Hirurgia Pozvonochnika 2017;14(1):14–23

© S.O. Ryabykh et al., 2017

Results of hemivertebra excision

through combined, posterior
and transpedicular approaches:
systematic review
S.O. Ryabykh, E.Yu. Filatov, D.M. Savin
Russian Ilizarov Scientific Center for Restorative Traumatology and Orthopaedics, Kurgan, Russia

The paper presents a review of 28 domestic and foreign publications with the level of evidence of not less than 2 reporting the treatment
results in children with congenital monosegmental anomalies of the spine over the past 15 years. A total of 657 clinical cases were analyzed,
including 593 literature cases and 64 cases from authors’ experience. Results of hemivertebra treatment in children using combined
approach, extended posterior approach and local posterior approach with transpedicular excision of hemivertebra were analyzed. The
following criteria were used for analysis: patient’s age at the time of treatment, magnitude of the local (segmental) curvature before and
after surgery, percentage of correction, blood loss volume, duration of surgery, type and length of fixation, and nature and structure of
complications. The advantages of transpedicular excision of abnormal vertebra through posterior approach were noted in terms of surgery
duration, intraoperative blood loss, risk of neurological complications after comparable correction of deformity, and time required for patient
activation and rehabilitation as compared with combined approach, as well as in terms of blood loss volume and correction of kyphotic
component as compared with extended posterior approach.
Key Words: congenital scoliosis, congenital kyphosis, monosegmental anomalies of the spine, hemivertebrae, posterior approach,
transpedicular excision, deformity correction.

Please cite this paper as: Ryabykh SO, Filatov EYu, Savin DM. Results of hemivertebra excision through combined, posterior and transpedicular approaches:
systematic review. Hir. Pozvonoc. 2017; 14(1):14–23. In Russian.
DOI: http://dx.doi.org/10.14531/ss2017.1.14-23.

During the last 10—15 years, surgical gressing kyphoscoliosis with underly- discussion. The latter fact determined the
resection of hemivertebrae have become ing pseudarthrosis necessitated the use objective of our review.
the standard treatment of this pathol- of metal fixation (plates, rods, cerclag- Evidence level 2++.
ogy in young children. Early interven- es) [10]. Subsequently, posterior instru-
tion (within the period from 2 to 5 years) mented fixation along with extirpation Material and Methods
maximizes deformity correction, pre- of hemivertebrae through the combined
vents the development and progression anterior and posterior approach has We analyzed 28 Russian and foreign
of secondary curves, minimizes the num- become more popular, and improvement articles published over the last 15
ber of fixed segments and preserves the of metal structures provided more reli- years, which describe the treatment
correct axial growth of intact spinal seg- able fixation of segments and improved outcomes of children with congenital
ments [1, 4, 6, 8, 9, 15, 22, 24 29]. deformity correction outcomes. Wide- monosegmental abnormalities of the
Hemivertebra excision (extirpation) spread implementation of the third gen- spine.
first described by Royle in 1928 [23] is eration instrumentation (CD) has led Thematic sources were searched in
one of the main methods of surgical to formation of two opposing camps of the PubMed (NCBI), Cochrane Library,
treatment of congenital monosegmen- pediatric spinal surgeons, who mainly The Cochrane Database of System-
tal deformity caused by hemivertebra or discuss, which fixators, hook or screw, atic Reviews, and eLIBRARY databases,
hemivertebrae. At the early stages, this should be favored after hemivertebra according to the following inclusion
operation was carried out alone through excision. At the same time, the issues of criteria:
the anterior approach without addi- hemivertebra excision methods, which 1) surgical resection of monosegmen-
tional stabilization or fixation. The high have also improved with the develop- tal defects using transpedicular or hook
incidence of poor outcomes due to pro- ment of new techniques, are beyond the fixation of the spine in children;

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 Hirurgia Pozvonochnika 2017;14(1):14–23
S.O. Ryabykh et al. Results of hemivertebra excision through combined, posterior and transpedicular approaches

2) case series or cohort studies with Statistical Package for the Social Sci- (p = 0.348), the volume of blood loss as
the level of evidence 2+, 2-, 3; ences (SPSS) version 22.0 (SPSS Inc., Chi- a percentage of the total blood volume
3) postoperative follow-up more than cago, IL, USA) software was used. could not be calculated, since morpho-
2 years; T-tests: metric data are missing in many articles;
4) age of the patients at the time of 1) comparison of the mean values of – operation time was 217 to 284 min-
operation from 1 to 8 years; the angular scoliotic deformity before utes (p = 0.211).
5) available information about the and after the operation; Monosegmental unilateral fixation
magnitude of the deformity before 2) comparison of the mean values of was used in 53 cases, monosegmental
and after surgery, volume of blood loss, the angular kyphotic deformity before bilateral – in 306, polysegmental bilat-
duration of surgery, type and extent of and after the operation; eral – in 209. The average age of children
fixation, the nature and structure of 3) comparison of intraoperative blood who were operated on through the com-
complications. loss volume and operation time. bined approach was 5 years 3 months,
Patients described in 22 publications The differences were considered as through posterior approach – 6 years
had deformities with underlying local statistically significant at p < 0.05. Pair- 1 month, and using transpedicular exci-
isolated or unsegmented hemiverte- wise correlation analysis with rank-based sion – 6 years 6 months.
bra. Three articles describe treatment of Kruskal-Wallis test for independent sam- Correlation analysis of the preopera-
patients with hemivertebra or asymmet- ples showed insignificant correlation: tive and postoperative magnitude of local
ric butterfly-like vertebra as the leading p < 0.5 — weak correlation; 0.5 < p < 0.7 spinal deformity shows linear relation-
component of the spine deformity in — intermediate correlation; p > 0.7 — ship between the residual deformity and
combination with the neutral form of strong correlation. its initial magnitude (Fig. 2a). However,
segmentation disorder at another level the low value of the coefficient of deter-
[12, 16, 18]. Result duplication could not Results mination indicates that the relationship
be ruled out in three publications and is affected by random factors, which
therefore they were not included in the Summary of the results of analysed cannot be taken into account based on
final data analysis [3, 4, 25]. When the publications are shown in Table 2. the information provided in the litera-
authors had similar studies discussing Authors’ experience ranged from several ture. This is also confirmed by the results
similar clinical material [1, 3, 4, 6, 25, 26], tens to hundreds of clinical cases. of approximation of similar data for
we analyzed data from only one publica- Summary analysis of the publications kyphotic component of the deformity,
tion of these authors, which included the enables some generalizations: where the data are even more scattered.
largest number of cases (Table 1). – hemivertebrae were most frequently When considering the volume of blood
A total of 657 cases of monosegmen- located at the thoracolumbar junction loss as a factor limiting surgery duration
tal defect treatment in children were T10–L2, 56 % (354 cases), which is fully in different hospitals, it was shown that
analyzed, including 593 cases found consistent with the data of one of the increase in the blood loss volume often
in the literature and 64 cases from the first Russian publications in 1936, which forced surgeons to limit the extent of
experience of the authors of this review focused on the spinal deformities [5]; the surgical intervention (Fig. 2b).
obtained at the clinic of the Ilizarov thoracic spine T1–T9 is the second most The patients were divided into three
Scientific Center for Restorative Trau- common location, 25 % (152 cases); lum- groups based on the operative approach
matology and Orthopaedics. The cases bar spine L3–L6 is the third, 19 % (121 used for hemivertebra excision: I – com-
of hemivertebra excision through the cases; Fig. 1); bined approach (203 patients), II – pos-
combined approach were analyzed in 10 – hemivertebrae are more com- terior (390 patients), and III – transpe-
articles, through isolated posterior — in mon in girls than in boys (56 and 44 %, dicular (64 patients).
18. Treatment outcomes were compared respectively); The average preoperative magnitude
taking into account the approaches used – the average age of patients ranged of scoliotic component and its correc-
for extirpation: combined, extended pos- from 5 to 6.5 years in all comparison tion were almost equal in all the groups
terior and local posterior with transpe- groups; and amounted to 38° and 71 % in group I,
dicular excision. – scoliotic deformity component was 40° and 74 % in group II, 37° and 72 % in
The following parameters were ana- 37–40° (p = 0.297) before surgery and group III, respectively. However, preoper-
lyzed: location of abnormal vertebra, age 10–11° (p = 0.722) after surgery, correc- ative value of local kyphosis and its cor-
of patients at the time of treatment, local tion ranged from 71 to 74 %; rection (42° and 83 %, respectively) were
(segmental) curve magnitude before and – kyphotic component of the defor- significantly higher in group III com-
immediately after surgery (Cobb angle, mity was 22 to 42° (p = 0.218) before pared to groups I (22° and 64 %) and II
degrees), correction percentage, volume surgery and 7–10° (p = 0.214) after sur- (28° and 62 %).
of blood loss, duration of surgery, fixa- gery, kyphosis correction was 62–83 %; Duration of operation was 284 min
tion type and length, as well as the nature – the volume of intraoperative in group I, which significantly exceeded
and structure of complications. blood loss ranged from 345 to 588 ml

15
Spine deformities
 Table 1
Comparative analysis of the results of hemivertebra treatment in children using the combined, extended posterior, and posteior with transpedicular excision approaches

Source Patients, Age, Preoperative Postoperative Correction Blood Operation Monosegmen- Monosegmen- Polysegmen-
n months scoliotic/kyphotic scoliotic/kyphotic (scoliosis/ loss, time, tal unilateral tal bilateral tal bilateral
component, component, degrees kyphosis), ml min fixation fixation fixation
degrees %

Combined approach
S.V. Vissarionov 26 47.0 30.1/18.4 2.5/2.2 92/88 225 140 8 18 –
et al. [1 ]

D.N. Kokushin et al. 37 – 32.7/22.0 6.5/4.6 80/79 – – – 14 23

[6]

Wang et al. [28] 30 38.5 52.5/46.0 14.4/17.6 73/62 1290 451 – – –

Xu et al. [29] 34 145.2 45.3/10.1 14.9/-6.2 67/100 590 235 – 34 –

Bollini et al. [12] 33 41.0 34.8/20.0 17.4/8.6 50/57 – 280 – 33 –

Jalanko et al. [16] 12 38.4 30.8/0 7.4/0 76/0 258 258 – 12 –

Hedequist et al. [14] 18 38.0 40.0/0 9.0/0 78/0 159 308 18 – –

16
Mladenov K. et al. [19] 13 69.0 40.0/0 18.0/0 55/0 – 319 – – –

Spine deformities
Posterior approach
С.В. Виссарионов 18 67.0 37.35/18.40 3.25/8.20 91/55 225 140 – 18 –
с соавт. [2]

Wang L. et al. [28] 30 20.6 40.2/36.4 11.5/15.6 71/57 910 248.5 – – –

Hirurgia Pozvonochnika 2017;14(1):14–23

Ruf M. et al. [24]: 28 41.0 36.1/21.7 7.1/7.7 80/65 309 187 – 23 8

группа с единичными
полупозвонками

Ruf M. et al. [24]: груп- 13 – 69.2/23.9 23.3/9.1 66/62 723 272 – – 13

па с множественными
аномалиями развития

Jalanko et al. [16] 11 – 32.6/0 8.8/0 73/0 401 228 – 11 –

Zhu et al. [32] 60 84.0 41.6/23.3 5.1/7.3 88/69 350.5 172.7 – 60 –
Li et al. [18] 12 204.0 43.8/11.8 16.5/6.2 62/47 312 155 – – 12
Peng et al. [22] 10 39.6 35.21/19.61 13.11/4.31 63/78 114 142 10 – –
Ocampo et al. [21] 7 38.4 35.0/42.0 20.0/29.0 43/31 312 225 – – 7
Hedequist et al. [15] 10 51.0 44.0/0 9.0/0 80/0 270 – – 10 –
S.O. Ryabykh et al. Results of hemivertebra excision through combined, posterior and transpedicular approaches

Zhang et al. [31] 56 118.8 42.4/42.0 11.5/12.6 73/10 812.1 210.1 – – 56

Chang et al. [13] 20 79.2 34.4/17.4 8.6/-1.3 75/100 472.5 158.0 20 – –
 Table 1 (Continued)
Source Patients, Age, Preoperative Postoperative Correction Blood Operation Monosegmen- Monosegmen- Polysegmen-
n months scoliotic/kyphotic scoliotic/kyphotic (scoliosis/ loss, time, tal unilateral tal bilateral tal bilateral
component, component, degrees kyphosis), ml min fixation fixation fixation
degrees %

Aydogan et al. [11]: – –

– scoliosis group; 3 84.0 40.3/0 10.7/0 73/0 375 312 3
— kyphosis group; 5 0/53.4 0/8.5 0/84 5
— kyphoscoliosis group 11 38.2/49.4 7.5/12.0 80/76 11

Shono et al. [27] 12 168.0 49.0/40.0 18.0/17.0 63/58 600 260 – 12 –

Nakamura et 3 120.0 49.0/48.0 22.3/15.0 55/69 660 350 – – –
al. [20]: группа с
кифосколиозом
Nakamura et al. [20]: 2 – 34.5/0 23.5/0 32/0 – – – – –
группа с кифозом
Ruf et al. [26] 25 40.0 45.3/21.8 14.4/9.8 68/55 496 225 15 13 –
Mladenov et al. [19] 12 68.0 39.0/0 16.0/0 59/0 – 272 – – –
Yaszay et al. [30] 42 60.0 35.0/18.0 10.0/14.0 71/22 455 255 – – –
Transpedicular excision method: S.O. Ryabych et al. [7]
Monosegmental 17 47.8 32.2/30.0 9.8/3.0 70/90 215.4 173.3 17 – –
unilateral fixation

17
Monosegmental bilateral 15 60.1 34.4/32.3 9.4/2.7 73/92 281.0 194.6 – 15 –
fixation

Spine deformities
Polysegmental bilateral 32 105.5 41.7/53.8 11.3/11.5 73/79 443.2 271.6 – – 33
fixation

0 – conventional value, since one of the deformity components (scoliotic/kyphotic) was not considered by the authors of the aforementioned articles as a significant one.
Hirurgia Pozvonochnika 2017;14(1):14–23

Table 2
Average values of hemivertebra treatment outcomes in children through the combined, posterior approach, and transpedicular excision

Source Patients, Age, Preoperative Postoperative Correction Blood loss, Operation Monosegmen- Monosegmental Polysegmental
n months scoliotic/kyphotic scoliotic/kyphotic (scoliosis/ ml time, tal unilateral bilateral fixation bilateral fixation
component, component, kyphosis), min fixation
degrees degrees %

Combined 251 63.2 38.0/10.9 21.7/7.9 71.3/63.6 588.1 284.3 26 121 29

Dorsal 410 76.1 40.4/10.7 27.6/10.5 73.6/62.1 505.9 216.6 10 170 147
S.O. Ryabykh et al. Results of hemivertebra excision through combined, posterior and transpedicular approaches

Transpedic- 64 79.5 37.5/10.4 42.5/7.2 72.2/83.1 344.7 227.5 17 15 33

ular excision
 Hirurgia Pozvonochnika 2017;14(1):14–23
S.O. Ryabykh et al. Results of hemivertebra excision through combined, posterior and transpedicular approaches

this values in groups II (217 min) and III loss, duration of surgery, type and extent pediatric transpedicular fixation systems,
(227 min). of fixation are the key criteria to evaluate the studies on the impact of screws on
Transpedicular approach was the least the results of different methods of the development of vertebrae and verte-
traumatic in terms of the blood loss vol- hemivertebra excision in children. Meta- bral canal proved the absence of adverse
ume (average value 345 ml) as compared analysis is not available due to the low effects in infants and young children [16,
to the combined (588 ml) and posterior level of reproducibility of the material. 17, 25, 26, 33]. Preferences of vertebral
(505 ml) approaches, by 243 ml and 161 The most complete randomized analysis surgeons were changed toward hemiver-
ml, respectively. of these factors could determine the tebra excision and deformity correction
Extended bilateral polysegmental fix- advantages and disadvantages of the through the posterior approach under
ation was used in groups I, II and III in used treatment techniques. However, it the influence of modern implants along
16.5, 45.0, and 51.5 % of cases, unilateral is in some aspects limited or impossible with the use of power equipment, evolu-
monosegmental – 10.3, 2.4, and 26.6 % due to the deficit or incomparability tion of surgical instruments, and develop-
of cases, respectively (in absolute values, of the information provided by the ment of the implants that enable reposi-
26 out of 251, 10 out of 410, and 17 out articles, which necessitated exclusion tion maneuvers
of 64 cases). of some data from evaluation of a Integrated analysis of the results of
Surgical complications are shown in certain parameter. S.V. Vissarionov the use of various approaches showed
Table 3. et al. [1] did not report precise values advantages of transpedicular hemiverte-
According to the literature, when of local correction associated with bra excision for correction of kyphotic
using combined and posterior approach- extirpation of the lateral hemivertebrae, component of the deformity, which sug-
es, implants fractures are among the most and deformity value was measured gests that it is a universal deformity cor-
common complications, accounting for at the level of vertebrae located three rection technique, especially in infants
23 % (17 cases), followed by superfi- segments more craniad and more and young children. It should also be
cial wound infection – 20 % (15 cases), caudad from the apex, rather than at the noted that the profile and incidence of
and local deformity progression – 17 % apical angle. In some cases, Xu et al. [29] complications are comparable to those
(13 cases). When considering character- supplemented bilateral monosegmental in other groups.
istics of approaches, another structure of system by screws above and below the In terms of fixation length, monoseg-
complications was observed: instrumented region for higher fixation mental unilateral fixation was most often
– in case of combined approach, rigidity. In the article of Jalanko et used in transpedicular excision. This fixa-
persistent neurological disorders were al. [16], fixation options were defined tion option enables operating young chil-
observed in 4 (13 %) cases, pneumotho- only in the presented cases. Mladenov dren due to minimal operative trauma
rax – 3 (10 %); these complications were et al. [19] reported the data of the [8]. However, it is associated with higher
not observed in the case of the posterior final follow-up examination without percentage of postoperative progression
approach; immediate postoperative results. Finally, of the deformity.
– in case of posterior approach, verte- Zhu et al. [32] analyzed the results of The average volume of blood loss dur-
bral arch fracture was the most common monosegmental bilateral fixation, as ing transpedicular excision was 345 ml,
complication, 6 (13 %) cases; the inci- reflected in the title of the work, but which is significantly lower compared to
dence of transient neurological disorders provided bilateral polysegmental fixation the combined and posterior approach-
was 11 % (5 cases); deep wound infec- as an illustration. es with allowance for the fact that most
tion occurred in 3 (7 %) cases, which was The volume of blood loss is described patients (73.4 %) were operated on using
not observed in the case of combined in the articles quite irregularly. bilateral approach and polysegmental
approach; Trends in the surgery for monose- fixation. The incidence and structure of
– in case of transpedicular excision, gmental vertebral malformations in complications of posteior and transpe-
the most common complications includ- children over the past 15 years suggest dicular approaches are comparable.
ed deformity progression, 6 (55%) cas- the expansion of transpedicular fixa- These results justified revision of fix-
es and transient neurological disorders, tion, shift of emphasis towards poste- ation tactics: in early age patients and
3 (27 %) cases; there was one case of met- ior approach, and wider use of posterior LBW infants (up to 10 kg), this opera-
al fixator fracture and one case of super- vertebrotomy techniques. According to tion is advantageous in term of surgi-
ficial wound infections. the researchers [8, 22, 31, 32], the main cal aggression (duration of surgery and
advantages of the posterior approach blood loss), but may necessitate reop-
Discussion include possible extirpation of all col- eration and system remounting at a later
umns of the abnormal hemivertebrae age. In younger patients with medium
In our opinion, the age of patients at the through one approach, reduced surgical centile parameters of physical develop-
time of treatment, the severity of local aggression and duration of the operation, ment, bilateral monosegmental or poly-
deformity before and after correction, as well as postoperative patient’s reha- segmental instrumentation is the most
correction percentage, volume of blood bilitation period. When implementing adequate technique, since it is character-

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 Hirurgia Pozvonochnika 2017;14(1):14–23
S.O. Ryabykh et al. Results of hemivertebra excision through combined, posterior and transpedicular approaches

ized by low risk of system instability and

recurrent deformity.
500 This analysis shows that the avail-
able data are currently insufficient for
400 comprehensive meta-analysis and con-
clusions, which could form the basis of
300 high-evidence-level recommendations
for doctors on the best way of hemiverte-
200 bra resection followed by fixation of the
spine. We should state that many articles
100
either lack statistical analysis or provide
not comparable data, which motivates
0
further investigation of this issue with
more strict compliance with the general
number of hemivertebrae
analysis protocol.
Key provisions:
1) evolution of treatments for mono-
segmental vertebral malformations is
Fig. 1 clearly related to evolution of spinal fix-
Topical concentration of hemivertebrae ation systems, manipulation tools, and
intraoperative monitoring techniques;
2) the optimal age for hemivertebra
excision and spinal deformity correction
25 is 2–5 years;
3) literature data suggest middling
20 results of deformity correction and fixa-
tion length regardless of the applied tech-
15 niques of abnormal vertebra excision;
y= 0,3918х-3,4031 4) posterior transpedicular excision
R2 = 0,3032
10
with bilateral transpedicular fixation is
the method of choice in terms of apical
5
deformity correction value, minimal sur-
gical aggression, and comparable amount
0
of postoperative complications.
а 20 30 40 50 60 70 80

Conclusion
500

Comparative analysis of therapies for

400
monosegmental vertebral malformations
showed that transpedicular excision of
300
the abnormal vertebra through the dor-
sal approach reduces the time of surgery,
200
y= 0,1765х+150,55 intraoperative blood loss, risk of neuro-
100
R2 = 0,4255 logical complications, provides adequate
deformity correction, facilitates early
0
activation and rehabilitation of patients
б 0 500 1000 1500 compared to the combined approach.
It is superior to posterior approach in
terms of the blood loss volume and
Fig. 2 correction of kyphotic component.
The relationship between the magnitude of spine deformity before and after the opera- Of course, any conclusions are
tion (a), blood loss and operation time (b), wherein R2 is determination coefficient interim in a historical context, suggesting
the need for further research.

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 Hirurgia Pozvonochnika 2017;14(1):14–23
S.O. Ryabykh et al. Results of hemivertebra excision through combined, posterior and transpedicular approaches

Table 3
Integral structure of complications during surgical treatment for hemivertebrae in children through the combined and posterior approaches
and transpedicular excision method

Sources

necessitating metal fixator removal

Persistent neurological disorders

Transient neurological disorders

Superficial wound infection

Herniated abdominal wall

Metal fixator migration
Vertebral arch fracture

Deformity progression
Metal fixator fracture
Deep wound infection

Pneumothorax

Tracheospasm
Hemothorax

Pleurorrhea
Atelectasis
Combined approach
S.V. Vissarionov et al. [3] 1
Wang et al. [28] 1 1
Bollini et al. [12] 3 2 5 6 3 1
Hedequist et al. [14] 1
Jalanko et al. [16] 1
Xu et al. [29] 1 1
Mladenov et al. [19] 1 1 1 1
Total 5 0 3 1 2 5 6 4 1 1 1 1 1
Posterior approach
Wang et al. [28] 1 2 1
Ruf et al. [25] 1 1 2 2
Ruf et al. [26] 1 3
Ruf et al. [24] 1 1 3 2
Jalanko et al. [16] 1 1 1 1
Hedequist et al. [15] 1 1
Shono et al. [27] 1
Zhang et al. [31] 1 2 2 1
Chang et al. [13] 1 2
Zhu et al. [32] 2 3 2
Total 3 9 1 0 6 12 7 4 2
Transpedicular excision method
Total 1 1 6 3

The study was not supported by any sponsors. The authors declare the absence of the conflict of interest.

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S.O. Ryabykh et al. Results of hemivertebra excision through combined, posterior and transpedicular approaches

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S.O. Ryabykh et al. Results of hemivertebra excision through combined, posterior and transpedicular approaches

Address correspondence to: Received 07.06.2016

Ryabykh Sergey Olegovich Review completed 13.09.2016
Russian Ilizarov Scientific Center for Restorative Passed for printing 18.09.2016
Traumatology and Orthopaedics,
M. Ulyanovoy str., 6, Kurgan, 640014, Russia,
rso_@mail.ru

Sergey Olegovich Ryabykh, DMSc, pediatric surgeon, orthopedist, vertebrologist, Head of Laboratory of Axial Skeletal Pathology and Neurosurgery, Russian Ilizarov
Scientific Center for Restorative Traumatology and Orthopaedics, Kurgan, Russia, rso_@mail.ru;
Egor Yuryevich Filatov, post-graduate student, Russian Ilizarov Scientific Center for Restorative Traumatology and Orthopaedics, Kurgan, Russia, filatov@ro.ru;

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