Lumbar Hemivertebra in an Adult Treated by Transpedicular Osteotomy

Peer-Review Short Reports

Lumbar Hemivertebra in an Adult Treated by Transpedicular Osteotomy
Ahmad Khan1, Cédric Barrey1,2, Hélène Massourides1, Gilles Perrin1
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INTRODUCTION

The term congenital scoliosis is classicallyused to describe a lateral curvature of thespine resulting from abnormal vertebral de-velopment. It has been reported to occurduring the first 6 weeks of embryonic life (7)and most commonly occurs in thoracic orlumbar regions (1, 10, 12). Congenital spi-nal deformity is generally secondary to aformation failure that results in an abnor-mal shape of the involved vertebra—so-called hemivertebra (1). Most reports onhemivertebra concern pediatric patients(1–5, 7, 10). We report here the case of anadult patient with lumbar hemivertebratreated surgically with a combined ap-proach.

CASE REPORT

HistoryA 46-year-old woman presented in January2009 with a complaint of severe chronic lowback pain of 6 years’ duration. The pain waslocated in the lumbar area with typical fea-tures of discogenic pain. She also com-

Key words� Adult deformity� Congenital coliosis� Hemivertebra� Osteotomy

Abbreviations and AcronymsTPO: Transpedicular osteotomy

From the 1University of Lyon 1, andDepartment of Neurosurgery and Spine

Surgery, Pierre Wertheimer Hospital, Hospices Civil deLyon, Lyon; and 2Laboratory of Biomechanics, Arts etMetiers PARISTECH, Paris, France

To whom correspondence should be addressed:Cédric Barrey, M.D. [E-mail: [email protected]]

Citation: World Neurosurg. (2012) 77, 3/4:592.e5-592.e9.DOI: 10.1016/j.wneu.2011.04.029

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plained of L5 sciatica of 6 months’ duration, p

WORLD NEUROSURGERY 77 [3/4]: 592.e

or which she had undergone medical treat-ent and several epidural corticosteroid in-

ections that were unsuccessful. She had aisual analogue scale score of 8 out of 10 forack pain and 6 out of 10 for radicular pain.valuation of disability was done using therench version of the Roland Morris dis-bility questionnaire (ie, EIFEL scale [Echelle’incapacité fonctionnelle pour l’évaluation desombalgies]), and the patient scored 16 outf 24.

linical and Radiologic Assessmenthysical examination showed no neuro-

ogic deficit. Standard anteroposterior andateral x-rays revealed a partially segmentedemivertebra of L3 associated with a 30-egree lumbar scoliosis. Upper and lower

imit vertebrae were L1 and L4 (Figure 1A). Aomputed tomography scan with multipla-ar two-dimensional (Figure 1B and C) and

hree-dimensional (Figure 2) reconstruc-ions allowed the confirmation of the hemi-ertebra at L3 and the associated lumbarcoliosis. Three-dimensional images pro-ided a good illustration of the shape of L3ith a trapezoidal deformity in the frontallane and a kyphotic deformity in the sagit-

al plane. This anomaly corresponds to a

� BACKGROUND: Hemivertebra frequtreated with vertebral excision to stopof L3 hemivertebra associated with lum

� CASE DESCRIPTION: A 46-year-oldback pain of 6 years’ duration. Radivertebra had a trapezoidal shape reve

� RESULTS: The patient underwent astage consisted of a transpedicular otation from L1 to L5 and a bone graft;were performed at L2-3 and L3-4 usingprotein. No postoperative complicatio

� CONCLUSIONS: TPO improved clinmity, and reduced the lumbar kyphosi

artially segmented hemivertebra (type B fi

5-592.e9, MARCH/APRIL 2012 www.WO

ccording to the Moe et al. (12) classifica-ion).

Frontal and sagittal balance was ana-yzed with full spine standing radio-raphs (Figure 3). The L2-S1 angle was 29egrees; the L2-4 segment was �5 de-rees (kyphosis orientation). Magneticesonance imaging showed multileveliscopathy at L2-3, L3-4, and L4-5. Discrotrusion at L4-5 compressed the left L5oot, and the discopathy was considereds a compensation of the adjacent kypho-is of the spine.

urgical Techniquehe patient underwent a two-stage surgeryith a 1-month delay between stages. Therst surgery was performed via a typicaledian posterior approach with the pati-

nt in the ventral decubitus position. Theorrective transpedicular osteotomy (TPO)hrough the right and upper left pedicles of3 was found to correct mainly the sagittallane and to achieve a minimal correctionf the frontal plane. The essential objectiveas the correction of the lumbar kyphosis

Figure 4). After osteotomy, the spine was

y occurs in pediatric patients and isprogression of the deformity. A case

kyphoscoliosis in an adult is reported.

man presented with severe chronicic examinations showed that the L3

a partially segmented hemivertebra.

o-stage corrective surgery. The firsttomy (TPO) with posterior instrumen-onth later, anterior interbody fusionsrbody cages and bone morphogenetics reported after 2 years of follow-up.

symptoms, corrected the spinal defor-

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nally stabilized and fixed in lordosis (the

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PEER-REVIEW SHORT REPORTS

AHMAD KHAN ET AL. LUMBAR HEMIVERTEBRA IN AN ADULT

kyphotic angle of L2-4 was �5 degrees pre-operatively vs 21 degrees for the lordotic an-gle after TPO). Arthrodesis was achievedwith the use of supralaminar hooks over L1and transpedicular screws in L2, L4, and L5.To enhance the fusion, a cortico-cancellousbone graft was harvested from the posterioriliac crest and applied over interlaminar andinterarticular spaces throughout the wholelength of the instrumentation. The durationof the procedure was 4 hours, and bloodloss was 1300 mL. A mini-lumbotomy wasperformed 1 month later through a left ret-roperitoneal approach, with the patient inthe lateral decubitus position. A two-levelanterior lumbar interbody fusion wasachieved, adjacent to the hemivertebra (ie,L2-3 and L3-4). After separation of thepsoas muscle, two polyetheretherketonecages (height 9 mm and lordosis angle 9degrees) filled with bone morphogeneticprotein were inserted into the disc spaces.The duration of the procedure was 1 hour,45 minutes, and blood loss was 100 mL.

Postoperative CourseNo postoperative complication was re-ported at 2-year follow-up. The patient hadto wear an orthopedic corset for 6 months.The low back pain decreased postopera-tively (from 8/10 preoperatively to 3/10 at1-year follow-up and 2/10 at 2-year follow-

Figure 1. Anteroposterior sacrolumbtomography scans show the trapearrows).

up). The rad

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ar plain x-ray (A) shows hemivertebrae of L3. Frontal (B) and sagittal view (C) computedzoidal shape of L3 and the two pedicles on left side, implanted on the same vertebral body (C,

icular pain completely resolved

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Figure 2. Preoperative three-dimensional computed tomography scan (A–D) shows partiallysegmented hemivertebrae at L3 (C, white arrows) and kyphotic orientation of the L2-4 segment. The
presence of a left hemisacralization of L5 is visible (A, black arrow).
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2011.04.029

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during the postoperative period. The EIFELrating scale was 8 and 6 out of 24 at 1-yearand 2-year follow-up.

Figure 3. Preoperative full spine ante7 cervical, 12 thoracic, and 5 lumbarmeasured: Cobb’s angle (�) � 30 dedegrees, lumbar lordosis (�) � 29 decalculated: pelvic tilt (PT) � 21 degreand sacral slope (SS) � 21 degrees.posterosuperior corner of the S1 ver

Figure 4. Preoperative (A) and postop(B) computed tomography scans shovertebra from kyphosis to lordotic ge
be seen at the posterior and superior part

Postoperative full spine x-rays (Figure 5)ermitted evaluation of the degree of ky-hosis and scoliosis correction. The reduc-

erior (A) and lateral (B) views showrae. Spinal parameters were

, thoracic kyphosis (�) � 19. Pelvic parameters were alsolvic incidence (PI) � 42 degrees,mb line was projected at thebody (dotted line).

e (after transpedicular osteotomy)changes in the shape of the L3

ry. Osteotomy line (B, arrows) can

lof the L3 vertebral body.


ion of lumbar kyphosis, by about 25 de-rees at the L2-4 segment, was mainlychieved by correcting the kyphotic shapef the L3 hemivertebra to a lordotic shape,s shown by postoperative computed to-ography scan (Figure 4). X-rays at 2-year

ollow-up showed fusion with no secondaryisassembly of the hardware (Figure 6).

ISCUSSION

tatistically, male-to-female frequency ofongenital scoliosis is 1:1.3 and of right toeft curve is 1.4:1 (10, 12, 13). Most docu-

ented cases of congenital scoliosis in-olve pediatric patients (1–5, 7, 10). McMas-er and Ohtsuka (11) observed that thehoracic region was the most common siteor congenital scoliosis. In their series, Mo-anty and Kumar (13) noted that the lumbaregion was involved in only 8% of cases.

By definition, hemivertebra is a wedge-haped vertebra (1, 10, 12) with only oneedicle on one side. It is considered an em-ryologic failure of segmentation, associ-ted with a risk of progressive scoliosis.emivertebra may be associated with other

ongenital anomalies, which have been re-orted to be present in 61% of patients (2,7). Different classifications exist in the lit-rature. The classification by Touzet et al.15) is based on two criteria: First, the hemi-ertebra can be fused or is separate from thedjacent vertebra; second, the upper andower adjacent vertebrae may or may nothow transitional abnormality. Moe et al.12) classified hemivertebra into four typesA to D) in relation to cranial or caudal ad-acent vertebral bodies, which may be fullyegmented, partially segmented, or uniseg-ented.Practically, three main surgical options

an be used to correct the deformity: (a)xcision of hemivertebra, (b) vertebral os-eotomy, and (c) in situ fusion (4 – 6, 9, 14,6). The first report of the excision of hemi-ertebra was by Royle in 1928 (9). A two-tage corrective surgery was first estab-ished by Von Lackum and Smith in 193316). During the first stage, the vertebralody and the posterior elements were ex-ised; during the second stage, the spineas “fused.” More recently, Suk et al. (14) rec-mmended the posterior approach alone for

umbosacral deformity, reasoning that com-ined surgery requires a longer duration. Bol-

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ini et al. (4) recommended a two-stage proce-


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dure—anterior then posterior arthrodesis—achieving a better correction in the sagittalplane and resulting in a lower pseudoarthro-sis rate. However, these authors emphasizedthat the anterior approach should be used forthoracolumbar or lumbar segments becausethe thoracic spinal cord is associated with ahigh risk of neurologic deterioration. In pedi-atric patients, two-stage correction by closingwedge osteotomy was reported by Leather-man and Dickson in 1979 (9). These authorsreported a correction of 43% of scolioticcurves during follow-up with two patientshaving transient neurologic deficit.

In the present case, we planned to treatthe spinal deformity using a combined ap-proach with TPO as the first step. Preopera-tively, the global frontal balance of ourpatient was preserved, as shown on antero-posterior full spine radiographs, whereasthe sagittal balance was associated withlumbar kyphosis and adjacent compensa-

Figure 5. Postoperative anteroposteradiographs show instrumentationdegrees, thoracic kyphosis (�) � 26degrees. L2-4 was �5 degrees kyplordotic postoperatively. PI, pelvic islope.

ory discopathy. The L4-5 discopathy was T

592.e8 www.SCIENCEDIRECT.com

onsidered as a compensation of the adja-ent kyphosis of the spine. The goal of theurgery was predominantly to correct theagittal plane without making majorhanges in the frontal plane. Given theyphotic shape of the L3 hemivertebra,nly a bone resection procedure at L3ould enable us to restore a sufficientmount of lordosis. Complete vertebralxcision was considered to be unneces-ary for this patient, and this surgical pro-edure seemed much too aggressive.

TPO was estimated to be safer, minimiz-ng the risk of neurologic complications,nd sufficient to correct the sagittal balancend maintain frontal alignment. TPO per-itted correction of the L2-4 segment from5 degrees kyphotic to �20 degrees lor-

otic orientation, as shown on postopera-ive radiographic examinations. The goal ofhe anterior approach after TPO was to en-ance fusion at the two levels adjacent to the

) and lateral (B) full spine1-5. Cobb’s angle (�) � 15ees, lumbar lordosis (�) � 44preoperatively vs 21 degreesce; PT, pelvic tilt; SS, sacral

PO level and increase the overall stability

WORLD NEUROSURGE

f the spinal construct. The major step inur surgical strategy was the posterior sur-ery. However, this case illustrates well thatreoperative assessment, with full spine ra-iographs and three-dimensional com-uted tomography scan, is essential to un-erstand fully the causes of the deformity and

ts consequences on the balance. In accor-ance with Kawakami et al. (8), we believe

hat preoperative radiologic assessment in-luding two-dimensional and three-dimen-ional images contributes greatly to guidinghe surgical strategy.

ONCLUSIONS

he combined approach with TPO cor-ected the lumbar kyphosis and achievedusion. This approach may constitute aood compromise between complete verte-ral excision and simple in situ fusion toorrect spinal deformities associated withumbar hemivertebra in adult patients.

CKNOWLEDGMENTS

e express our gratitude to Chloé Loiraudnd Sandrine Jamen, Hôpital NeurologiqueWertheimer, Lyon, France, for their assis-

ance in paper’s translation.

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onflict of interest statement: The authors declare that therticle content was composed in the absence of anyommercial or financial relationships that could beonstrued as a potential conflict of interest.

itation: World Neurosurg. (2012) 77, 3/4:592.e5-592.e9.OI: 10.1016/j.wneu.2011.04.029

ournal homepage: www.WORLDNEUROSURGERY.org

vailable online: www.sciencedirect.com

878-8750/$ - see front matter © 2012 Elsevier Inc.

erior (mbar

ll rights reserved.


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Lumbar Hemivertebra in an Adult Treated by Transpedicular Osteotomy