Late Onset Potts Paraplegia Results with Pedicle Subtraction Osteotomy

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Late Onset Potts ParaplegiaResults with Pedicle
Subtraction Osteotomy
European World Congress, Vienna 2009
Principal author Dr. Ashok S Gavaskar Presenting
author Dr. Naveen Chowdary Tummala
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Kyphosis in tuberculosis Anterior disease
90 of all spinal tuberculosis No of
vertebral body involvement/ age-
children Progressive kyphosis 15 of the
patients treated conservatively Kyphosis Pai
n postural, loss of sagital balance Subluxation
of facet joints
Kawahara N, Tomita K, Baba H, et al.
Closing-opening wedge osteotomy to correct
angular kyphotic deformity by a single posterior
approach. Spine. 200126391402.
Murrey DB, Brigham CD, Kiebzak GM, et al.
Transpedicular decompression and pedicle
subtraction osteotomy (egg shell procedure).
Spine. 20022723382345.
Neurological deficits falling of the cord
forwards Internal gibbus Spinal dislocation
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Late onset Potts paraplegia gt 2 years after the
onset of disease Progressive deformity Internal
gibbus Vascular etiology
Objectives of surgery Neurology decompression
excision of internal gibbus Deformity
posterior based closing wedge osteotomy Pseudoarth
rosis instrumented fusion
Approaches Anterior decompression / Deformity
?? Combined single stage/ staged Posterior
single stage/ good deformity correction
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Our series N 22 patients Mean age 27 years
20 40 years Males 17, females 5
All patients treated conservatively ATT for 7
18 months Average time of presentation 3.6
years after diagnosis of disease
Level Dorsal, lumbar D6 L3 Etiology
Internal gibbus 21 patients Syrinx formation
1 patient Pre operative K angle 60 degrees
Neurological status Frankel B 2
patients Frankel C 13 patients Frankel D 7
patients
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Surgical technique Posterior approach Pedicle
screws minimum 2 levels on either side of
proposed osteotomy Single PSO at the level of
compression Closure of the osteotomy
Final few centimeters of the gap left open Fusion
with the graft obtained during decompression
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Results

• Peri operative data
• Surgical time 140 minutes
• Blood loss 700 ml
• Dural tear 1 patient

Fusion all patients fusion mass, dynamic x
rays Post operative K angle 6 degrees Loss of
correction 4.8 degrees 2 years
Neurological recovery Recovery in all patients
by atleast 1 grade 1 patient lost due to TB
meningitis
Quadruple visual analog scale
significant SRS -30 all
subsets
improvement p 0.001
Transient neurological disturbance 2
patients Tuberculous meningitis 1
patient Superficial wound infection 2 patients
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22/ F, pre op K angle 100 degrees, Frankel grade
D
Solid fusion of the osteotomy, K angle 20 degrees
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31/M, L2 L3 healed TB, K angle 50 degrees
Solid fusion, post op K angle 0 degrees
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27/M, L2 L3 healed TB, K angle 45 degrees
Sound fusion, post op K angle 5 degrees
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Single stage posterior surgery

• Less morbidity early mobilization
• Less anesthetic complications
• No need for intra-op change of position
• Shorter surgery time

• More technically demanding
• More neurological complications
• More blood loss
• More tissue damage from prolonged retraction
• Steep learning curve

• More familiar approach
• Less risk for visceral damage
• No need for chest tube
• Excision of internal gibbus
• Global fusion possible early mobilization
• Better instrumentation better deformity
  correction
• Fixation in normal bone (pedicle)

Posterior approach