Case report: Impact of the NSpine Arosa meeting collaboration

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Case performed by Oded Hershkovich and Bronek Boszczyk (both Centre for Spinal Studies and Surgery, Queen’s Medical Centre, Nottingham, UK). nspine

Introduction
We would like to present an interesting clinical case of adolescent idiopathic scoliosis (AIS), in which the concave costoplasty technique we utilise was modified after a very productive case-based discussion with faculty during the last Nspine meeting (29 January–2 February 2018, Arosa, Switzerland). We usually utilise a Z-plate costoplasty to elevate concavity ribs in cases of severe chest wall asymmetry and presented such a case during the meeting.

The case
We present a 22-year-old healthy female with adolescent idiopathic scoliosis with Right  Lenke 1B curve of T5–T12 of 73 degrees bending down to 57 degrees. The compensating lumbar curve measured from T12 to L4 was 33 degrees bending down to 9 and the pelvic tilt curve measured 35 degrees bending to 20 degrees. (See preoperative X-rays and photos: A, B and E). Physical examination revealed a severe posterior chest wall asymmetry through convex rib hump and a very significant concave chest wall depression.

The surgical procedure
The procedure was performed from the posterior direction. Due to the dysplastic pedicles, the new Ennovate system (B braun) was used, which allows cannulated screw placement over K-wires, improving the accuracy in the concavity screw placement. Screw placement was completed under fluoroscopy.

Chevron osteotomies were completed at T5–6, T6–7, T7–8, T8–9 and T9–10. Concave and convex costoplasties were achieved from sixth to eleventh ribs removing 1cm of rib beyond the knuckle deformity on the convex side. Concave retropleural exposure to the bridging anterior ostrophytes at T8 and T9 allowed an additional release of the anterior column (see CT images). Further release at the T9–10 level was abandoned due to MEP (Motor-evoked potentials) drop after retractor placement which presumably reduced spinal cord blood flow. After MEP stabilisation surgery was continued.

Sublaminar bands placed at T8 and T9 complemented the pedicle screw construct for the reduction manoeuvre. Curve correction was satisfactory and uneventful. Chevron osteotomies closed gently with sequential compression. Careful segmental de-rotation was performed across the curve apex with the Ennovate reduction devices.

The convex ribs (with the apical deformity removed) were approximated with Ethibond sutures. For the correction of the concavity, a third rod was contoured and attached to the main construct. The concavity ribs were lifted onto this rod and sutured in place. Utilising this third rod allowed lateral expansion of the rib cage which created a more harmonious flank shape.

Finally, the procedure was completed with decortication and layering of local bone. An epidural catheter was inserted along with a chest drain on the right due to small pleural breaches. We estimated one litre of blood lost.

Post-operative
Patient was kept in an ICU for 24 hours post operatively with patient- controlled analgesia (PCA) line for her pain. On day three post-operatively, our patient developed respiratory distress and a standing X-ray revealed a left retro-pleural haematoma that was not resolved over time. After needle aspiration of the retropleural haematoma the patient improved gradually and was discharged home on day 18.

Conclusion
There are various techniques to correct posterior chest wall deformity. We expanded our arsenal after the NSpine Winter Masterclass, demonstrating the value of case discussion forums between experts for the advancement of complex spinal reconstruction.

Masterclass
We took part in the NSpine Winter Masterclass 2nd Platinum Small Group Educational Event (29 January–2 February 2018, Arosa, Switzerland).

The NSpine Winter Masterclass is truly interactive; it is probably the only event running across an entire week covering virtually all aspects of spinal surgery.

The event is primarily aimed at established spinal surgeons. The format is open discussion focusing on treatment options and technical surgical details. All areas of spinal surgery are within the scope of the meeting whereby the more specific programme is structured around delegate’s preferences and interests. Delegates are encouraged to bring cases for discussion to supplement those brought by the faculty. A typical case will run for around 20 minutes, although some have been debated for over an hour. Discussions are friendly and open with learning points being made equally from cases that went well and those that did not.

The meeting is led by six faculty members: experienced surgeons with different subspecialty focuses, so that all complex surgical aspects can be debated effectively. This year we included more cases dealing with pediatric deformity challenges. Morning sessions included all delegates together for more common problems, and the afternoon included split sessions narrowing down on subspecialty details. We covered cases from all aspects including complex tumour resections of the entire spine sacrum to craniocervical junction; intramedullary and nerve sheath tumours; complex adult deformity corrections with multilevel anterior reconstruction or complex osteotomies; trauma of the entire spine from atlas to sacrum; and complex pediatric and adolescent deformity. This was a unique opportunity to discuss very specific surgical techniques with the highly-experienced faculty and delegates.

In addition to the case above, Henry Halm, (Department of Spinal Surgery and Scoliosis, Schön Klinik Neustadt, Germany) demonstrated a simpler technique, which utilises osteotomy of the rib at the costovertebral junction, allowing elevation of the rib onto the concavity rod where they are sutured in place. Both techniques can be combined with convex costoplasty as needed to harmonise the posterior chest wall appearance. The detailed discussion allowed us to offer a modification of the technique with a three rod  construct and demonstrates the value of expert case discussion forums.

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