Myelokyphectomy in Spina Bifida: The Modified Fackler or Sagittal Shilla Technique

Severe focal kyphosis occurs in approximately 5-10% of infants with myelomeningocele with the apex of the curve centered around the second lumbar vertebra. The kyphosis is fixed in nature and is usually associated with a compensatory thoracic lordosis proximally. Indications for surgery include an impaired sitting balance, recurrent skin ulcerations, respiratory depression, and pain. The modified Fackler or sagittal Shilla technique is used to solve these problems in a child of 9 years of age or younger. It combines aspects of both the Shilla technique described by McCarthy and the originally described Fackler technique for myelokyphosis. The specific steps to performing this procedure include (1) exposure of the midthoracic spine to pelvis with dissection around the gibbus, (2) pedicle screw instrumentation at the 2 vertebrae to be joined, (3) Luque wire instrumentation, (4) removal of vertebral bodies, (5) presacral rod insertion through the sacral foramina, (6) cantilevering and fixation of the rods to the pedicle screws, (7) tensioning the rods to the Luque wires, (8) grafting to create a limited apical fusion, and (9) tension-free wound closure. This procedure is associated with good long-term outcomes including an increased and sustained curve correction, decreased overall surgeries, and height gain.