What are the surgical options for correction of the sagittal plane deformity in the previously fused spine

Smith-Petersen osteotomy (resection of a posterior column wedge to achieve correction through the disc space or through a prior anterior osteotomy) and pedicle subtraction osteotomy (resection of a three-column wedge hinging at the anterior longitudinal ligament) are powerful methods for correction sagittal deformity. Combined coronal and sagittal deformity may be corrected with a vertebral column resection procedure. See Figure 53-3.

Figure 53-3. A, Preoperative lateral x-ray film of a SS-year-old woman who sustained Ts and T8 compression fractures and a T12 burst fracture when she was hit by a falling tree. The patient underwent posterior segment al spinal instrumentation from T2 to Li with posterior spinal fusion from T11 to Li, where a year after the initial surgery, the instrumentation was removed. The patient presented approximately 6 years after the removal of instrumentation with increasing thoracic pain and hyperkyphosis. She was treated with multiple Smith-Petersen osteotomies from TS to Li and an instrumented posterior spinal fusion from T2 to LS by using pedicle screws with restoration of normal sagittal contours and balance as seen in (B) the postoperative lateral x-ray films of the spine. (From Buchowski JM, Kuhns CA, Bridwell KH, et al. Surgical management of posttraumatic thoracolumbar kyphosis. Spine J 2008;8:666-77.)

Key Points

1. Any adult spinal deformity patient considered for surgical treatment involving multilevel spinal instrumentation and fusion requires detailed preoperative analysis of sagittal plane alignment.

2. Prevention of postoperative sagittal imbalance following spinal instrumentation and fusion begins with patient positioning on an operating table, which permits enhancement of lumbar lordosis.

3. Important techniques for achieving optimal sagittal alignment include appropriate sagittal rod contouring and restoration of segmental sagittal alignment using interbody fusion, wide posterior releases, and spinal osteotomies as needed.

4. Surgical options for treatment of sagittal imbalance in the previously fused spine include Smith-Petersen osteotomies, Ponte osteotomies, pedicle subtraction osteotomy, combined anterior and posterior osteotomy, and vertebral column resection.

Websites

Spinal osteotomies: http://www.coa-aco.org/coa-bulletin/issue-85/themes-complex-procedures-revision-surgeries-and-spinal-osteotomies.html

Vertebral column resection: http://www.spinal-deformity-surgeon.com/vcr-paper.html

Adult sagittal plane deformity: http://www.spineinstituteny.com/research/assets/Joseph_2009.pdf

Pedicle subtraction osteotomy: http://www.spineuniverse.com/professional/pathology/deformity/ankylosing-spondylitis-treated-pedicle-subtraction

Decisions and expectations with osteotomy surgery: http://www.spineuniverse.com/professional/technology/surgical/thoracic/ decisions-expectations-osteotomy-surgery-fixed

BiBLiOGRAPHY

1. Bernhardt M, Bridwell KH. Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction. Spine 1989;14:717-21.

2. Bradford DS, Tribus CB. Vertebral column resection for the treatment of rigid coronal decompensation. Spine 1997;22:1590-9.

3. Bridwell KH. Decision making regarding Smith-Petersen vs. pedicle subtraction vs. vertebral column resection for spinal deformity. Spine 2006;31:S171-8.

4. Buchowski JM, Kuhns CA, Bridwell KH, et al. Surgical management of posttraumatic thoracolumbar kyphosis. Spine J 2008;8:666-77.

5. Joseph SA, Morena AP, Brandoff J, et al. Sagittal plane deformity in the adult patient. J Am Acad Orthop Surg 2009;17:378-88.

6. Lafage V, Schwab F, Patel A, et al. Pelvic tilt and truncal inclination: two key radiographic parameters in the setting of adults with spinal deformity. Spine 2009;34:E599-E606.

7. Legaye J, Duval-Beaupere G, Hecquet J, et al. Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J 1998;7:99-103.

8. Rinella AS, Bridwell KH. Iatrogenic fixed sagittal imbalance. In: Herkowitz HN, Garfin SR, Eismont FJ, Bell GR, Balderston RA, editors. Rothman and Simeone The Spine. 5th ed. Philadelphia: Saunders; 2006. p. 1564-78.

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