Efficacy of Intraoperative Neurologic Monitoring in Surgery Involving a Vertical Expandable Prosthetic Titanium Rib for Early-Onset Spinal Deformity
ABSTRACT The vertical expandable prosthetic titanium rib (VEPTR) device is used in the treatment of thoracic insufficiency syndrome and certain types of early-onset spinal deformity. The purpose of this study was to evaluate the risk of neurologic injury during surgical procedures involving use of the VEPTR and to determine the efficacy of intraoperative spinal cord neuromonitoring.
Data were collected prospectively during a multicenter study. Surgical procedures were divided into three categories: primary device implantation, device exchange, and device lengthening. Further retrospective evaluation was undertaken in cases of neurologic injury or changes detected with neuromonitoring.
There were 1736 consecutive VEPTR procedures at six centers: 327 (in 299 patients) consisted of a primary device implantation, 224 were a device exchange, and 1185 were a device lengthening. Perioperative clinical neurologic injury was noted in eight (0.5%) of the 1736 cases: these injuries were identified after five (1.5%) of the 327 procedures for primary device implantation, three (1.3%) of the 224 device exchanges, and none of the 1185 device-lengthening procedures. Of the eight cases of neurologic injury, six involved the upper extremity and two involved the lower extremity. The neurologic deficit was temporary in seven patients and permanent in one patient, who had persistent neurogenic arm and hand pain. Intraoperative neuromonitoring demonstrated changes during six (0.3%) of the 1736 procedures: five (1.5%) of the 327 procedures for primary device implantation and one (0.08%) of the 1185 device-lengthening procedures. The surgery was altered in all six cases, with resolution of the monitoring changes in five cases and persistent signal changes and a neurologic deficit (upper-extremity brachial plexopathy) in one. Two patients had false-negative results of monitoring of somatosensory evoked potentials, and one had false-negative results of monitoring of somatosensory evoked potentials and motor evoked potentials during implant surgery; two had a brachial plexopathy and one had monoplegia postoperatively, with all three recovering.
Neurologic injury during VEPTR surgery occurs much more frequently in the upper extremities than in the lower extremities. The rates of potential neurologic injuries (neurologic injuries plus instances of changes detected by monitoring) during primary implantation of the VEPTR (2.8%) and during exchange of the VEPTR (1.3%) justify the use of intraoperative neuromonitoring of the upper and lower extremities during those procedures. As neuromonitoring did not demonstrate any changes in children without a previous VEPTR-related monitoring change and there were no neurologic injuries during more than 1000 VEPTR-lengthening procedures, intraoperative neuromonitoring may not be necessary during those procedures in children without a history of a neurologic deficit during VEPTR surgery.
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ABSTRACT: Study Design. Multicenter retrospective study of 54 children.Objective. To describe the complication rate of the French VEPTR series involving patients treated between August 2005 and January 2012.Summary of Background Data. Congenital chest wall and spine deformities in children are complex entities. Most of the affected patients have severe scoliosis often associated with a thoracic deformity. Orthopaedic treatment is generally ineffective, and surgical treatment is very challenging. These patients are good candidates for VEPTR expansion thoracoplasty. The aim of this study was to evaluate the potential complications of VEPTR surgery.Methods. Out of 58 case files, 54 were available for analysis. The series involved 33 girls and 21 boys with a mean age of 7 years (range, 20 months-14 years and 2 months) at primary VEPTR surgery. During the follow-up period, several complications occurred.Results. Mean follow-up was 22.5 months (range, 6-64 months). In total, 184 procedures were performed, including 56 VEPTR implantations, 98 expansions, and 30 non-scheduled procedures for different types of complications: mechanical complications (i.e. fracture, device migration), device-related and infectious complications, neurological disorders, spine statics disturbances. Altogether, there were 74 complications in 54 patients, that is, a complication rate of 137% per patient and 40% per surgery. Comparison of the complications in this series with those reported in the literature led the authors to suggest solutions that should help decrease their incidence.Conclusion. The complication rate is consistent with that reported in the literature. Correct determination of the levels to be instrumented, preoperative improvement of nutritional status, and better evaluation of the preoperative and postoperative respiratory function are important factors in minimizing the potential complications of a technique that is used in weak patients with complex deformities.Spine 09/2013; 38(25). DOI:10.1097/BRS.0000000000000014 · 2.45 Impact Factor
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ABSTRACT: VEPTR has been developed for the treatment of thoracic insufficiency syndrome in cases of congenital scoliosis with or without rib fusions but quickly evolved as an alternative for the treatment of many types of early onset scoliosis. The efficacy of VEPTR instrumentation in controlling complex congenital spine deformities, the relative ease of application, and the spine-sparing approach have been factors to stimulate this conversion. VEPTR in non-congenital cases has been shown to be effective in correcting loss of balance and pelvic obliquity, control scoliosis, and moderately improve it. However, it requires periodic lengthening and thus has a high complications rate, and usually after a certain time lengthenings become less effective. VEPTR instrumentation remains a viable alternative to other methods of management of early onset scoliosis.12/2010: pages 167-172;
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ABSTRACT: Expansion thoracoplasty (ET) is claimed to be a spine-sparing procedure because of the fact that the spine is not exposed directly and intervention toward the spinal column is not performed. It is also recommended in cases of primary spine deformities without rib fusion/aplasia and when the primary problem is not in the thorax itself. The aim of this study was to report spontaneous spinal fusion after multiple thoracic distractions in patients with congenital thoracospinal deformities who have undergone ET in early childhood. In our clinic, between May 2003 and March 2010, ET treatment was started in 11 patients who had congenital spinal deformity along with thoracic asymmetry due to fused ribs. The lengthening procedures for 6 of them are still ongoing. This study includes 5 of these patients who had undergone 3-dimensional computed tomography (3D-CT) scans. Four of these patients underwent a CT scan as part of the graduation protocol and 1 was ordered a 3D-CT because a newly formed bony fusion of the ribs was observed in a lengthening procedure. The mean age of the patients (4 F, 1 M) was 4.2 years (range, 2 to 8 y) at the time of the index operation. The mean number of lengthening procedures was 9.4 (range, 7 to 13). The mean follow-up period was 73 months (range, 60 to 96 mo). All 5 patients in the latest follow-up were evaluated by x-ray and 3D-CT scans of the whole spine. The CT scans confirmed spontaneous spinal fusion in the thoracic spine. We speculate that distraction-based, growth-friendly instrumentations are not risk-free for spinal health and motion, even when the instrumentation is not primarily on the spine. Level IV.Journal of pediatric orthopedics 07/2012; 32(5):483-9. DOI:10.1097/BPO.0b013e318257d3a9 · 1.43 Impact Factor