What is a Vertebral Column Resection (VCR)?
Vertebral = relating to vertebrae, bones of the spine
Column = a pillar or upright stack
Resection = surgical removal of a part
The vertebrae, or bones of the spine, are arranged in an upright stack known as the vertebral column. A vertebral column resection (VCR) is the complete removal of one or more vertebrae from the vertebral column.
Vertebral column resection is used to correct certain spinal deformities in adults and children. For an overview of spinal deformities and options for their surgical correction, see the overview page here.
After a vertebral column resection is performed, hardware such as screws, rods, plates or cages hold the spine in place while it heals. Bone graft (transplant) is applied over the gap where the vertebra once was. The bone graft helps the bones fuse, or grow together into one solid bone. Good fusion of the bones results in a strong and stable section of spine.
When is this Procedure Performed?
A vertebral column resection is sometimes required to correct severe, rigid spinal deformities. (A flexible spinal deformity changes its size or shape when a patient assumes different positions, while a rigid deformity does not change.) It is also sometimes used to remove a bone tumor.
The VCR is generally reserved for treating the most severe cases of spinal deformity, including hyperkyphosis (abnormal forward curvature of the spine) or scoliosis (abnormal side-to-side curvature of the spine).
Of the deformity correction surgeries, the VCR removes the most substantial amount of bone. It also allows the most substantial amount of correction–80 degrees or more. For a sharp curve, one vertebra may be removed, while for a broader curve, more than one may be removed.
How is this Procedure Performed?
A vertebral column resection is performed under general anesthesia, which means the patient is unconscious and on a ventilator during the surgery.
Spinal cord monitoring such as SSEPs (somatosensory evoked potentials) and MEPs (motor evoked potentials) are used throughout the procedure to help ensure the safety of the spinal cord.
The surgical approach may be posterior (from the back) only, or it may be combined with an anterior (frontal) approach. The below description will be of the posterior approach only.
After the patient is unconscious, he or she is placed face-down on the operating table. The surgeon makes a skin incision and then exposes the bones of the vertebral column. The surgeon inserts pedicle screws into solid areas of the vertebrae above and below the vertebra that will be removed. These screws will later be connected with rods to help hold the spine stable.
Next, the surgeon begins a careful removal of the vertebra of interest, piece by piece, working from the back of the vertebra to front. First the bony outcroppings called processes at the back of the vertebra are removed. Then the flat bones called laminae that cover the spinal canal are removed, and then the facet joints –the parts of the back of a vertebra that interact with the backs of other vertebrae. Next the pedicles, sturdy areas of bones toward the side of the spinal canal, are removed. Now all of that one vertebral bone behind and to the side of the spinal cord has been removed. On the far side of the spinal cord, the surgeon can see the front section of the vertebra, called the vertebral body.
Working carefully around one side of the spinal cord, the surgeon removes one side of the vertebral body. Then temporary rods are inserted into the pedicle screws that were placed in the first stages of surgery. These rods hold the spine stable while the surgeon switches to the other side and removes the other half of the vertebral body. The removal of one vertebra is now complete. The surgeon repeats the procedure if other vertebrae are to be removed.
Then it is time to realign the spine. The surgeon aligns the spine in all three dimensions, “hinging” the realignment on the spinal canal. That is, while the surgeon manipulates the spine into a more optimal alignment, he or she is careful to keep the spinal cord stable, neither stretching nor compressing it.
Once a good alignment is achieved, the surgeon stabilizes the spinal column in its new position. The surgeon places an implant like a strut graft (solid piece of bone) or manufactured hardware like a cage (a small, porous implant filled with bone graft that can grow through it) in the space where the vertebral body once was. Permanent rods are inserted into the pedicle screws, and more bone graft is placed to bridge the gap at the back of the spine.
Implants like the cage, pedicle screws, and rods will hold the vertebral column stable in the short term, while it heals. As the bone graft fuses, or grows together with the surrounding vertebrae, the new bone will provide long-term strength and stability.
The incision is closed in layers, and the wound is dressed with a gauze bandage.
How Should I Prepare for this Procedure?
Nicotine interferes with bones’ ability to fuse. Good bone fusion is very important for good surgical outcome. If you smoke or use tobacco products, please speak to your neurosurgeon about quitting.
Many people find it helpful to write down their questions about the procedure, its goals, its risks, and/or the recovery period. Bringing the list to your or your child’s appointment can help you make sure you get all your questions answered.
Make sure to tell your doctor about any medications or supplements that you or the patient taking, especially medications that can thin the blood such as aspirin. Your doctor may recommend you or the patient stop taking these medications before your procedure. To make it easier, write all medications down before the day of surgery.
Be sure to tell your doctor if you or the patient have an allergy to any medications, food, or latex (some surgical gloves are made of latex).
On the day of surgery, remove any nail polish or acrylic nails, do not wear makeup and remove all jewelry. If staying overnight, bring items that may be needed, such as a toothbrush, toothpaste, and dentures. You will be given an ID bracelet. It will include your name, birthdate, and surgeon’s name.
What Can I Expect After the Procedure?
How long will I stay in the hospital?
Patients are encouraged to walk on the day following surgery, and typically stay in the hospital 1-3 days.
Will I need to take any special medications?
You will be prescribed pain medications to help manage post-surgical pain.
Will I need to wear a brace?
A brace may be worn for comfort after surgery, but is not required in most patients.
When can I resume exercise?
In the first stages of healing, 1-2 months after surgery, there is no advantage to pushing the limits in terms of physical activity. Short periodic walks are sufficient to prevent the medical complications associated with inactivity. The most important thing you can do in the beginning is be patient and allow your body time to heal.
After this initial healing period, you will undergo a gradual return to activity guided by your doctor.
What follow-up will I receive?
The surgeon will schedule the first follow-up visit 4-6 weeks after surgery, and periodically thereafter. X-rays are typically performed during the follow-up period to monitor how the bones are fusing.
Will I need rehabilitation or physical therapy?
Physical therapy is often useful. It usually begins several weeks after surgery and focuses on lower back strengthening and increasing range of motion.
Will I have any long-term limitations due to vertebral column resection?
There may be some reduction in the range of motion and mobility of the fused spinal segments. This is minimized by an active exercise and stretch program followed by the healing of the spinal fusion.
Preparing for Your Appointment
At the Spine Hospital at the Neurological Institute of New York, Drs. Peter D. Angevine, Christopher E. Mandigo and Sheng-fu (Larry) Lo are experts in vertebral column resection and other types of deformity correction. Dr. Richard C.E. Anderson (Pediatric) specializes in pediatric vertebral column resection.