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R. Morrison and U. Vieweg
Fig. 63.3 The opening of the pedicle is then enlarged with a sharp
center punch rst under AP control for the entry point and then under
lateral control to verify the correct sagittal angle
Fig. 63.4 Following the preparation of the screw hole, the channel can
be checked using a dissector or pedicle sonde to disclose possible perforations of the pedicle wall
cab
Fig. 63.5 (a–c) Repositioning examples ((a) repositioning, (b) parallel distraction, (c) lordosation) with a pedicle screw system (With permission
from Aesculap AG, Tuttlingen, Germany)
screw can be seen on the side of the trocar. To verify the
intact pedicle walls, the walls of the canal can be tested
with a ball-tipped pedicle probe (see Figs.63.3 and 63.4).
• The pedicle screw systems allow movements/corrections
in three directions, individually or combined, during the
repositioning procedure: compression, angulation (see
Fig.63.5a, c), distraction (see Fig.63.5b).
63.7 Sacrum
63.7.1 Entry Point/Trajectory
The entry point of the segment S1 is located on a vertical line
along the lateral wall of the superior facet and right on the
inferior border of the facet joint. Due to degenerative
ab
63 Transpedicular Stabilization withInternal Fixation intheThoracolumbar andLumbar Spine
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c
Fig. 63.6 (a–c) Preparation of the sacrum. The entry point for the converging screw channels in the sacrum is about 5mm inferior and 10mm
lateral to the inferior border of the facet of S1
changes, the identication of the exact entry point is sometimes quite difcult. A partial resection of the inferior facet
of L5 is helpful in these cases.
There are two different trajectories in the sacrum:
• The most common is the trajectory aiming at the anterior
corner of the promontorium with a 15–20° convergence
of the screws. Superior strength of xation is achieved by
bicortical xation of the screws along the pedicle axis in
this “safe zone” (see Fig.63.6b).
• The alternative safe zone is found in an angle of 45° deviation, aiming the screws toward the sacroiliacal joint. In
this case, the screws should be no longer than 45mm to
avoid interference with the SI joint.
The sacrum has particular anatomical properties. Here,
the values for the pullout strength are reversed, with anterior
cortical xation being responsible for 60%. Therefore, careful purchase of the anterior cortex is sometimes necessary
for optimal xation.
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R. Morrison and U. Vieweg
63.8 Tips andTricks
• Start out by marking the entry points with K-wires or
short pins using the uoroscopy in the AP direction!
• For easy rod placement, the screws should be placed in
one line and parallel to the upper endplates; the insertion
depth should be the same for all pedicle screws to achieve
aligned screw heads (see Fig.63.2).
• Using pedicle markers, the screw channels can be checked
under lateral X-ray control.
References
1. Olsewski JM, Simmons EH, Kallen FC, etal. Morphometry of the
lumbar spine: anatomical perspectives related to the transpedicular
xation. J Bone Joint Surg Am. 1990;71:541–9.
2. Weinstein JN, Spratt KF, Spengler D, etal. Spinal pedicle xation:
reliability and validity of roentgenogram-based assessment and surgical factors on successful screw placement. Spine. 1988;13:1012–8.
3. Roy-Camille R, Saillant G, Mazel C.Plating of thoracic, thoracolumbar, and lumbar injuries with pedicle screw plates. Orthop Clin
North Am. 1986;17:147–59.
4. Ebraheim NA, Rollins JR, Xu R, et al. Projection of the lumbar
pedicle and its morphometric analysis. Spine. 1996;21:1296–300.
Correction ofDegenerative Scoliosis
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withPolyaxial Internal Fixator
andIntercorporeal Fusion withTLIF
andPLIF Cages
UweVieweg andRobertMorrison
64
64.1 Introduction and Core Messages
The degenerative scoliosis is the so-called de novo
scoliosis. It is a form of secondary scoliosis in elderly
patients (patients >65years), as a result of gradual disk
degeneration with a lateral deviation and rotated vertebral bodies. Surgical correction using a polyaxial internal xation represents a possible treatment of a
degenerative scoliosis. The correction is performed
step by step using polyaxial pedicle screws, intercorporeal fusion (generally using TLIF at the caudal
level), a correction of the scoliosis using PLIF cages
(box-like) following the resection of the facet joints,
and an intercorporeal fusion using a TLIF cage
(banana-like or kidney-shaped cage), again at the cranial end. The remaining malposition is corrected by
restoration of the lumbar lordosis and the derotation of
the vertebras using the prebent rods [1–7].
U. Vieweg (*)
Department of Conservative and Surgical Spine Therapy with
Interdisciplinary Spinal Deformities Centre and Rummelsberg
Sectional Center, Hospital Rummelsberg,
Schwarzenbruck, Germany
e-mail: uwe.vieweg@sana.de
R. Morrison
Spine & Scoliosis Center, Asklepios Klinik Bad Abbach, Germany
e-mail: dr.r.morrison@googlemail.com
64.2 Indications
• Degenerative scoliosis >20°, with a signicant progression of the scoliosis
• Persistent back pain and or leg pain that interferes with
activities of daily living
• Failed conservative therapy and neurological decits
64.3 Contraindications
• Severe osteoporosis, osteopenia, or osteomyelitis
• Poor psychological or medical situation of the patient
64.4 Technical Prerequisites
Fluoroscopy, special cushions (e.g., Wilson Frame), polyaxial screw system with cross connectors, PLIF and TLIF
cages, distraction forceps, cell saver, radiolucent operating
table, and bone grinder.
64.5 Planning, Preparation, andPositioning
Extensive radiological diagnostics such as conventional
radiographs, functional radiographs (exion, extension, lateral bending), MRI, and determination of the bone density
are elemental. The lumbar myelography is a centerpiece of
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_64
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the diagnostics, as it shows the extent of the stenosis. These
ndings combined help to specify the extent of the instrumentation and the type as well as the location of the decompression. They are also elemental in planning the
intercorporeal fusion and reconstruction of the intervertebral
height. During the operation, the patient is in a prone position on a radiolucent operating table. Different positioning
systems can be used (Wilson frame, chest rolls, Relton hall
frame, Hasting frame, Hefngton frame). The patient should
be positioned to minimize intra-abdominal pressure and
thereby avoid venous congestion and excess intraoperative
bleeding. The incision is planned using the uoroscopy.
U. Vieweg and R. Morrison
64.6 Surgical Technique
64.6.1 Approach
• A midline posterior approach to the spine is performed
with subperiosteal exposure of the posterior elements
down to the transverse processes. For improved tissue
protection and in order to use a smaller skin incision, a
subcutaneous lumbar retractor system is advisable (see
Figs.64.1 and 64.2).
• The exposure of the spinous process should extend to at
least one additional level above and below the levels to be
instrumented. Care must be taken not to disrupt the facet
joint capsules of the joints above and below the intended
fusion segments.
64.6.2 Instrumentation
• Using the awl or Steinmann nail, the cortex is penetrated
under uoroscopy. The trajectory angle is determined preoperatively. Use the ball-tipped probe to make sure the
pedicle is intact under uoroscopy. The pedicle entry
point is intersected by the vertical line that connects the
lateral edges of bony crest extension of the pars interarticularis and the horizontal line that bisects the middle of
the transverse process. Subsequently, transpedicular
implantation of the polyaxial screws is carried out (see
Fig.64.3).
• After pedicle screw insertion, the superior and inferior
articular processes of the caudal facet joint (in the most
cases on the convex site) are resected with a high-speed
drill and a Kerrison punch, and the intervertebral disk
space is exposed. The disk is then resected subtotally
using angled rongeurs, shavers, and curettes. After preparation of the end plates, the anterior part of the disc space
Fig. 64.1 Placement of the subcutaneous lumbar retractor system
(SLR, Aesculap AG, Tuttlingen) in an axial view to reduce hematomas
and postoperative pain. (With permission from Aesculap AG, Tuttlingen,
Germany)
Fig. 64.2 Smaller skin incision with the SLR to reduce the operative
trauma. (With permission from Aesculap AG, Tuttlingen, Germany)
64 Correction ofDegenerative Scoliosis withPolyaxial Internal Fixator andIntercorporeal Fusion withTLIF andPLIF Cages
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477
Fig. 64.3 Extensive instrumentation from L1 through L5 using a poly-
axial internal xateur. (With permission from Aesculap AG, Tuttlingen,
Germany)
Fig. 64.4 First step of the correction by performing an intercorporeal
fusion using TLIF technique on the left side in the caudal segment
(L4/5). (With permission from Aesculap AG, Tuttlingen, Germany)
Fig. 64.5 Straightening of the scoliosis in the segment L3/4 by dis-
tracting the intervertebral space using a distraction forceps placed
underneath the screw heads. Then, a PLIF cage is placed into the space.
(With permission from Aesculap AG, Tuttlingen, Germany)
is packed with autologous bone. A curved PEEK cage
specially designed for the TLIF technique is also lled
with autologous bone and inserted into the disk space (see
Fig.64.4).
• Now, the next facet joint on the concave site is resected
using a high-speed drill and a Kerrison punch. The disk
space is distracted with angulated distraction forceps.
This distraction and the implantation of an additional
interbody cage (PLIF) reconstruct the disc space (see
Figs.64.5 and 64.6).
• The cranial disk space is resected coming from the contralateral side. Here, we also recommend a reconstruction using the TLIF technique described above (see
Fig.64.7).
• The appropriate-sized rod is bent to match the sagittal
contour of the spine using the rod bender. Place the rod
into the screws, and then lock it in place with the setscrews. By using this specic screw design with the
removable tabs, an additional correction can be achieved
(lordosis, reposition of a spondylolisthesis as well as a
derotation) (see Fig.64.8a, b).
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U. Vieweg and R. Morrison
ab
Fig. 64.6 Next step is the same procedure in the segment L2/3. (With
permission from Aesculap AG, Tuttlingen, Germany)
Fig. 64.8 (a, b) Additional correction of the lumbar lordosis and dero-
tation using an accordingly bent rod. (a) lateral (b) AP view. (With permission from Aesculap AG, Tuttlingen, Germany)
64.7 Tips andTricks
• Pedicle screw augmentation for the upper and lower ends
of the instrumentation.
• Note the sagittal balance, not only the anterior Cobb
angle.
• Note the junction regions with instrumentation of lower
thoracic spine (T10, T11, T12) or with S1 with or without
a ilium screw.
• Position the uoroscopy to where it is parallel to the
instrumented segment; the end plates of the vertebra will
be depicted as parallel lines.
• Guide pins are available and can be used to mark the pedicle before the pedicle screws are implanted. This allows
a perfect pedicle screw placement.
Fig. 64.7 To complete the correction, a TLIF cage is placed into the
segment L1/2, coming from the left side. (With permission from
Aesculap AG, Tuttlingen, Germany)
64 Correction ofDegenerative Scoliosis withPolyaxial Internal Fixator andIntercorporeal Fusion withTLIF andPLIF Cages
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References
1. Aebi M.The adult scoliosis. Eur Spine J. 2005;14:925–48.
2. Akbarnia BA, Ogilvie JW, Hammerberg KW. Debate:
degenerative scoliosis: to operate or not to operate. Spine.
2006;9(Suppl):S195–201.
3. Bradford DS, Tay BK, Hu SS. Adult scoliosis: surgical indications, operative management, complications and outcome. Spine.
1999;24:2617–29.
4. Glassman SD, Bridwell K, Dimar JK.The impact of positive sagittal balance in adult spinal deformity. Spine. 2005;30:2024–9.
5. Daffner SD, Vaccaro AR.Adult degenerative lumbar scoliosis. Am
J Orthop. 2003;32:77–82.
6. Dick W, Widmer H. Degenerative Lumbalskoliose und
Spinalkanalstenose. Orthopade. 1993;22:232–42.
7. Tribus CB.Degenerative lumbar scoliosis: evaluation and management. J Am Acad Orthop Surg. 2003;11:174–83.
Correction ofSpondylolisthesis
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UweVieweg
65
65.1 Introduction and Core Messages
The goals of surgical treatment of spondylolisthesis
are as follows: decompression of neuronal structures,
stabilization of spondylolytic instability, reduction of
slippage, restoration of the disk height, and restoration
of the sagittal alignment [1, 2]. With the appropriate
instruments, it is possible to instrument a single compartment and, in most cases, to completely reduce the
spondylolisthesis. This technique allows an instrumented monosegmental slippage reduction of low- and
middle-grade isthmic spondylolisthesis via fusion with
a polyaxial internal xator, titanium spacer, and crosslink connector.
65.2 Indications
• Spondylolytic spondylolisthesis Meyerding grade I–III
(IV) L5/S1 and L4/L5
• Signicant progression of the slip spondylolisthesis
• Persistent back pain and/or leg pain that interferes with
activities of daily living
• Failed conservative therapy
• Neurological decits [1–5]
65.3 Contraindications
• Reduction should not be attempted in patients with
spondyloptosis.
• Osteoporosis, osteopenia, or osteomyelitis.
• Poor psychological and/or poor general medical state of
the patient [1–5].
65.4 Technical Prerequisites
U. Vieweg (*)
Department of Conservative and Surgical Spine Therapy with
Interdisciplinary Spinal Deformities Centre and Rummelsberg
Sectional Center, Hospital Rummelsberg,
Schwarzenbruck, Germany
e-mail: uwe.vieweg@sana.de
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_65
Fluoroscopy, positioning device (e.g., Wiltse frame), adequate implants, and instruments with the following technical
requirements:
• Simultaneous correction of translation and slip angle.
• Reduction with single-level fusion and sparing adjacent
healthy vertebrae.
• Reduction of the listhetic vertebral body along the same
curved displacement route. This minimizes interference
with anatomical structures and eliminates the neurological decits that typically result from initial overdistraction of an already stretched nerve root.
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Mounting post
t
Reduction bolt
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Fig. 65.1 The S4 SRI
spondylolisthesis reduction
instrument (SRI) has a right
and a left component. Each
has two pedicle screw
attachments. One attaches to
the cephalad vertebral screw
that will be repositioned and
the other to the caudal
vertebral screw. (With
permission from Aesculap
AG, Tuttlingen, Germany)
U. Vieweg
Articulated head
Cephalad componen
Distraction spindle
Distraction nut
Mounting post
Caudal component
Fig. 65.2 The right and the left component of the S4 SRI. (With permission from Aesculap AG, Tuttlingen, Germany)
The S4 SRI = spondylolisthesis reduction instrument is
one possible method of reducing a spondylolisthesis (see
Figs.65.1 and 65.2). Other possibilities are Krypton (Ulrich,
prone on a radiolucent operating table. The abdomen is permitted to hang freely. The hips are extended to enhance lum-
bar lordosis.
Ulm, Germany), TSRH 3D Plus MPA (Medtronic, USA),
Xia (Stryker, USA), Pathnder (Abbott Spine, USA),
SOCON (Aesculap, Tuttlingen, Germany), and USS Click’X
(Synthes, Umkirch, Germany).
65.6 Surgical Technique
65.6.1 Approach
65.5 Planning, Preparation, andPositioning
Prior to surgery, the patient’s X-rays are reviewed to access
pedicle diameter, length, and orientation. Knowledge of normal pedicle anatomy is essential for proper placement of
pedicle screws, especially in L5. The patient is positioned
A midline posterior approach to the spine is performed with
subperiosteal exposure of the posterior bony elements to the
level of the transverse processes. On the lateral side, the pos-
terior segments are exposed including the facet joints.
(Access to L5/S1 should generally be made large enough to
ensure reliable instrumentation.)
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