Department of Spine Services, Indian Spinal Injuries Centre, Sector-C, Vasant Kunj, New Delhi, 110070, India.
Spinal Cord Ser Cases. 2024 Aug 20;10(1):61. doi: 10.1038/s41394-024-00676-9.
The incidence of preoperative neurological deficits in pediatric patients with complex deformities ranges from 15% to 23%. Furthermore, the likelihood of a postoperative neurological deficit can be considerably increased to 83.3% in the presence of a preoperative neurological deficit. Hence, the management of pediatric spinal deformities with neurological deficits is a challenge for every spine surgeon. Here, we describe four consecutive cases of pediatric spinal deformity with myelopathic cord, all of which were managed with decompressive surgery and stabilization without any attempts to correct the deformity. All the patients recovered well neurologically, without any progression of deformity.
The authors obtained the informed written consent from the patient and their parents for the print and electronic publication of the case. All four patients had clinical myelopathy with a progressive, worsening neurological deficit. The pathology was in the thoracic region in all the patients. Of the four cases, two were post-tubercular deformities, and two were congenital deformities. The treatment strategy for all patients was circumferential decompression of the spinal cord with posterior pedicle screw instrumentation. Although all patients had significant neurological deficits (Nurick grade 4 or 5) preoperatively, we used intraoperative neuromonitoring to prevent the worsening of the deficit during the procedure. None of the patients experienced intraoperative signal changes. All patients had significant neurological recovery (Nurick grade 0 to 2) and showed no worsening of deformity at their latest follow-up, up to 4 years. All showed good improvement in all domains of the SRS22r questionnaire.
It is challenging for spine surgeons to manage complex spinal abnormalities in pediatric patients with myelopathic cords. Even a minimal manipulation of the cord during surgery might result in severe long-term morbidity. The primary objective in managing such patients should be neurological recovery rather than deformity correction-"First do no harm," and if necessary, the deformity can be corrected at a later stage under neuromonitoring.
在患有复杂畸形的儿科患者中，术前神经功能缺损的发生率为 15%至 23%。此外，如果存在术前神经功能缺损，术后发生神经功能缺损的可能性可显著增加至 83.3%。因此，对于每一位脊柱外科医生来说，管理伴有神经功能缺损的儿科脊柱畸形都是一项挑战。在这里，我们描述了 4 例连续的伴有脊髓病的儿科脊柱畸形病例，所有病例均采用减压和稳定手术进行治疗，而不试图矫正畸形。所有患者的神经功能均恢复良好，且畸形无进展。
作者从患者及其父母处获得了书面知情同意，同意将该病例的印刷版和电子版出版。所有 4 名患者均有临床脊髓病，且神经功能逐渐恶化。所有患者的病变均位于胸椎。4 例中有 2 例为结核后畸形，2 例为先天性畸形。所有患者的治疗策略均为脊髓环形减压，后路椎弓根螺钉内固定。虽然所有患者术前均有明显的神经功能缺损（Nurick 分级 4 或 5 级），但我们使用术中神经监测来防止手术过程中神经缺损的恶化。所有患者均未出现术中信号变化。所有患者均有明显的神经恢复（Nurick 分级 0 至 2 级），且在随访期间，4 年内无畸形加重。所有患者的 SRS22r 问卷的所有领域均有明显改善。
对于脊柱外科医生来说，管理伴有脊髓病的儿科复杂脊柱畸形具有挑战性。即使手术过程中对脊髓进行最小的操作，也可能导致严重的长期并发症。管理此类患者的主要目标应该是神经恢复，而不是矫正畸形——“首先不要造成伤害”，如有必要，可在神经监测下在后期进行畸形矫正。
