TRANSORAL
Table II.
Previous
DECOMPRESSION
reports
of the
result
AND
of posterior
POSTERIOR
cervical
FUSION
operations
for
FOR
RHEUMATOID
patients
with
ATLANTO-AXIAL
myelopathy
secondary
Patients
Number
of
patients
Authors
Cregan
1966
Hamblen
1983
Operative
fixation
7
Occipito-cervical
Atlanto-axial
14
Occipito-cervical
355
SUBLUXATION
to atlanto-axial
with
subluxation
Peroperative
Two-year
no improvement
(per cent)
deaths
(per cent)
mortality
(per cent)
43
15
15
20
15
Atlanto-axial
Crellin,
Maccabe
Boyle
1971
Ferlic
et
Ranawat
Conaty
and
Hamilton
1970
6
Atlanto-axial
0
33
33
4
Occipito-cervical
25
50
75
z1. 1975
12
Atlanto-axial
33
25
33
et til. 1979
19
Occipito-cervical
Atlanto-axial
32
26
37
21
Occipito-cervical
Atlanto-axial
38
5
10
21
12
32
and
Mongan
1981
±
Meijers
et at. 1984
29
Decompression
Occipito-cervical
Atlanto-axial
± Decompression
compression
of the medulla.
The knowledge
that there
may be a mass of pannus
between
dens and dura
helps
explain
the frequent
observation
that the severity
of the
neurological
deficit
does not correlate
with the degree
of
atlanto-axial
graph
(Cregan
1978;
Marks
and
The
accurate
causes
of
allow
bution
to
subluxation
1966; Rana
revealed
et al.
Sharp
1981).
localisation
compression
at
the
1973;
by
a lateral
Cabot
and
and
definition
craniocervical
radioBecker
of
compression
of
the
cord
would
the
junction
Neurological
considerable
immobilisation.
providing
the
logic
of
decompression,
removing
both
the bony
components,
and relieving
any medullary
from
a vertically
translocated
odontoid.
and Moran
(1972)
performed
a transoral
decompression
in a tetraparetic
an
occipitocervical
fusion
symptoms.
argue
recovery
morbidity
which
This consideration
nursing
care
patient
six months
had
failed
to
for these
was
resulted
and
disabled
marred
the
from
prolonged
the difficulties
patients,
they have long periods
on skull traction,
encouraged
authors
to combine
transoral
decompression
with
tenor
stabilisation,
so as to allow earlier
the patient.
Transoral
decompression
provides
advantages.
Since the structures
causing
after
relieve
by
traction
casts
on
of
when
that occipitocervical
pre-moulded
collar
atlanto-axial
porating
Three
demands
apical
and
alar
ligaments.
The
in situ,
for
surgical
minimal
tion
put.
increase
by the
In the
bone
Sweetnam
1969).
at
ing though
the
had an adequate
The
in movement
sublaminar
long term,
3.
MAY
1986
routinely
the loss
incorof the
division
of
all
results
chips
of the
at this
level
after
stabilisa-
wiring
of C 1 and C2 to the occibony
fusion
is achieved
by using
from
the
combined
iliac
crest
procedure
(Newman
are
improvement
avoiding
will further
and
encourag-
follow-up
is short.
The 13 patients
decompression
and stabilisation
been no pen-operative
deaths.
This may
the success
of the anterior
decompression,
No.
with a firm
mobility
at
continuity
and provides
a major
check
to movement
in
the anteroposterior
plane.
This has been confirmed
by
radiographic
studies
at follow-up,
which
show
only
a
success
found
68 B.
compression
considered
fixation
in combination
would
adequately
control
shown
continued
neurological
ment
of the operative
technique.
ostomy
and soft-palate
split,
VOL.
and
ligaments
between
occiput
and axis, if not already
destroyed
by disease,
would
allow
some forward
migration
ofthe
atlas on the axis (Werne
1957). However,
the membrana
tectoria,
though
it is perforated
centrally
during
the approach
to the pre-spinal
space,
retains
its lateral
cancellous
and Mongan
1981).
Ferlic
et a!. (1975)
arthritic
patients
were unable
to tolerate
skull
patience
spinal
therefore
the anterior
cervico-medullary
junction
are excised,
preoperative
traction
to reduce
the subluxation
and intraoperative
methods
of securing
the reduction
are no
longer
necessary.
Conventional
operation
requires
prolonged
postoperative
immobilisation
to maintain
the
improved
Cl-C2
configuration,
often
with very limited
(Conaty
that these
months’
“great
of acute
authors
level. Stabilisation
occiput,
compensates
the
of
some immediate
compression
bed
the possibility
elements.
The
the
pos-
mobilisation
or plasterjackets.
a Stryker
endurance
from
the patients
and
from
all those
who
cared for them”
(Meijers
ci al. 1974).
The excision
of the odontoid
peg and the pannus
eliminates
from
these
a more
direct
approach
to operation.
The contriof both rheumatoid
pannus
and the odontoid
peg
direct
anterior
and soft-tissue
compression
Sukoff.
Kadin
halo-braces,
who
have
. Developboth
trachereduce
soft-
tissue
complications.
Postoperatively,
meticulous
oral
hygiene
and the use of nasogastric
feeding
have helped
to
avoid
infection
of the pharyngeal
wounds.
There
have
reflect
but
not
also
only
that
356
H. A. CROCKARD,
J. L. POZO,
A. 0.
J. M. STEVENS,
RANSFORD,
of the regime
of early
mobilisation,
which
must
reduce
morbidity
and mortality
in this susceptible
group.
However. it must be emphasised
that this operative
procedure
can be recommended,
at present,
only for patients
with
established
cervical
myelopathy
in whom
pannus
has
been
shown
to contribute
to cervico-medullary
compres-
Conaty
JP, Mongan
ES. Cervical
Joint Surg [Am] 198 1 :63-A
Conlon
PW, Isdale
IC, Rose
spine: an analysis
of333
Cregan
Atiti
Crellin
sion.
with
The diagnosis
long-standing
index
of suspicion
of cervical
rheumatoid
and
myelopathy
in
arthritis
requires
painstaking
monitoring
patients
a high
reveal
unsuspected
Hamilton
1970).
ciated
with
myelopathy
Nevertheless,
progressive
(Crellin,
the poor
neurological
Maccabe
prognosis
deterioration
and
asso-
diagnosis
and
effective
surgical
treatment
even
important(Marks
and Sharp
1981).
Conclusions.
Computerised
myelotomography
allows
an
factors
acting
atlanto-axial
role
level.
transoral
cord.
Ann
arthritis
of the cervical
Di.s 1966:25:
120-6.
rheumatoid
Severe
J Bone
approach
R CollSurg
cervical
subluxation
Joint
Surg
of the cer[Br] 1970:
to the base of the
EngI 1985:67:321
Mr
D. Ellis
for
his consistent
and
and
treatment
arthritis.
fusion:
indications,
l967:49--B:33-.45.
Hamblen
DL.
cal spine.
thopaedics.
of rheumatoid
arthritis:
the cerviPostgraduate
textbook
ofclinical
orPGS,
1983:487
97.
Jeifreys
E. Disorders
106-18.
1980:
Marks
Surgical
management
In: Harris
NH, ed.
Bristol
etc: Wright
of the
cervical
JS, Sharp J. Rheumatoid
199:307
19.
Mathews
JA.
5-year
Atlanto-axial
follow-up
study.
spine.
cervical
subluxation
Ann Rheum
technique
London
etc:
Q
myelopathy:
in
Dis
and
Butterworths,
J Med
rheumatoid
1974:33:526-31.
1981:
arthritis:
a
Luyendijk
W, Duijfjes
F. Dislocacord
compression
in rheumatoid
1974:56
B:668
80.
at the
sub-
Meijers
KAE, Cats A, Kremer HPH, Luyendijk W, Onvlee GJ, Thomeer
RT. Cervical
myelopathy
in rheumatoid
arthritis.
C/in Exp Rheu-
in the
Nakano
1984:2:239-45.
KK. Neurologic
C/in North
Am
complications
1975:6:861-80.
of rheumatoid
Newman
P, Sweetnam
R. Occipito-cervical
nique
and
its indications.
J Bone
423-3 1.
Rana
NA, Hancock
DO,
luxation
in rheumatoid
55-B:458-70.
Taylor
AR,
arthritis.
arthritis.
excellent
Redlund-Johnell
ti.s. Thesis,
Smith
REFERENCES
I. Dislocations
oft/ic
Malm#{246}, 1984:69-89.
Orthop
fusion:
an operative
techJoint
Surg
[Br]
l969;51-B:
Hill AGS.
Atlanto-axial
J Bone
Joint
Surg
[Br]
Ranawat
CS, O’Leary
P, Pellicci
P, Tsairis
P, Marchisello
Cervical
spine
fusion
in rheumatoid
arthritis.
J Bone
[Am] 1979:61-A:
1003-10.
to thank
brain
5.
KAE,
Van Beusekom
GTh,
tion of the cervical
spine
with
arthritis.
J Bone Joint Surg [Br]
mortality.
wish
spine.
Meijers
Transoral
anterior
decompression
and
posterior
cervical
stabilistion
removes
both
the bony
and
softtissue
elements
of compression
and allows
early mobilisation
of the patient,
thereby
reducing
morbidity
and
The authors
photography.
of the unstable
242-52.
J Bone
arthritis.
DC, Clayton
ML, Leidholt
JD, Gamble
WE. Surgical
ofthe
symptomatic
unstable
cervical
spine in rheumatoid
J BoneJoint
Surg[Am]
I975:57--A:349
-54.
matol
important
at this
fusion
in rheumatoid
: I218-27.
RQ, Maccabe
JJ, Hamilton
EBD.
vical
spine
in rheumatoid
arthritis.
52-B: 244-5 1.
The
K. ESSIGMAN
Hamblen
DL.
Occipito-cervical
results.
JBoneJointSurg[Br]
makes
early
more
accurate
analysis
of the compressive
craniocervical
junction
in rheumatoid
luxation.
Rheumatoid
pannus
plays an
pathogenesis
ofcervical
myelopathy
Ferlic
W.
BS. Rheumatoid
cases.
Ann R/ieum
JC. Internal
fixation
Rhewn
lJi.s I 966;25:
Crockard
HA.
uppercervical
of symp-
toms
and signs.
Multiple
joint
involvement
and
peripheral
neuropathies
often make clinical
assessment
very
difficult;
only detailed
examination,
including
position
sense,
sensory
appreciation
and plantar
responses,
will
B. E. KENDALL,
cervicalspme
in rheumatoid
PH, Benn RT, Sharp J. Natural
history
of rheumatoid
luxations. Ann Rheuni
Dis 1972:31:431
-9.
sub1973;
P, Dorr L.
Joint
Surg
art hricervical
Sukoff
Boyle
AC. The
Proc R Soc
rheumatoid
neck (Ernest
.%led 1971 :64: 1 161 5.
Cabot
A, Becker
A. The
Orthop
1978:131:130
cervical
40.
spine
Fletcher
in rheumatoid
memorial
arthritis.
lecture)
Cliti
MH, Kadin MM, Moran
T. Transoral
decompression
for myelopathy
caused
by rheumatoid
arthritis
of the cervical
spine:
case
report.
JNeuro.surg
1972:37:4937.
Werne S. Studies
in spontaneous
atlas dislocation.
Acta Orthop
Scand
1957:Suppl
23:11-141.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
VASCULARISED
RIB
GRAFTS
DAVID
Front
The
years
results
of vascularised
(average
34 months).
(average
8.5
a useful
alternative
healing
(Weiland,
ing that
weeks);
kyphosis
In
andor
the
body
grafts
fracture
may take up to two
during
the healing
of bridgpopular
of
resection
years
phase
for
structural
is available
more
readily
to incorporate
and
(Streitz
ci al. 1977;
and
analysed
and
KYPHOSIS
DAI-IER
Minneapolis
in 25 patients
rapid
1 1 weeks
followed
incorporation
(range
up for
of the
grafts
5 to 24 weeks).
an avascular
were
more
than
two
in 4 to 16 weeks
The
rib or fibula
small-vessel
12 women
to 66 years
was trauma
since
technique
seems
it promotes
and
13 men
whose
ages
(average
33 years).
The
in 20, infection
in three
tuberculosis
in
myelomeningocele
tumour,
homografts
or
and Stock
ci al. 1977;
Bonnett
1977;
McBride
and
however,
that
Bradford
(i (Ii.
1982). A vascularised
fibular
graft
could
avoid
these difficulties
by providing
immediate
stability
and rapid
healing
(Johnson
and Robinson
1968).
but a
vascularised
rib graft might
be preferable
since this type
ofgraft
Center,
employing
and it is thus surprismore
frequently
to
management
vertebral
are
early
H.
OF
rapid
techniques.
as a method
increasingly
I 983).
applied
YOUSSEF
averaged
or homografts
STABILISATION
Scoliosis
transfers
showed
trauma.
or infection.
strut
grafting
with
allografts
is a standard
procedure
(Hodgson
1960: Hodgson
1965: Stener
1972: Bradford
Hall and Poitras
1977; Streitz,
Brown
and
Moe
ci (11. 1978;
Bradford
ci al. 1982;
Bradford
1983).
It is well documented,
such
may
Cities
immobilisation
surgical
techniques
defects
have
become
deformities.
Titi,i
microsurgical
Moore
and Daniel
they have not been
spinal
BRADFORD,
rib graft
external
needing
S.
Radiographs
to allografts
without
Microvascular
ing bone
the
FOR
one).
post-laminectomy
in one.
Radiographs
were
ranged
from
cause of the
(osteomyelitis
in
evaluated
16
kyphosis
in two.
one.
and
pre-operatively.
a
post-
operatively.
and at follow-up
and the angles
of kyphosis
and scoliosis
were measured
using
the Cobb
technique.
Additional
investigations
included:
lateral
planograms
of the injured
segment:
myelography
performed
in all
patients
with persistent
or increasing
neurological
deficit;
and a CT
to evaluate
scan both
the spinal
pre-operatively
canal and
tion
of the
rib
strut
graft.
was
done;
in
one
the
patency
difficult
and postoperatively
the quality
of incorpora-
In two
quality
to discern.
patients
was
In the
poor
second
an aortogram
and
the
vascular
aortogram
anasto-
mosis
is unnecessary.
Rose.
Owen.
and Sanderson
(1975)
proposed.
for
stabilisation
of kyphosis.
a technique
of transposing
the
rib with its blood
supply
intact.
and in an independent
report
Bradford
1980).
To date
have
not
presented
been
our
a similar
patients
reported.
this technique
reconstructive
who
and
had
it is our
and to discuss
surgery.
PATIENTS
technique
have
(Bradford
this
purpose
its possible
AND
role
procedure
to review
in spinal
METHODS
From
June
1978 to July 1982. the first author
treated
27
patients
using vascularised
rib grafts;
two patients
were
lost to follow-up.
leaving
25 for review
(Fig.
I). There
D. S. Bradtrd.
MD, Professor
ofOrthopaedic
Surgery
Y. H. Daher,
MD. Research
Fellow
Department
of Orthopaedic
Surgery,
University
of Minnesota,
189 Mayo.
420 Delaware
Street
SE. Minneapolis.
Minnesota
USA.
Requests
(
for reprints
1986
British
should
Editorial
he sent
Society
to Dr
of Bone
Box
55455.
D. S. Bradford.
and
Joint
Fig.
Levels
0301-
620X
86 3072
VOL.
68 B.
No.
3.
S2.00
MAY
986
I
Surgery
of fusion
using
a vascularised
rib strut graft
were lost to follow-up
(x).
in 27 patients:
two
357
358
D. S. BRADFORD.
showed
that
patent
and
hypertrophy
as well
the
intercostal
vessel
that the graft was
(Bradford
1980).
as the number
rib
graft
was
intact
with apparent
The rib chosen
was
of vertebrae
distance
measured
of the strut
graft
from
on the lateral
radiograph
than
ofscoliosis,
25
to the
within
the
Y. H. DAHER
bony
noted
Artery
.lntercostal
the fusion.
The
apical
vertebra
or, if there was
was
more
Cava
on the oblique
film.
Sixteen
of the 25 patients
had
had previous
non-operative
treatment
for kyphosis:
four
were treated
by bed rest, seven by bed rest and a brace or
cast. two by a brace.
two by a cast. and one by a halo
Indications
for
cast.
The
operative
tomy
plus
operation.
remaining
treatment:
arthrodesis
nine
patients
a laminectomy
in two. and
had
had
in four,
arthrodesis
previous
laminecalone
in
three patients.
In all patients
the indication
for operation
was either
progression
of the kyphosis
or pain or both.
Thirteen
patients
pression.
six
with a femoral
ised rib graft.
and
developed
anterior
tenor
spinal
were
patients
neck
treated
one patient
implant.
fusion
by anterior
by a vertebral
allograft
associated
with
spinal
decom-
body
replacement
with a vascular-
by the insertion
ofa
Five had an additional
instrumentation.
The
newly
pos-
vascular-
ised rib grafts
ranged
in length
from
average
length
being 9 cm.
In I 7 patients
the grafts
were inlaid
the vertebral
bodies;
in eight patients
the
ior to the vertebral
bodies
at the apex of
were classified
as strut grafts.
The distance
5 to
cal vertebra
on the lateral
oblique
27 mm).
to the strut
graft
radiographs)
The number
(measured
16cm,
the
The
into slots within
grafts
lay anterthe kyphos
and
from the apior
ranged
from
10 to 45mm
(average
of fused
vertebrae
averaged
four
(range
two to eight);
posterior
arthrodesis
was
in five patients
with
compression
Harrington
also done
rods
in
three.
and
compression
and
distraction
rods
in one,
traction
rod with segmental
wire fixation
in one.
loss ranged
from 450 to S000ml
(average
1978ml).
operative
immohilisation
consisted
ofa Rissercast
a disBlood
Postin six,
tenth
rib is mobilised
The
skin
skin
incision
cautery
superior
on its vascular
is prepared
is made
cut distally
at its sternocostal
sels are ligated
with
clips.
proximally.
identification
is planned
so that
the blood
supply
of the rib to be removed
will not be
compromised
by the bony procedure.
lfstabilisation
and
fusion
in situ is planned
for a kyphosis
extending
proximal to T5. a rib one or two segments
below the distal vertebra of the kyphosis
is removed;
the distal end of the rib
graft
is rotated
to reach
the proximal
vertebra
whose
fusion
is planned.
If the kyphosis
does not extend
proximal to T5, a rib one or two above
the distal
vertebra
of
the kyphosis
is removed,
reach
the distal
vertebral
rotating
its distal
body
to be fused.
portion
If, on
to
the
other
hand,
an anterior
cord decompression
is planned,
it is preferable
to remove
the rib corresponding
to the
level of the apex
of the kyphosis
in order
to facilitate
exposure
for the decompression.
For arthrodesis
thoracolumbar
or lumbar
spine.
removal
of the
(maintaining
its vascularised
pedicle)
is sufficient.
of the
tenth rib
as the graft.
fashion
and
the
to be mobilised.
chest
junction
Detachment
Chest
retractors
of the intercostal
facilitates
more
proximal
the anterior
longitudinal
mobile
vascular
pedicle
thoracotomy
rib
used
be
The
muscle
used
at the
on the
inferior
border,
but
a cuff
of intercostal
muscle
of
approximately
4 to 5 mm should
be left attached
to the
rib to avoid
damaging
the intercostal
vessels.
The rib is
immobilisation.
A
the
knife is used to cut the intercostal
border
of the rib; it can also
divided
dissection
technique.
and
in a routine
along
a body jacket
or brace in 1 1 , a cast followed
by a brace in
five, and a halo cast in one; two patients
had no external
Operative
pedicle
at its posterior
angle
and the intercostal
and
the distal yesthen
proceeds
are placed
in position
vessel on the inside
dissection.
after careful
vessels
are
The
and
of the
rib
is
subperiosteal
mobilised
over
ligament
facilitating
(Fig.
2). The rib may
a more
be short-
ened from its proximal
or distal
portion
depending
upon
the length
needed
for fusion.
The rib on its vascularised
pedicle
is then placed
loosely
into the chest and exposure
to the spine increased
pression
be necessary,
damaging
in situ
if needed.
Should
great care must
the intercostal
vessels
arthrodesis
is indicated,
vertebral
bodies
are exposed
triangle
is cut into the bodies,
snugly
into the slot and is then
above
and below.
Circulation
by making
over
the
anterior
be taken
decomto avoid
during
this procedure.
If
the proximal
and distal
and
the disc excised.
A
the graft is trimmed
to fit
wedged
into the vertebrae
of the rib may be checked
an incision
I to 2cm long
rib: brisk
bleeding
confirms
in the periosteum
an intact
blood
supply.
may
With a thoracolumbar
be used
through
THE
kyphosis,
the same
a thoraco-abdominal
JOURNAL
OF BONE
AND
JOINT
technique
approach
SURGERY
VAS(UI.ARISEI)
RIB GRAFTS
mobilising
the ninth or tenth rib in a similar
3). The graft
is wrapped
in a saline-soaked
placed
into
twist
along
the
chest
cavity.
taking
care
fashion
sponge
not
the vascular
pedicle.
The diaphragm
its posterolateral
chest wall insertion
peritoneal
space
isolated
prepared
is entered.
The
FOR
STABILISATION
359
OF KYPHOSIS
(Fig.
and
to kink
or
is then incised
and the retro-
segmental
vessels
and ligated
with clips and the vertebral
to accept
the vascularised
rib graft.
are
bodies
After
anterior
decompression
a femoral
head
and
neck allograft
niay be used to occupy
the space left after
vertebral
body
resection.
A laminectomy
spreader
is
placed
between
calcar
ltcing
A high-speed
the two opposing
anteriorly.
the graft
dental
burr is then
vertebrae
and. with the
is wedged
into position.
used to cut a slot in the
lateral
of the allograft
also
cortex
and
in the adjacent
ver-
tebral
bodies
above
and below
the decompression
area.
The vascularised
rib graft is then trimmed
to the appropriate
lellgth
and the soft tissue
on the side of the rib
opposite
one-third
the intercostal
or one-half
vessel
is carefully
rib width
to allow
the
elevated
to
direct
bone
contact
when
the graft
is inserted.
The
rib is then
impacted
into the slot with the intercostal
vessel on the
lateral
aspect
of the slot: this prevents
any compromise
of rib vasculature.
The diaphragm
and chest
are then
closed
ill a routine
fashion.
An anterior
implant.
may be inserted
after decompression,
distracted
allow
for
insertion
of the
improve
fIxation
Postoperative
graft
and
of the graft.
management
then
depends
if used,
gently
to
compressed
upon
to
the
mdi-
cations
and technique
of operation.
If the operation
was
to correct
kyphosis.
and if discectomies
with interbody
fusions
were done
at each
level,
then posterior
instrumentation
may
he necessary
as a second-stage
this
were
analysed
procedure
igure
was
4- --An
discectoiiiv
25 of the
performed:
adult
W1S
for
not
l:ig.
with
4
a severe
performed.
27 patients
follow-up
kyphosis
Figure
it
VOL.
68 B.
No.
3. SlAV
986
in whom
ranged
of I 28
6--Eighteen
remains
from
associated
months
intact
and
between
Tl2
incision
is made
L2 in a slot cut
and
and the tenth
into the vertebral
to 62 months
(average
operative
immobilisation
34 months),
ranged
(average
Radiographic
II
weeks).
incorporation
ofthe
bone
about
eight-and-a-halfweeks
Pain.
Before
operation
despite
minimal
tially
operation.
discomfort
graft
bodies.
the duration
from
5 to
24
evidence
was
(range
14 patients
pain
associated
with
the
follow-up
12 had complete
rib
graft
placed
of postweeks
of
early
seen in all patients
at
4 to 16 weeks).
had significant
back
kyphosis.
reliefofpain;
When
last seen at
in one the pain,
remains
the same and another
though
his pain has been
still has
substan-
relieved.
Correction
of the
kyphosis.
The
degree
of correction
has
varied
and seems
related
to the pre-operative
condition
(Figs
4 to 9). In one patient
presenting
with
a myelomeningocele.
a pre-operative
thoracolumbar
kyphosis
of
procedure.
RESULTS
Results
A thoraco-abdominal
24
with
after
appears
135
later
was corrected
to 36
it was 41 : this patient
tion
and
Fig. 5
achondroplasia.
operation
a lateral
to be completely
vertebral
Figure
and at follow-up
had undergone
body
5-A
radiograph
consolidated.
resection
vaseularised
shows
that
Fig. 6
rib graft
the graft
62 months
cord
resec-
posteriorly
has
has
been
inserted:
hypertrophied:
with
360
I).
S. BRADFORI),
Y. H. I)AHER
Figure
7--The
radiograph
of a patient
who presented
with an incomplete
paraparesis
following
an old burst
fracture
of LI . Figure
8After
anterior
cord decompression
and anterior
spinal
fusion
using a vascularised
rib graft with a femoral
head allograft,
the kyphosis
has been partially
corrected
and the spinal
canal decompressed.
Figure
9-At
follow-up
partial
loss ofcorrection
with partial
collapse
of
the fernoral
head allograft
is noted.
Fusion
is, however,
solid.
The patient
has recovered
some neurological
function
and pain has been
relieved.
Harrington
instrumentation,
followed
by anterior
final
vascu-
follow-up.
The
larised
rib grafting
as a second-stage
procedure.
In the
three
patients
with
osteomyelitis.
the
average
preoperative
kyphosis
was
39 : at follow-up
(average
37
months)
it was 40
In the patient
with post-laminectomy
initially
showed
improvement
kyphosis,
became
worse
.
the
months
recovery.
kyphosis.
from 7
deformity
was
later
it was
42
In the remaining
the pre-operative
to 90 ): at follow-up
68
.
while
at follow-up
47
with
complete
neurological
20 patients
with
traumatic
kyphosis
averaged
36 (range
(average
34 months),
it was
31 (range
7 to 85 ). Seven ofthe
five degrees
or more ofcorrection
6 to 19 average
12 ).
25 patients
postoperatively
(28%)
deficit.
Thirteen
cord decompression:
1 2 had
the time of the anterior
strut
terolateral
dislocation
patients
incomplete
icular
decompression
at the time
the indication
neurological
pain.
A
modified
function
10 patients,
with
subsequently
and was classified
four had complete
in neurological
20 months
after
scan and myelogram
on
the anterior
decompression
osteomyelitis
had
as
return
“
E”
recovery,
function,
operation:
. Of
and
a follow-up
of
the
five
one
CT
this patient
demonstrated
was incomplete.
that
COMPLICATIONS
anterior
in two,
spinal
transient
fusion
ileus
ficial
over
wound
site
infection
in one.
in one, a neuroma
and loosening
of the
underwent
spinal
anterior
fusion
decompression
and one had
at
a pos-
with reduction
ofthe
fractureof posterior
spinal
fusion.
In I I
for a cord
decompression
was
deficit
and. in two, severe
radclassification
patient
“B”
Complications
after
patients:
atelectasis
patients
Frankel
neurological
remaining
one
as
lost
(range
,
Neurological
classified
system
(Frankel
ci a!. 1969) was used to classify
the neurological
deficit and the results
at follow-up.
The two patients
with
radicular
pain had complete
relief of their symptoms
at
thoracotomy
the thoracotomy
anterior
implant
with
a loss
of correction
occurred
in one,
in six
super-
of 9
in one
patient.
A seventh
spasticity
in the
patient
lower
(Case
extremities
8)
developed
increasing
and a gradual
loss
of
sensitivity
to pinprick
in the upper
thoracic
area (T2-T3)
20 months
after
anterior
decompression
and
anterior
spinal
fusion.
A metrizamide
myelogram
and a CT scan
showed
minimal
compression
of the spinal
cord
at the
apex of the kyphosis;
this patient
underwent
hemilaminectomy
and
posterolateral
THE
JOURNAL
decompression
OF
BONE
of the
AND
JOINT
spinal
SURGERY
VAS(ULARISEI)
canal
at T2
in gait.
Seven
5
T3
and
improvement
soIl.Ie
at
the
recent
in the spasticity
GRAFTS
follow-up
but
FOR
had
no improvement
STABILISATION
patients
(range
6
had
a loss
to 19 : average
no further
correction
ofcorrection
12.3
seen
): three
ofthese
than
by creating
ofcontinuing
posterior
and
no subsequent
loss
of
mote
eventual
to provide
fusion
the
use
anterior
is a useful
of fibular
support
(Bradford
Frankel
et
1977; Malcolm
ci of. 1981).
In severe
kyphosis,
it has
been k)tlIld
that placement
of the bone graft
anterior
to
the vertebral
bodies
over the apical
segments
affords
the
best results:
it provides
a distinct
mechanical
advantage
by preventing
further
collapse
of the deformity
in the
sagittal
plane
(White.
Panjabi
and Thomas
1977). However,
we had previously
found
that bone
grafts
placed
more
than 4 cm anterior
to the apical
vertebral
body are
more
likely
to fracture
during
bone
consolidation,
and healing
(Bradford
ci al.
has also been reported
by other
1974: Streitz
ci al. 1977; Stagnara
I 98 1 ). Our technique
of vascularised
appear
where
to be advantageous,
particularly
the strut graft
is anterior
to the
Of the I I patients
in this
technique
was used. three
anterior
to the
apical
graphically.
these
and
this corn(Yau ci
Gonon
would
the anterior
strut
lay 4cm or more
not
one
of these
interesting
to note how
healing
occurred:
assessed
grafts
appeared
ci al.
thus
in those
cases
vertebral
bodies.
series where
of the grafts
vertebra
fractured.
It was particularly
bony consolidation
and
revas-
1982):
authors
1978;
grafting
a!.
to
heal
has
of the graft.
impossible
impression
The
more
rapidly
radio-
within
radical
iii
the
suIt.
stahilisation
approaches
procedure
In growing
for kyphosis
contra-indicated.
VOl..
68 B.
hand,
was
difficult
No.
since
3. MAY
1986
for
correction
II
if not
is uniquely
suited
kyphosis,
for
stabilisa-
children
a single-stage
using
this approach
one
may
produce
in
would
a progressive
bone
grafting
of anlerior
1977:
Ort/iop
for the
treatment
:680-90.
HL, Hancock
tion in the
paraplegia
DO, Hyslop
initial
management
and tetraplegia.
G, et a!. The value
of closed
I. Paraplegia
GP, de Mauroy
JC, Frankel
P. Campo-Paysaa
Grefles
ant#{232}rieure: en #{234}taidans
Ic traitement
cyphoscolioses.
Rev C/dr Ort/zop
1981 :67:731
Hall
JE, Poitras
myelomeningocele.
B.
The
Hodgson
AR. Correction
nication.
JBoneJoint
management
C/in Ortliop
of
1977:
ofpostural
reducof the spine
with
179-92.
injuries
1969:7:
Gonon
A, Stagnara
des cyphoses
45 (Eng.
Abstr.).
kyphosis
128: 33 40.
of fixed spinal
curves:
Surg[Am]
1965:47
in
patients
a preliminary
A: 1221 7.
P.
et
with
commu-
Hodgson
AR, Stock
FE. Anterior
spine
fusion
for the treatment
of
tuberculosis
of the spine:
the operative
findings
and
results
of
treatment
in the first one hundred
cases.
J Bone Joint
Stag
IA,;,]
1960:42
A:295
310.
Johnson
JTH,
Robinson
RA. Anterior strut grafts for severe kyphosis:
results
of 3 cases
with
a preceding
progressive
paraplegia.
C/in
Orthop
1968 :56: 25-36.
Malcolm
BW, Bradford
DS, Winter
RB, Chou
SN.
Post-traumatic
kyphosis:
a review
of forty-eight
surgically
treated
patients.
J Bone
JointSurg[Am]
1981:63
A:89I
9.
McBride
GG, Bradford
neck
allograft
and
treating
post-traumatic
1983:8:406-IS.
Moe
JH,
Winter
spinal
GK, Owen
Rose
RB,
deforniitie.s.
OS. Vertebral
body
replacement
rib strut
graft:
with
neurologic
vascularized
kyphosis
Bradford
Philadelphia
R, Sanderson
DS,
with femoral
a technique
for
deficit.
Spim’
Lonstein
JE. Seolio.si.s
etc: WB Saunders.
1978.
JM.
Transposition
of a spinal
kyphos.
aFl(l
of rib with
J Bone Joint
JW. Rib transposition
vascularized
bone grafts-hemodynamic
assessment
ofdonor
rib graft and recipient
vertebral
body.
Trans 1984:8: 153.
Stagnara
P, de Mauroy
other
blood
Surg
Gonon C, Campo-Paysaa
A. Scolioses
et greffes
ant#{233}rieures. International
orthoetc: Springer-Verlag,
1978: 149 65.
BSC. Resection
of the spine
for tumours.
Orthopaedic
.surgeri’
and traumatologv.
Proceedings
of the 12th Congress
of the International
Society
of Orthopaedic
Surgery
and Traumatology.
Tel
Aviv 1972. Amsterdam:
Excerpta
Medica
1973:384
6.
Streitz
W, Brown JC, Bonnett
CA. Anterior
fihular
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in the
treatment
ofkyphosis.
Cli,, Orthiop
1977:128:
140 8.
Weiland
AJ. Moore
JR, Daniel
AA III, Panjabi
kyphotic
be
Ort hop
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situ
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(SICOT).
Berlin
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of
Moe JH. Techniques
of kyphosis.
(‘li,i
Shaffer
to measure
accurately,
although
it is our
that this has indeed
occurred
in several
cases.
use of the technique
described
does not preclude
although
tiOll
on the other
a
is advisable.
vascular
pedicle
Spine 1980:5:318
23.
supply
for the stabilisation
[Br]1975:57
B:112.
weeks
of insertion.
As has recently
been
reported,
the
blood
flow gradient
from a graft
to a vertebral
body
is
favourable
for graft
viability
(Shaffer
1984).
Hypertrophy
arthrodesis
DS. Anterior
1982:64--A
to pro-
(ii.
cularisation
plication
if
is contemplated.
Bradford DS, Ganjavian 5, Antonious D, Winter RB, Lonstein JE, Moe
JH. Anterior
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for the treatment
of kyphosis:
review
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with
forty-eight
patients.
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and
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DS, Winter
RB, Lonstein
JE,
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Bradford
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in the presence
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management
strut
tether
In children,
patients
DISCUSSION
In the
growth.
posterior
ofkyphosis.
or rib strut
an anterior
vascularised
second-stage
spinal
fusion
with
Harrington
one had insertion
of an anterior
the anterior
procedure.
All seven
complications
was
ofmore
361
OF KYPHOSIS
deformity
anterior
also
had
a posterior
instrumentation,
while
implant
tt
the time
of
had
most
RIB
Yau
deformities.
ACMC.
Hsu
sis: correction
anterior
and
1419- 34.
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autografts.
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95.
MM,
Thomas
Cli,,
Orthzop
CL. The
I 977:
clinical
biomechanics
128 : 8 I 7.
of
LCS, O’Brien
JP, Hodgson
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and
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J Bone Joint
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A: