Uso del sistema de corrección coplanar en Escoliosis Neuromuscular. Comparación con la técnica de desrotación apical y análisis de las complicaciones y comorbilidades

Abstract

The concept of neuromuscular scoliosis includes a wide variety of pathologies associated with both the nervous and muscular systems they represent a challenging population to treat. As such, determining the correct surgical plan can oftentimes be complex given the multitude of variables to consider, ranging from clinical (i.e., ventilatory function, comorbidities) to biomechanical (i.e., pelvic obliquity, curve magnitude and rigidity, bone quality, sitting balance. Currently, no clear patterns of neuromuscular curvatures have been described in the literature and there remains a lack of consensus on the best technique to achieve a balanced posture. In the setting of neuromuscular scoliosis, a surgeon has multiple corrective techniques at his or her disposal to select from. The use of traction, either preoperatively or intraoperatively, has been previously reported in patients with high grade curves. Combined approaches have a role in correction when treating patients with rigid curves and permit better control of pelvic obliquity; however, they are also associated with increased OR time and EBL. The posterior-only approach on the other hand has been associated with fewer complications and thus remains the preferred technique for a majority of spine surgeons. The Vertebral Coplanar Alignment (VCA) technique takes into consideration aspects of vertebral anatomy that the Apical Derotation (AD) techniques do not. Because the medial cortex of the vertebral body is wider and more resistant than the lateral cortex, this allows for more anchor points during derotation for a better distribution of forces. Furthermore, VCA takes advantage of the fact that children have stronger ligaments and more elastic bones by relying on this strong attachment to guide correction. By relocating the normal coplanar axis into a single plane, translation and derotation can be achieved in one gesture. With such a heterogeneous group of disorders, it is difficult to establish guidelines for preoperative planning, surgery, and postoperative treatment. Although patients are evaluated individually, the identification of shared characteristics can be valuable for treatment algorithms. Complications in neuromuscular scoliosis surgery are difficult to anticipate and no association has been studied between perinatal comorbidities, preoperative evaluation, surgical parameters, and postoperative complications. One of the complications is profuse bleeding, the mechanisms of addressing this issue are either replacing blood, involving autotransfusions, cell saver and allotransfusions, all which are potentially associated with complications, increase procedures and higher costs, or saving blood. In recent years tranexamic acid has taken precedence in this matter.Existen múltiples consideraciones en escoliosis neuromuscular, grandes deformidades, curvas rígidas, mala calidad ósea y oblicuidad pélvica. No hay consenso en cual es la mejor técnica quirúrgica para seguir con estos pacientes. La técnica de desrotación coplanar considera tres aspectos, no evaluados previamente: que la corteza medial del pedículo es mas gruesa que la corteza lateral, el aumento de los puntos de torque permite una mejor distribución de las fuerzas y el uso de ligamentotaxis como coadyuvante en la maniobra de reducción. Si logramos realinear la coplanaridad normal, la traslación y desrotación vertebral son posibles en un solo gesto quirúrgico. Las comorbilidades y complicaciones son considerable en este grupo de pacientes y difíciles de predecir. Una de las complicaciones mas importantes es el sangrado masivo, dentro de los mecanismos para enfrentarlo, está el uso de acido tranexámico, habitualmente utilizado de manera endovenosa, se ha explorado también su uso tópico. OBJETIVO: Comparar la capacidad de corrección de el Sistema de desrotación coplanar (DC) versus el de desrotación apical (DA) en pacientes pediátricos con escoliosis neuromuscular. Como objetivo secundario, determinar los factores predictores de riesgo de complicaciones en escoliosis neuromuscular, con énfasis en el sangrado y el uso de acido tranexámico endovenosos y tópico para su prevención.