Tratamiento de la escoliosis con el TSRH

IV JORNADAS CANARIAS DE TRAUMATOLOGIA Y CIRUGIA ORTOPEDICA
Tratamiento de la escoliosis con el TSRH
Dr. ROACH
Te.ra.~
.'il'othish Hite.
Dalla.~. f:.~tados Unido.~
lf the curve progresses in spite of bracing often leaves you with a very
severe deformity.in a very young child and initially we tried to instrument
without fusion . We would do a rod without fusion using the rod as interna! splint. However the majority of these failed. The children did not grow
the rods became unstable, they came out of the skin, there was infection.
lt was a terrible problem. So, 1do not believe that instrumentation without fusion is accesible. 1do not believe that the children grow.
Now we use a small implant, a much smaller hook. lt attaches to the
rod in exactly the same way as the adult iniplant with an eye bolt and it
cramps or fastens to the rod in exactly the same way. We have done only
six patients of 4 to 12 years of age. Two of the patients were tour years
old at the time of surgery and because they were so young and so small
we only put in one rod. However we did both an anterior and a posterior
chemiepifhasienisis, fusion on one half of the spine and instrumented posterior! y and put them in a brace.
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This was one child with a severe curve preoperating 96 degrees, had
failed both casting and bracing .
Single rod with early postoperating result . Still in but any apepsiadisis
both front and back.
The second child was more severe. Single rod, both front and back surgery. Both of these have held up. So 1think the fusion is a tether and mantains stability. These children will have short trunks but will stay straight.
We had tour patients who were bigger, larger and we were able to put
in the pediatric implant with two rods. An example and the postoperational situation . These are small rods, three sixteen rods with small hooks.
Next 1would like to tell you a little about how we instrument paralitic
scoliosis. Neuromuscular scoliosis is one of the hardest and difficult deformities because there are so many acting on the implant which we can.not control. You have two deformities, both scoliosis and pelvic obliquity.
Hopefully it does not get this severe. Pelvic obliquity produces difficult
sitting. In spina bifida or paralisis it produces pressure sores. Your options
and choices are to try to fix the scoliosis all the way to the pelvis using
either saple screws,the CD eliosacris screws with connectors or the galveston technic which is a rod.
Clinically we looked at one year's work on patients, sixteen patients with
neuromuscular diagnosis, average age 15 years, and we only looked at
them for 12 months because we wanted to know the acute failure problems with pelvic fixation. Operating time was long, blood loss was high.
We used a cell saver, so we replaced a lot of them, but still a lot of blood
lost. The methods of fixation vary depending on the anathomy of each
patient. Six patients had bilateral sacral crews. Two had sacral screws with
ileosacral connectors, two had initially the galveston technique and six had
accomodation depending on their anathomy.
We had many complications. We had mechanical complications at surgery, during surgery. Two of the patients had pull out the sacral screws
right the operating room and had to be revised to a different instrumentation. Pqstoperativelly we had morecomplications. Five patierhs had delayed implant failure. Two hada partial pull out of the sacral screw and three
had completed failure.
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This is an example of spina bifida. Seventy five degree curve . Suki instrumentation first. Sacral screw fixation second. Postoperativ_ely on the
right it looks pretty good. Four months later pull out, rods are coming
through the skin and there is infection.
After we had problems with our patients we went to·the taboratory and
tested the three different devices. We used test spines and each one was
loaded in flexion to failure. The sacral screws pulled out directly form the
bom as you would expect. The illeo sacral connector is strong here but
is not fixed here and so the whole spine can rotate around that point and
it fails by pulling out of the illeo sacral screw out and rotating around the
unfixed portion of the connector. However it is not too bad. The galveston technique did not fail in bom, it bit the rod.
These were the results. The galveston was the strongest. The sacral screws
were only half the strenght of the galveston technique approximatedly.
The illeo sacral screws were half way approximatedly in between.
We believe that the galveston technique is the best method of pelvic
fixation at this time. We now correct our scoliosis independent of the pelvic obliquity. 1hope to show down this model. First we place hooks on
the convexity of the curve. Then w~ counter our rod to achieve what we
hope is ouc final lateral curvature . The rod is placed into the lumbar portion first and it is not attached to the thrass portion. This hook is very important beca use as you rotate the rod is a downwards direct force to rotate the lumbar spine. Maybe it would be better to use pedicular screws because you would have a belter forward force. Right now we are still using
hooks, ocasionally using screws. You rotate the rod in the lumbar spine
to correct the lumbar scoliosis and you do not attach above yet. After you
have rotated yo u can compress to attached above. After the lumbar spine
is straight you counterlever the rod over to the toracic spine is straight
you counterlever the rod over to the toracic spine and drove it into the
open hooks. The hooks are all open so that they can be lifted over and
drop directly in to correct the toracic portion .
The open hooks allow this to be done because ther is no obstruction
and you do not have to thread the rod up and down. Short galvestone rods
now can be linked to the scoliosis right above. They do not have to be
long, rather short. Two short rods, it is véry quick andthey can be crosslinked above. lt is very important, 1believe, to have a hook below to stabilize this structure. 1do not believe it is safe to come down and do this wit. hout having furher stability with this hook. After you have the two gallieston rods in you can tore the spine for obliquity correction and this child
had a severe curve with spinal muscular atrophy and this is the construct.
A lot of metal. You have to be very careful to el ose all of this over so that
infection is not a problem because this is a large amount of space taken
up by metal. But good correction in the pelvic obliquity and scoliosis is
achieved using that technique.
Galvestone rods go a way out, 8 centimeters at least and 1think they
provide as good a correction as can be provided for pelvic fixation.
This is a problem. These do not have any stability below and it is hard
to see but this fell apart. lt fell apart six days post operation. Very disappointing . So 1believe it is ímportant to have the scoliosis rod stand down
with a screw or something soto stabilize it and the galvestone rod be attached above not at the level where the scoliosis rod ends.
Now we do it liké this. The scoliosis rod first, the galvestone rod second linked above, spine in straight. Many times all you need is a single
galvestone rod on the other side, very quick. Not very quick but a little
easier. He re the lateral. A good maintenance of lower dosis.
Last 1want to show a few slides on pelvical fixation. These are not my
cases because 1only operate on children : 1have given these by a friend
who does as well surgery.
The screws attached to the rod exactly the same way. The first case
was a child . This child was a sixteen or seventeen years old with scoliosis. Charlie Amstrong, one of my partners, operated on this child for scoliosis. The correction of the scoliosis was quite good. However the girl
seven weeks postoperatively was in a car wreck. This was the initial post
operational X-ray.
Seven weeks later the child was in a car wreck. This is a true story. In
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© Del documento,los autores. Digitalización realizada por ULPGC. Biblioteca Universitaria,2011.
Hospital dt• Cirugía Ortopédica dt•l
Dr. Roach
car. Seven weeks post operation it vyas ok here, fracture here, and it was
salvaged by new eye bolts. Fairly easy!
This man was a friend of mine in Dalias, he was operated by a friend
of mine. He had spinal stenosis and surgeon decompresed him posteriorly
and puta Herrington rod, which flattened forward and carne apart. So he
had removal osteotomies front and back, and multiple screws pulling him
back with a hook above and a brace to straight him up.
Another fracture. Vertical screws. That is it.
© Del documento,los autores. Digitalización realizada por ULPGC. Biblioteca Universitaria,2011.
Texas we have armadillos, and she was driving . In order to avoid the armadillo, she hit a tree.
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She sustained a burst fracture seven weeks post operation. Burst fracture was here as you see. This is what Charlie did. He went back and removed these two hooks, he put two eye bolts on, eye bolt here and eye
bolt there, put these two hooks back in, cross linked down, pedicular screw
here and a new hook called a fracture hook that has extensions that let
you come under and pull the child back. The instrument was tested in the
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