were replaced with magnetically controlled rods, eliminating the need for surgery for future lengthening procedures. This implant choice, coupled with the lack of distal dissection into the region covered by the often-precarious skin associated with the MMC closure, should help further reduce the risk of infection, a devastating complication all too common after spinal surgery in MMC.25 In our case, no infection was identified; however, whether this was a result of the technical choices unique to this procedure is not known.
In this case, due to the child's size, we chose 4.5-mm titanium rods for distal anterior vertebral fixation. In practice, however, it is best to choose the largest diameter rod possible (preferably 6.0 mm or above) which is made of the stiffest material (eg, cobalt-chromium) to avoid rod fracture in this nonfusion construct.4,18
In this case, the intraoperative blood loss was 200 mL and the surgical time was 419 minutes. Comstock et al assessed the blood loss associated with the Halifax kyphectomy and found it to be 765 mL, substantially lower than in other kyphectomy reports.18 The decreased blood loss in our case and in Comstock's series was likely due to the reduced distal exposure required as compared with other techniques.
A potential disadvantage of this technique over traditional techniques that use segmental posterior instrumentation is the lack of the ability to restore a more normal lumbar lordosis in exchange for a straight distal lumbosacral segment. That said, the goal of kyphectomy correction is to prevent recurrent skin ulceration at the gibbus, which was reliably achieved in our patient and in other series using the Halifax kyphectomy technique.24 Another potential disadvantage is the lack of iliac fixation which may decrease the efficacy of pelvic obliquity correction when needed. Despite this theoretical concern, we feel that the stable anterior multilevel intravertebral fixation achieved with the Halifax kyphectomy technique allows for a cantilever to reduce both sagittal and coronal plane deformity in the lumbosacral spine, particularly when the distal extent of fixation extends to S1 or below, as is technically feasible.15,24
According to this report, the combination of distal anterior multilevel vertebral body fixation with spine-based thoracic growing rods can successfully achieve kyphosis correction in MMC and it has the potential to reduce complication rates by minimizing blood loss, wound dehiscence, and deep wound infection while facilitating thoracic growth. Further investigation is necessary to prove whether the outcomes and the complication rates are superior to other established techniques.
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