P68. Thoracic Pedicle Subtraction Osteotomy for Fixed Sagittal Deformity: Clinical and Radiographic Outcomes

Abstract Minimally invasive surgery (MIS) approaches for the correction of adult spinal deformity have gained popularity in the past decade. MIS approaches can result in decreased hospitalization times and decreased morbidity. However, compared to open techniques, MIS approaches are challenging in the setting of fixed sagittal deformity and strategic surgical staging. Combined MIS and miniopen techniques are described as “hybrid” techniques. We report on the surgical approach for a fixed sagittal deformity using both MIS and miniopen techniques, specifically a miniopen pedicle subtraction osteotomy (PSO) and an anterior column release (ACR). The patient gave written informed consent for surgical treatment; institutional review board approval was not required. The patient first underwent the placement of percutaneous modular pedicle screws from T12 to the pelvis as well as a mini-PSO across the previously fused L5 vertebral body, with the placement of a temporary rod. The following day, the patient underwent lateral transpsoas interbody fusion and ACR at L2/3; a percutaneous rod was then passed from T12 to the pelvis for segmental fixation. The patient recovered well and was discharged home without complication 6 d after the initial day of surgery. The combined use of surgical staging and traditional open techniques in a selective, minimalistic fashion and adherence to minimally invasive principles provide for a powerful set of surgical techniques that capitalize on less invasive approaches to deformity management. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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A novel approach to sagittal balance restoration following iatrogenic sacral fracture and resulting sacral kyphotic deformity

Journal of Neurosurgery Spine ◽

10.3171/spi.2007.6.4.15 ◽

2007 ◽

Vol 6 (4) ◽

pp. 368-372 ◽

Cited By ~ 21

Author(s):

Patrick C. Hsieh ◽

Stephen L. Ondra ◽

Robert J. Wienecke ◽

Brian A. O'Shaughnessy ◽

Tyler R. Koski

Keyword(s):

Sagittal Balance ◽

Pelvic Incidence ◽

Morphological Characteristics ◽

Pedicle Subtraction Osteotomy ◽

Sacral Fracture ◽

Novel Approach ◽

Sagittal Spinal Alignment ◽

Fixed Parameter ◽

Lumbar Hyperlordosis ◽

Sagittal Deformity

✓The authors describe the use of sacral pedicle subtraction osteotomy (PSO) with multiple sacral alar osteotomies for the correction of sacral kyphosis and pelvic incidence and for achieving sagittal balance correction in cases of fixed sagittal deformity after a sacral fracture. In this paper, the authors report on a novel technique using a series of sacral osteotomies and a sacral PSO to correct a fixed sagittal deformity in a patient with a sacral fracture that had healed in a kyphotic position. The patient sustained this fracture after a previous surgery for multilevel instrumented fusion. Preoperative and postoperative radiographic studies are reviewed and the clinical course and outcome are presented. Experts agree that the pelvic incidence is a fixed parameter that dictates the morphological characteristics of the pelvis and affects spinopelvic orientation and sagittal spinal alignment. An increased pelvic incidence is associated with a higher degree of spondylolisthesis in the lumbosacral junction, and increased shear forces across this junction. The authors demonstrate that the pelvic incidence can be altered and corrected with a series of sacral osteotomies to improve sacral kyphosis, compensatory lumbar hyperlordosis, and sagittal balance.

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Surgical management of global sagittal deformity in ankylosing spondylitis

Neurosurgical FOCUS ◽

10.3171/foc/2008/24/1/e8 ◽

2008 ◽

Vol 24 (1) ◽

pp. E8 ◽

Cited By ~ 26

Author(s):

Charles A. Sansur ◽

Kai-Ming G. Fu ◽

Rod J. Oskouian ◽

Jay Jagannathan ◽

Charles Kuntz ◽

...

Keyword(s):

Ankylosing Spondylitis ◽

Preoperative Planning ◽

Sagittal Plane ◽

Axial Skeleton ◽

Pedicle Subtraction Osteotomy ◽

Review Article ◽

Cervicothoracic Junction ◽

Plane Deformity ◽

Sagittal Deformity ◽

Review Current

✓ Ankylosing spondylitis (AS) is an inflammatory rheumatic disease whose primary effect is on the axial skeleton, causing sagittal-plane deformity at both the thoracolumbar and cervicothoracic junctions. In the present review article the authors discuss current concepts in the preoperative planning of patients with AS. The authors also review current techniques used to treat sagittal-plane deformity, focusing on pedicle subtraction osteotomy at the thoracolumbar junction, as well as cervical extension osteotomy at the cervicothoracic junction.

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A novel mathematical model of the sagittal spine: application to pedicle subtraction osteotomy for correction of fixed sagittal deformity

The Spine Journal ◽

10.1016/j.spinee.2007.05.001 ◽

2008 ◽

Vol 8 (2) ◽

pp. 359-366 ◽

Cited By ~ 12

Author(s):

Benson P. Yang ◽

Larry A. Chen ◽

Stephen L. Ondra

Keyword(s):

Mathematical Model ◽

Pedicle Subtraction Osteotomy ◽

Sagittal Deformity

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The comprehensive anatomical spinal osteotomy and anterior column realignment classification

Journal of Neurosurgery Spine ◽

10.3171/2018.4.spine171206 ◽

2018 ◽

Vol 29 (5) ◽

pp. 565-575 ◽

Cited By ~ 13

Author(s):

Juan S. Uribe ◽

Frank Schwab ◽

Gregory M. Mundis ◽

David S. Xu ◽

Jacob Januszewski ◽

...

Keyword(s):

Interobserver Reliability ◽

Spinous Process ◽

Pedicle Subtraction Osteotomy ◽

Anterior Column ◽

Disc Space ◽

Interspinous Ligament ◽

Radiographic Outcomes ◽

Grade 5 ◽

Grade 3 ◽

Additional Resection

OBJECTIVESpinal osteotomies and anterior column realignment (ACR) are procedures that allow preservation or restoration of spine lordosis. Variations of these techniques enable different degrees of segmental, regional, and global sagittal realignment. The authors propose a comprehensive anatomical classification system for ACR and its variants based on the level of technical complexity and invasiveness. This serves as a common language and platform to standardize clinical and radiographic outcomes for the utilization of ACR.METHODSThe proposed classification is based on 6 anatomical grades of ACR, including anterior longitudinal ligament (ALL) release, with varying degrees of posterior column release or osteotomies. Additionally, a surgical approach (anterior, lateral, or posterior) was added. Reliability of the classification was evaluated by an analysis of 16 clinical cases, rated twice by 14 different spine surgeons, and calculation of Fleiss kappa coefficients.RESULTSThe 6 grades of ACR are as follows: grade A, ALL release with hyperlordotic cage, intact posterior elements; grade 1 (ACR + Schwab grade 1), additional resection of the inferior facet and joint capsule; grade 2 (ACR + Schwab grade 2), additional resection of both superior and inferior facets, interspinous ligament, ligamentum flavum, lamina, and spinous process; grade 3 (ACR + Schwab grade 3), additional adjacent-level 3-column osteotomy including pedicle subtraction osteotomy; grade 4 (ACR + Schwab grade 4), 2-level distal 3-column osteotomy including pedicle subtraction osteotomy and disc space resection; and grade 5 (ACR + Schwab grade 5), complete or partial removal of a vertebral body and both adjacent discs with or without posterior element resection. Intraobserver and interobserver reliability were 97% and 98%, respectively, across the 14-reviewer cohort.CONCLUSIONSThe proposed anatomical realignment classification provides a consistent description of the various posterior and anterior column release/osteotomies. This reliability study confirmed that the classification is consistent and reproducible across a diverse group of spine surgeons.

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